Delmar Gardens Of O'fallon
Inspection history, citations, penalties and survey trends for this long-term care facility in O Fallon, Missouri.
- Location
- 7068 South Outer 364, O Fallon, Missouri 63368
- CMS Provider Number
- 265792
- Inspections on file
- 21
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Delmar Gardens Of O'fallon during CMS and state inspections, most recent first.
A resident with otitis media had an order for ciprofloxacin ear drops to be instilled into the right ear four times daily, with the order and MAR specifying otic administration and no orders for ophthalmic drops. A nurse working as a CMT misread the medication label and administered the ciprofloxacin ear drops into the resident’s right eye instead of the ear, after which the resident experienced immediate pain and blurred vision. Facility policies and CMT training materials required triple-checking labels, cross-checking orders, and following the five rights of medication administration, but interviews showed some LPNs reported not receiving recent in-services on medication administration, and the Administrator did not believe all staff needed such in-servicing.
A resident with multiple comorbidities and significant lower extremity weakness was improperly transferred using a sit-to-stand lift, which was used as a transport device against manufacturer instructions. Staff, aware of the resident's fatigue and inability to consistently bear weight, proceeded with the transfer, resulting in the resident's legs giving way and a severe leg injury. Communication lapses and unclear care planning contributed to the unsafe transfer and subsequent harm.
The facility's pest control program was ineffective, leading to rodent feces in multiple resident rooms. Observations and staff interviews confirmed the presence of mice and feces in various locations, including drawers and closets. Despite a policy requiring regular inspections and sanitation, there was confusion about cleaning responsibilities, and bait boxes were not placed in all necessary areas. A resident reported mice entering their room from the air conditioning unit.
The facility failed to maintain sanitary conditions in food storage, preparation, and service. Staff did not label or seal food items, store food per instructions, or discard expired items. Ice machines were not cleaned properly, and hygienic practices were not followed. Dishwashing parameters were not monitored, and personal food was consumed in preparation areas. The dietary manager acknowledged these issues, but standards were not met.
The facility failed to ensure call lights were accessible for residents, leading to delayed assistance and incontinence. Residents with varying cognitive and physical dependencies were unable to reach their call lights, resulting in unmet needs and distress. The DON and administrator acknowledged the expectation for call lights to be within reach, but observations showed a systemic failure to meet this standard.
The facility failed to adhere to physician orders and care plans for three residents, resulting in deficiencies in dietary and weight monitoring. A resident with dysphagia received incorrect liquid consistencies, while two residents on the rehab unit did not have their weights monitored weekly as required. Staff interviews revealed issues with order entry and electronic charting, leading to a lack of compliance with professional standards of practice.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, including showers, nail care, shaving, oral care, incontinence care, and meal assistance. Observations revealed residents with poor hygiene and unmet care needs, such as long, dirty fingernails, greasy hair, and facial stubble. Incontinence care was delayed, leading to skin irritation, and meal assistance was lacking, with residents struggling to eat independently. Oral hygiene and denture care were also neglected, with residents not receiving necessary help.
The facility failed to provide proper catheter care for three residents, leading to potential health risks. A resident with a history of UTIs had their catheter handled with soiled gloves by a CNA. Another resident's catheter bag was improperly positioned above the bladder, causing urine backup. A third resident's catheter bag was also placed above the bladder during a transfer. Staff interviews confirmed the expectation for catheter bags to be below bladder level and off the floor, which was not consistently followed.
A facility failed to ensure proper insulin administration for three residents using the Humalog Kwik pen. An LPN did not prime the insulin pen or hold the needle in place for the recommended time, leading to potential medication errors. The residents, diagnosed with type 2 diabetes, received incorrect doses due to these oversights, despite the facility's policy and manufacturer's guidelines.
The facility failed to properly secure and dispose of controlled medications, with observations showing medications stored in unsecured sharps containers and medication carts left unlocked and unattended. Staff interviews confirmed these practices, highlighting a systemic failure to adhere to policies, posing risks of diversion and accidental exposure.
The facility failed to serve meals according to residents' dietary needs, as staff did not prepare or serve required food items and used incorrect portion sizes. Specific items like fruit garnish and sugar-free pudding were missing, affecting residents on various diets. Staff were unaware of menu requirements, leading to non-compliance with dietary orders.
The facility failed to serve food at safe and appetizing temperatures, with cold items served warm and hot items served cool. Observations showed incomplete temperature logs and deviations from recipes, affecting meal quality. Dietary staff did not adhere to expected standards, and the dietary manager had not evaluated food taste or temperature since starting at the facility.
The facility failed to provide residents with the appropriate texture-modified diets as per physician orders. Residents on a mechanical soft diet were served improperly prepared food items, such as broccoli salad with hard edges and fried fish with a crispy crust, making them difficult to chew and swallow. The dietary manager confirmed that food should be prepared at the correct texture.
The facility failed to follow proper infection control procedures, affecting 12 residents. Staff did not consistently use appropriate hand hygiene, gloving techniques, or PPE during care. Enhanced Barrier Precautions were not properly implemented, and respiratory care supplies were improperly stored. Observations revealed staff neglecting hand hygiene, failing to change gloves between tasks, and not wearing gowns when required. Additionally, staff lacked awareness of infection control policies, and supplies like hand sanitizer were inadequate.
The facility failed to administer pneumococcal vaccines to three residents according to CDC guidelines. One resident over 65 with COVID-19 was not offered the vaccine despite consenting to it. Another resident with chronic respiratory failure was not offered the PCV15 or PCV20 vaccines, and their MDS inaccurately showed their vaccination status as up to date. A third resident under 65 with diabetes and stroke was not offered the PCV15 or PCV20 vaccines upon admission, despite having received PPSV23 outside the facility.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving two residents. A resident with a history of stroke reported being yelled at and treated harshly by an aide during an incontinent episode. Another resident with Alzheimer's was referred to as a 'cry baby' by a nurse aide within earshot of the resident and a state surveyor. Both incidents highlight a lack of respect and dignity in resident care.
A facility failed to prevent accident hazards for two residents. One resident with a history of ingesting non-food items was served food in Styrofoam containers, leading to ingestion. Another resident with hemiplegia was improperly transferred by staff who did not follow gait belt procedures. The facility's policies were not adhered to, and staff lacked awareness of care plans and dietary restrictions.
Facility staff failed to provide food as ordered by the physician and did not monitor weights or notify the physician of nutritional supplement refusals for two residents with significant weight loss. One resident, on a mechanically altered diet, was served inappropriate food and frequently refused supplements, with no documentation or physician notification. Another resident with dementia experienced poor intake and significant weight loss, with inconsistent provision of recommended supplements and inadequate monitoring of meal intakes.
The facility failed to maintain essential equipment, including a frayed power cord on a food processor and a non-functional refrigerator compartment, posing potential hazards. Staff were unaware of these issues, and there was a lack of communication regarding necessary repairs.
The facility failed to provide written notice of the bed hold policy to two residents with Alzheimer's disease and their representatives when they were transferred to the hospital. Despite sending transfer packets with the residents, there was no documentation that the bed hold policy was provided in writing. Interviews with staff revealed inconsistencies in the process, and the facility's log showed no record of the policy being sent.
The facility failed to follow their policy for skin assessments and timely treatment of pressure ulcers for a resident with multiple health conditions, resulting in delayed care and inadequate documentation of skin issues.
Significant Medication Error Involving Misadministration of Ear Drops to Eye
Penalty
Summary
The facility failed to prevent a significant medication error when staff administered ciprofloxacin ear drops into a resident’s right eye instead of the ordered route to the right ear. Facility policy on medication administration required staff to read medication labels three times and to cross-check all new or questionable medication orders against the physician’s order, the eMAR, and the drug label, and the CMT training manual emphasized the five rights of medication administration (right resident, medication, dose, route, and time). The resident, who had a diagnosis of otitis media and a hospital discharge order for ciprofloxacin 0.3% solution, two drops to the right ear four times daily, had corresponding physician orders and MAR entries specifying ciprofloxacin 0.2% ear drops to the right ear four times daily. There were no physician orders for eye drops. On the date of the incident, RN A, working in the role of a CMT, administered the ciprofloxacin ear drops into the resident’s right eye instead of the right ear after misreading the label as indicating eye rather than ear. The resident reported immediate pain and blurred vision after the administration and notified another nurse, and subsequent documentation noted blurred vision without redness or discharge. Reference material from Drugs.com cited in the report stated that ear drops and eye drops are not interchangeable and that ear drops placed in the eye can cause immediate burning, itching, redness, blurred vision, and swelling. Interviews with nursing staff revealed that some LPNs could not recall recent in-service training on the rights of medication administration or had not received training on eye or ear drop administration, and the Administrator stated she did not believe all staff needed in-servicing on medication administration because RN A acknowledged making the mistake.
Failure to Safely Transfer Resident Using Sit-to-Stand Lift Results in Serious Injury
Penalty
Summary
Facility staff failed to safely transfer a resident using a sit-to-stand mechanical lift, resulting in a significant injury. The resident, who had diagnoses including arthritis, osteoporosis, malnutrition, dementia, and generalized weakness, was dependent on staff for all transfers and had a history of lower extremity edema, pain, and prior fractures. Despite the manufacturer's instructions that the sit-to-stand lift was not to be used as a transport device and was only for transfers between seated surfaces, staff transported the resident from the bathroom to the bed using the lift. During this process, the resident's legs, which were known to be weak and edematous, began to give way, causing the resident to slide out of the sling. Staff rushed the resident to the bed, during which the resident's leg struck the bed rail, resulting in a large, complex laceration that required surgical repair. Interviews and record reviews revealed that staff were aware of the resident's fluctuating ability to bear weight, particularly in the evenings when the resident was more fatigued. There were previous incidents where the resident's legs buckled during sit-to-stand transfers, and staff had expressed concerns about the appropriateness of using the sit-to-stand lift versus a Hoyer lift. However, these concerns were not consistently communicated to therapy or reflected in the resident's care plan. The care plan and physician orders for the resident's transfer method changed multiple times, alternating between sit-to-stand and Hoyer lift, but did not clearly address the resident's variable tolerance for the sit-to-stand lift or provide guidance for staff when the resident was unable to support their own weight. Staff interviews indicated a lack of understanding regarding the proper use of the sit-to-stand lift, with some staff believing it was acceptable to transport residents short distances in the device. The facility's policy required adherence to the manufacturer's instructions and specified that residents must be able to support the majority of their own weight for sit-to-stand transfers. Despite this, staff proceeded with the transfer even though the resident was unable to bear weight, leading to the accident and injury. There was also a lack of documentation and communication regarding the resident's declining condition and the challenges encountered during transfers.
Ineffective Pest Control Program Leads to Rodent Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodent feces in multiple resident rooms. Observations revealed rodent feces in various locations, including drawers containing resident clothing, behind cabinets, around toilets, and on closet floors. Interviews with staff, including CNAs, housekeepers, and LPNs, confirmed sightings of mice and rodent feces in resident rooms and common areas. The facility's pest control policy, revised in October 2022, designates the Director of Environmental Services as the coordinator for pest management, requiring regular inspections and maintenance of proper sanitation to prevent pest harborage. Despite these measures, staff interviews indicated a lack of clarity regarding responsibilities for cleaning resident cabinets and nightstands, where rodent feces were found. The Maintenance Director acknowledged dealing with reports of mice, particularly in rooms on the 200 hall, and stated that glue traps and bait boxes were used as control measures. However, bait boxes were not placed in areas with only grass, potentially contributing to the issue. A resident reported mice entering their room from the air conditioning unit, highlighting the ongoing problem despite temporary measures like glue boards.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as observed by surveyors. Staff did not label, date, or seal opened food items, and food was not stored according to manufacturer's instructions. Expired or deteriorated food items were not discarded, and ice machines were not properly cleaned or maintained. Additionally, food and beverage containers and utensils were not handled or stored in a sanitary manner, and trash cans were left uncovered when not in use. In the kitchen and serveries, staff did not follow proper hygienic practices, such as using hair restraints, practicing hand hygiene, and avoiding bare hand contact with ready-to-eat food. Staff also failed to monitor dishwashing machines for appropriate parameters, leading to concerns about the cleanliness and sanitation of dishes. Observations revealed that food items were stored in areas with resident medications, and food was found on the floor in various locations. The facility's policies on food handling, ice machine maintenance, and dishwashing were not adhered to, resulting in unsanitary conditions. Staff were observed consuming personal food and drink items in food preparation areas, and there was a lack of proper handwashing and glove usage. The dietary manager acknowledged these issues and expressed expectations for proper food storage, handling, and equipment cleanliness, but these standards were not met during the survey.
Inaccessible Call Lights Lead to Delayed Assistance
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for several residents by not ensuring that call lights were accessible at all times. This deficiency was observed in multiple instances where residents were unable to reach their call lights, leading to delays in receiving necessary assistance. For example, Resident #78, who had moderately impaired cognition and was dependent on staff for transfers and toileting, was found with the call light out of reach on several occasions. This resident experienced incontinence and skin irritation due to the inability to call for timely assistance. Resident #121, who was cognitively intact but required substantial assistance for toileting, reported waiting 40 minutes for help to use the bathroom, resulting in incontinence. The resident expressed distress over the situation, highlighting the emotional impact of the deficiency. Similarly, Resident #26, who was dependent on staff for toileting and transferring, was observed with the call light inaccessible, preventing the resident from requesting assistance when needed. Other residents, such as Resident #140 and Resident #43, also experienced similar issues with call light accessibility. These residents, who had varying degrees of cognitive impairment and physical dependency, were unable to reach their call lights, which hindered their ability to communicate their needs to the staff. The Director of Nursing and the administrator both acknowledged the expectation for call lights to be within reach for all residents, yet the observations indicated a systemic failure to meet this standard.
Deficiencies in Adherence to Physician Orders and Care Plans
Penalty
Summary
The facility failed to ensure that residents received care and services in accordance with professional standards of practice, as evidenced by the deficiencies found in the care of three residents. Resident #403, who had a physician's order for nectar thick liquids due to dysphagia following a stroke, was observed with thin liquids during a meal. Despite the resident's awareness and communication of their dietary needs, staff repeatedly provided incorrect liquid consistencies. Interviews with staff revealed a lack of adherence to the resident's dietary orders, with CNAs and nursing staff failing to ensure the provision of nectar thick liquids as prescribed. Resident #307, admitted to the rehab unit, had a care plan and physician's order for weekly weight monitoring due to potential nutritional deficits. However, the facility did not document the resident's weight weekly as required. The resident's weight was not recorded on the specified dates, indicating a failure to follow the care plan and physician's orders. Interviews with staff highlighted issues with the electronic health record system, where orders were entered incorrectly, preventing proper monitoring and documentation of the resident's weight. Similarly, Resident #309, also on the rehab unit, had a care plan and physician's order for weekly weight monitoring. The facility failed to document any weights after the resident's admission weight, missing the required weekly checks. Staff interviews revealed that the electronic charting system did not allow CNAs to verify if weights had been recorded on previous days, leading to a lack of accountability and oversight in weight monitoring. The Director of Nursing acknowledged the errors in order entry and the resulting failure to monitor residents' weights as expected.
Inadequate Assistance with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, including showers, nail care, shaving, oral care, incontinence care, and assistance at meal times. Observations and interviews revealed that residents were not receiving showers as scheduled, with some going up to 14 days without a documented shower. Residents were observed with long, dirty fingernails, greasy hair, and facial stubble, indicating a lack of personal hygiene care. Staff interviews confirmed that residents often refused care, but there was no documentation of refusals, and care was not consistently offered again. Incontinence care was also inadequately provided, as evidenced by a resident who waited over 30 minutes for assistance after reporting incontinence. When care was finally provided, the resident was found with a soaked brief and dried feces on the skin, leading to skin irritation and a skin tear. The Director of Nurses (DON) acknowledged that it was inappropriate for residents to wait for such extended periods for care. Additionally, meal assistance was lacking, with a resident observed struggling to eat independently due to difficulty opening packaging and using utensils, while staff did not offer assistance. Oral hygiene and denture care were neglected, as one resident reported not receiving help with dentures or oral care. Observations showed dentures left on the sink with dirty water in the denture cup. Staff interviews indicated that aides and nurses were responsible for assisting with oral care, but this was not consistently done. Overall, the facility's failure to provide necessary ADL care resulted in residents experiencing poor hygiene, discomfort, and potential health risks.
Improper Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for urinary catheters for three residents, leading to potential health risks. Resident #58, who had a history of UTIs and neuromuscular dysfunction of the bladder, was observed receiving improper catheter care. A CNA used soiled gloves to handle the resident's catheter drainage tube after picking up trash, violating infection control protocols. This improper handling could contribute to the resident's risk of recurrent UTIs, as noted in their care plan. Resident #20, who had an indwelling catheter and was on hospice care, was observed with a urinary drainage bag improperly positioned above the bladder level. This was done by a CNA, causing urine to back up in the catheter tubing, which could lead to infections. The resident's care plan emphasized the importance of keeping the catheter bag below the bladder level, which was not adhered to during the observation. Resident #11, who required substantial assistance and had a history of UTIs, was also subjected to improper catheter care. During a transfer, CNAs placed the urine collection bag above the bladder level, contrary to the care plan's instructions. The urine in the tubing was noted to be yellow with mucous and had a strong smell, indicating potential infection. Interviews with staff, including CNAs and the Director of Nursing, confirmed the expectation that catheter bags should be kept below the bladder level and off the floor, which was not consistently practiced.
Failure to Properly Administer Insulin Using Humalog Kwik Pen
Penalty
Summary
The facility failed to ensure that three residents receiving insulin injections were free from significant medication errors. The staff did not follow the manufacturer's instructions for administering insulin using the Humalog Kwik pen. Specifically, the staff failed to prime the insulin pen, which involves removing air from the needle and cartridge, before administering the medication. This step is crucial to ensure the correct dose is delivered. Additionally, the staff did not hold the needle against the resident's skin for the recommended time after administering the medication, which is necessary for proper absorption. Resident #51, diagnosed with type 2 diabetes mellitus, was observed receiving a Humalog insulin dose without the pen being primed. The LPN administered 36 units of insulin, combining a scheduled dose and a sliding scale dose, but did not hold the dose knob in for the required five seconds. Similarly, Resident #39, also with type 2 diabetes, received 16 units of insulin without the pen being primed, and the dose knob was not held in place for the recommended time. Resident #109, with a diagnosis of type 2 diabetes and hyperglycemia, was given 14 units of insulin without priming the pen, and the dose knob was not held in for the necessary duration. Interviews with the LPN and the Director of Nursing confirmed that the staff was aware of the need to prime the insulin pens and hold the needle in place for the recommended time. However, these steps were not followed during the administration of insulin to the residents. The facility's policy and the manufacturer's guidelines clearly outline these procedures, but they were not adhered to, leading to the medication errors observed.
Medication Security and Disposal Deficiencies
Penalty
Summary
The facility failed to adhere to proper disposal methods for controlled medications, leading to potential risks of diversion and accidental exposure. Observations revealed that controlled medications were stored in small sharps containers without being under double lock as required by the facility's policy. Interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that the process involved placing medications in sharps containers with water for dissolution, but these containers were not secured as per policy guidelines. Additionally, the facility did not ensure that medications were kept locked or secured when unattended. On multiple occasions, medication carts were left unlocked and unattended in hallways, with medications visibly accessible. For instance, a medication cart was observed unlocked and unattended near a resident's room, with several medication cards left on top. Staff members, including LPNs, acknowledged that the carts should have been locked and medications secured, but failed to do so. The report also highlighted specific incidents involving residents, such as a resident with severe cognitive impairment being left near unattended medications on a nurse's desk. Another incident involved a medication cart left unlocked in a hallway, with staff and visitors passing by, posing a risk of unauthorized access to medications. These observations and interviews indicate a systemic failure in maintaining medication security and adherence to established policies.
Failure to Serve Meals According to Dietary Needs
Penalty
Summary
The facility failed to ensure that meals were served according to the dietary needs of residents, as evidenced by the absence of specific food items and incorrect portion sizes during meal service. On the lunch meal of 5/8/24, staff did not prepare or serve fruit garnish, peach half, pureed tomato, or pureed peach as required by the diet spreadsheet menu. This affected residents on various diets, including regular, mechanical soft, and pureed diets. Dietary Aide H was unaware of these requirements and referred to an incorrect menu, while Dietary Aide I only served what was prepared by the kitchen. Additionally, the facility did not provide sugar-free chocolate pudding to residents on a no concentrated sweets (NCS) diet or low-sodium soup to those on a low sodium (LS) diet. Instead, regular chocolate pudding and minestrone soup were served, which did not meet the dietary restrictions of these residents. The facility's dietitian confirmed that the correct items were not delivered or served, and Dietary Aide H was unaware of the need for sugar-free pudding, which was not available in the facility. The facility also failed to adhere to portion size requirements as outlined in their policy. During the lunch meal, a 3-ounce scoop was used to serve chocolate pudding, despite the diet spreadsheet menu indicating a 4-ounce portion size. Dietary Aide H was unaware of the correct portion size and routinely used the smaller scoop. The dietary manager expected staff to follow the diet spreadsheet menu and serve correct portion sizes, but this was not done during the observed meal service.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to prepare and serve food at safe and appetizing temperatures, as well as to conserve the flavor of food items, affecting the quality of meals served to residents. The facility's policy on monitoring food temperatures was not adhered to, as evidenced by the lack of recorded temperatures for several food items during a lunch meal service. Observations showed that cold food items, such as pureed broccoli salad and turkey on hoagie roll, were served at temperatures significantly above the required 41 degrees Fahrenheit, making them warm to taste. Additionally, mayonnaise was not kept on ice, resulting in a temperature of 78.3 degrees Fahrenheit. Interviews with dietary staff revealed a lack of adherence to expected food temperature standards. Dietary Aide I stated that hot foods should be served close to 160 to 170 degrees Fahrenheit, while cold foods should be at or below 40 degrees Fahrenheit. However, the dietary manager indicated that hot foods should be held at 140 degrees Fahrenheit and served at 130 degrees Fahrenheit, with cold foods held and served at or below 40 degrees Fahrenheit. Despite these expectations, the temperature logs were incomplete, and the dietary manager had not conducted a test tray to evaluate food taste or temperature since starting at the facility eight weeks prior. The preparation of meals also deviated from established recipes, impacting the flavor of the food. For instance, the mechanical soft ground Italian meat and cheese on hoagie sandwich was prepared with mayonnaise instead of broth, resulting in an overwhelming mayonnaise taste. The dietary aide responsible for this preparation did not refer to the recipe and assumed mayonnaise was appropriate for moistening the meat. The dietary manager confirmed that recipes should be followed and available to staff, yet this was not the case, contributing to the deficiency in meal preparation and service.
Failure to Provide Proper Texture-Modified Diets
Penalty
Summary
The facility failed to ensure that residents with a physician's order for a mechanical soft diet received food items with the proper texture, which is crucial for safe consumption. The facility's policy requires that diet orders be reviewed upon admission and that a speech therapist evaluates residents on texture-modified diets. However, during the lunch meal service, residents on a mechanical soft diet were served broccoli salad with hard edges and large chunks, making it difficult to chew and swallow. Additionally, the alternate food items, such as French fries and cheeseburgers, had hard edges and were tough to chew, which did not conform to the mechanical soft diet requirements. Further observations revealed that residents were served fried fish with a crust that was too crispy and difficult to cut, especially for those with limited chewing ability. One resident, who had no teeth, struggled to chew the fish despite assistance from a Restorative Aide. The dietary manager acknowledged that food should be prepared at the correct texture and should not be tough or difficult to chew, indicating a lapse in adherence to the facility's dietary policies and procedures.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control procedures, affecting 12 residents out of a sample of 35. Staff did not consistently use appropriate hand hygiene, gloving techniques, or personal protective equipment (PPE) during resident care. Enhanced Barrier Precautions (EBP) were not properly implemented for residents with multi-drug resistant organisms (MDROs) or indwelling medical devices. Observations revealed that staff often neglected to wash hands before and after care, failed to change gloves between tasks, and did not wear gowns when required. Specific incidents included staff entering rooms without washing hands or donning PPE, handling resident items with soiled gloves, and failing to change gloves between dirty and clean tasks. For instance, a CNA entered a resident's room without washing hands or wearing a gown, handled a catheter bag, and touched the resident's belongings without proper hand hygiene. Another incident involved a nurse applying a new dressing to a resident's wound without changing gloves after cleaning the wound, and placing dressing supplies on an unclean surface. Additionally, the facility did not ensure proper storage of respiratory care supplies, such as CPAP and nebulizer masks, which were observed lying unbagged on bedside tables. This lack of adherence to infection control policies was compounded by staff's lack of awareness regarding the purpose and implementation of EBP, as well as inadequate supplies like hand sanitizer. These deficiencies highlight significant lapses in infection control practices, potentially increasing the risk of infection transmission among residents.
Failure to Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to provide pneumococcal vaccinations to three residents as per the CDC guidelines. Resident #26, who was over the age of 65 and had a diagnosis of COVID-19, was not offered the pneumococcal vaccine upon admission or during their stay. Despite having signed a consent form indicating a desire to receive the PPSV23 vaccine, there was no documentation in the resident's electronic health record (EHR) showing that the vaccine was offered, administered, or refused. During an interview, the resident expressed a belief that their vaccines were up to date, although they could not recall receiving any pneumonia vaccination at the facility. Resident #94, who had chronic respiratory failure and was over the age of 65, had previously received the PPSV23 vaccine but was not offered the PCV15 or PCV20 vaccines as recommended by the CDC. The resident's quarterly Minimum Data Set (MDS) inaccurately indicated that their pneumococcal vaccine was up to date. The resident's responsible party confirmed that the PCV20 vaccine had never been offered, despite their willingness for the resident to receive it. Resident #403, who was under the age of 65 and had diagnoses of diabetes and stroke, had received the PPSV23 vaccine outside the facility but was not offered the PCV15 or PCV20 vaccines upon admission. The resident's admission MDS showed that the pneumococcal vaccine was not offered, and there was no documentation in the medical record indicating that the vaccines were offered, administered, or refused. The Director of Nursing (DON) and the Administrator both stated expectations that residents should be offered and administered vaccines according to CDC guidelines, yet these expectations were not met in these cases.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by incidents involving two residents. Resident #403, who is cognitively intact and has a history of stroke and diabetes, reported being treated harshly by an aide. The resident described an incident where they were incontinent and the aide, who was on a lunch break, yelled at them, ripped their brief and blanket off without explanation, and was generally mean and hateful. This incident was corroborated by the resident's family member, who received a distressed call from the resident about the treatment they received. Resident #80, who has moderately impaired cognition due to Alzheimer's and osteoporosis, was observed being transferred to bed by two staff members. During this process, the resident cried out, and one of the nurse aides referred to the resident as a 'cry baby' within earshot of the resident and a state surveyor. This behavior was acknowledged as inappropriate by both the nurse aide involved and the Director of Nursing, who stated that staff should not refer to residents in such a manner and should treat them with dignity and respect.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure the safety of Resident #72, who had a known history of ingesting non-food items such as Styrofoam. Despite this, the resident was served food and drinks in Styrofoam containers on multiple occasions. Observations showed that the resident bit into a Styrofoam cup, and staff had difficulty retrieving the material from the resident's mouth. The resident's care plan explicitly stated that they should not be served meals or drinks in Styrofoam, yet this directive was not followed, leading to the ingestion incident. Additionally, the facility did not provide adequate supervision and proper transfer techniques for Resident #306, who had a history of stroke with hemiplegia. The resident's care plan lacked specific instructions on transfer methods, and staff were observed using improper techniques by placing their hands under the resident's arms instead of using the gait belt correctly. Interviews with staff revealed a lack of awareness and understanding of the proper procedures for transferring the resident, which could have compromised the resident's safety. The facility's policies on gait belt use and dining services were not adhered to, contributing to the deficiencies observed. Staff interviews indicated a lack of communication and understanding of the residents' care plans and dietary restrictions. The facility's dishwasher was out of service, leading to the use of Styrofoam, but alternative measures were not effectively implemented to ensure resident safety. The failure to follow established care plans and policies resulted in unsafe conditions for the residents involved.
Failure to Provide Proper Nutrition and Monitor Weight Loss
Penalty
Summary
The facility staff failed to provide food in the form ordered by the physician and did not adequately monitor the weights or notify the physician of the refusal of nutritional supplements for two residents experiencing significant weight loss. Resident #59, who was cognitively intact and on a mechanically altered diet, experienced a significant weight loss over several months. Despite orders for a mechanical soft diet and nutritional supplements, the resident frequently refused supplements, and staff failed to document weights or notify the physician of these refusals. Observations showed that the resident was served food inconsistent with the mechanical soft diet order, such as whole sandwiches and uncut vegetables, which the resident could not chew. Resident #305, admitted with dementia and other diagnoses, also experienced significant weight loss. The resident's intake was poor, and staff failed to obtain weekly weights as ordered. The resident often left meals uneaten, and staff did not monitor or document meal intakes adequately. Despite recommendations from the Registered Dietician for nutritional supplements, the resident did not receive them consistently, and there was no documentation of physician notification regarding the resident's refusal to eat or take supplements. Interviews with staff revealed a lack of awareness and communication regarding diet orders and resident refusals. Dietary aides and nurse aides in training were not consistently aware of the specific diet orders for residents, leading to inappropriate meal service. Additionally, there was a lack of documentation and communication between staff members regarding residents' refusals to eat or take supplements, contributing to the failure to address the significant weight loss in these residents.
Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain essential equipment in good repair and safe operating condition, posing potential hazards to staff, residents, and visitors. During an observation in the kitchen, a food processor was found with a frayed power cord, missing part of its protective coating. This issue was not reported to the maintenance department, as expected by the director of environmental services and the dietary manager, who were both unaware of the problem. The dietary manager expected staff to inform her of such issues so she could submit a work order for repairs. Additionally, a refrigerator compartment in the 700 servery was found to be non-functional, with a temperature reading of 105 degrees Fahrenheit. The compartment was warm, with no food items inside, and lacked signage to indicate it was not operational. The dietary aide confirmed the refrigerator had not worked for some time, and the director of environmental services decided against repairing it due to unavailable parts. The dietary manager was aware of the issue and planned to have the compartment screwed shut, but the administrator was unaware of both the refrigerator and food processor issues, expecting staff to report such deficiencies for appropriate action.
Failure to Provide Written Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to two residents and/or their representatives when they were transferred to the hospital. This deficiency was identified during a review of 35 sampled residents, with the facility's census being 149. The facility's undated Bed Hold Policy requires that residents and/or their representatives be notified in writing of the bed hold policy at the time of admission, upon any changes, and when transferred to a hospital or during therapeutic leave. For Resident #5, who has a diagnosis of Alzheimer's disease, the facility did not provide written notice of the bed hold policy when the resident was transferred to the hospital for a behavioral evaluation. The resident's family was informed of the transfer, but there was no documentation in the medical record indicating that the bed hold policy was provided in writing. Similarly, Resident #81, also diagnosed with Alzheimer's disease, was transferred to the hospital due to a change in condition, including vomiting and a high pulse rate. Although the transfer packet was sent with the resident, there was no documentation that the bed hold policy was provided in writing to the resident or their representative. Interviews with staff, including LPNs and the staffing coordinator, revealed inconsistencies in the process of providing and documenting the bed hold policy. The staffing coordinator is responsible for mailing the bed hold policy to the responsible party within 24 hours of transfer and maintaining a log of these actions. However, the log showed no documentation that the bed hold policy was sent to the representatives of Residents #5 and #81. The facility administrator acknowledged that the business office might have mailed the information but failed to document it properly.
Failure to Follow Skin Assessment and Pressure Ulcer Protocols
Penalty
Summary
The facility failed to consistently follow their policy to complete skin assessments to identify areas of concern and ensure timely implementation of interventions and treatment for one resident. The resident, who had diagnoses including sepsis, diabetes with chronic diabetic kidney disease, and heart failure, was at risk for skin breakdown due to limited mobility. Despite this, there were multiple instances where skin assessments were not documented, and no interventions were put in place to address potential pressure ulcers (PU/PI) in a timely manner. Upon the resident's readmission, there was no documentation of a skin assessment, and subsequent assessments were either missing or incomplete. The resident's Treatment Administration Record (TAR) showed gaps in documentation, and there was no record of a skin assessment being completed on several occasions. Additionally, the resident's family reported that the resident had been complaining about heel pain for several weeks before any treatment was initiated, and a large fluid-filled blister on the right heel was not addressed until it had already opened and worsened. Interviews with facility staff, including the Assistant Director of Nursing/Wound Nurse and the Director of Nursing, revealed that the expected protocols for skin assessments and documentation were not followed. The staff failed to conduct thorough skin assessments as scheduled and did not document or report the resident's skin issues adequately. This lack of adherence to the facility's policies and procedures resulted in delayed treatment and inadequate care for the resident's pressure ulcers.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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