Delmar Gardens On The Green
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterfield, Missouri.
- Location
- 15197 Clayton Road, Chesterfield, Missouri 63017
- CMS Provider Number
- 265156
- Inspections on file
- 25
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Delmar Gardens On The Green during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a history of falls was found with several unexplained injuries, including bruises and abrasions. The facility did not conduct a thorough investigation as required by policy, failed to obtain staff statements, and did not ensure agency staff were in-serviced or interviewed regarding the incident. Documentation was incomplete, and the source of the injuries was not clearly established.
A resident with multiple diagnoses, including muscular dystrophy, did not receive a new treatment order for a wound due to staff failing to transcribe it onto the eTAR. This resulted in the wound showing signs of infection. The facility's policy required immediate entry of physician orders into the EHR, but the order for gentamicin was not documented. Interviews revealed a lack of communication and documentation, leading to the resident's condition deteriorating and requiring hospital treatment.
The facility failed to maintain resident dignity and privacy by leaving residents exposed, inadequately dressed, and with visible catheter bags. Staff entered rooms without knocking, disregarding residents' preferences and privacy. The administration acknowledged these lapses in maintaining dignity.
The facility failed to issue required transfer notices to residents during hospital transfers, affecting seven residents with various medical conditions, including cognitive impairments and chronic illnesses. Despite multiple transfers and returns, the facility did not adhere to its policy of providing due notice, as confirmed by the Administrator.
The facility failed to provide written notice of the bed hold policy to residents or their representatives during hospital transfers. Seven residents with various medical conditions, including cognitive impairments and heart failure, were affected. Interviews revealed that the policy was not issued upon discharge, indicating a systemic issue.
The facility failed to accurately reconcile controlled drugs, specifically tramadol, due to discrepancies in the electronic narcotic count. The electronic system showed 120 tablets, while the cart had 114 tablets. Despite being reported to the DON, the issue persisted for days, highlighting a failure in the facility's medication administration policy.
A long-term care facility was found to have a medication error rate of 16.67%, exceeding the acceptable limit of 5%. Errors included improper insulin administration without priming the pen and failure to follow physician orders for mouth rinsing after using Advair Diskus. These deficiencies were observed in multiple residents, with staff failing to adhere to established protocols.
The facility failed to properly label and store medications, with expired and undated medications found in a medication room and cart. Personal items were improperly stored in the medication area. Staff interviews revealed a lack of awareness and adherence to policies regarding medication management.
The facility failed to ensure cleanliness and proper food storage in the kitchen, affecting all residents. Observations showed dirty floors, cluttered preparation areas, and appliances with rust and grease. Outdated food items were found in storage, and interviews revealed a lack of adherence to cleaning protocols due to short staffing.
The facility failed to follow infection control standards, with staff neglecting hand hygiene between glove changes and not using PPE for residents requiring Enhanced Barrier Precautions. Instances included improper hand hygiene by an RN and LPN during insulin administration and blood sugar tests, a catheter bag left on the floor, and inadequate PPE use for a resident with an MDRO and indwelling catheter.
The facility did not complete TPL forms within 30 days for deceased residents, resulting in delayed final accounting for three residents with remaining funds. The BOM recognized the lapse in timely submission upon reviewing records, noting that funds were not managed within the required timeframe.
A resident with severe cognitive impairment and mobility limitations fell and was injured during a transfer on a shower bed. The CNA used an incorrect sling and was alone, contrary to policy requiring two staff members. The resident attempted to hold onto the wall and fell, resulting in a laceration and other injuries.
Failure to Investigate Unexplained Resident Injuries
Penalty
Summary
The facility failed to conduct a thorough investigation after a nurse discovered a resident with multiple unexplained injuries, including a bruise on the chest, an abrasion above the right eye, a skin tear on the nose, and an abrasion on the right elbow. The resident, who was cognitively intact but had some confusion at the time, could not recall how the injuries occurred. The facility's policies required a complete investigation, including staff statements, body assessment, and timely notifications, when injuries of unknown source were identified. However, documentation and interviews revealed that the source of the injuries was not clearly established, and the required investigative steps were not fully completed. The resident had significant medical history, including congestive heart failure, peripheral vascular disease, end stage renal disease, diabetes, and an above-knee amputation. The resident required substantial assistance with mobility and transfers and had a history of falls. Progress notes indicated that the resident reported rolling out of bed, but staff were unsure who assisted the resident back to bed, and there was a lack of documentation regarding the incident. The Director of Nursing (DON) and Administrator acknowledged that the investigation was incomplete, and staff statements were not obtained as required by policy. On the night of the incident, the facility was staffed primarily by agency nurses and facility CNAs. Interviews with agency staff indicated inconsistent familiarity with facility policies and procedures, and the DON confirmed that agency staff were not in-serviced regarding the incident. The facility did not complete a full investigation into the injuries, did not ensure all staff were interviewed, and did not provide in-service training to agency staff involved, as required by their own policies for injuries of unknown origin.
Failure to Transcribe Treatment Order Leads to Wound Infection
Penalty
Summary
The facility failed to ensure professional standards of practice were met when staff did not transcribe a new treatment order for a resident onto the electronic treatment administration record (eTAR). This oversight resulted in the resident not receiving the prescribed treatment from July 24 to August 2, as ordered by the physician. The resident, who was cognitively intact and had diagnoses including anemia, high blood pressure, diabetes, and muscular dystrophy, had an alteration in skin integrity requiring wound monitoring. The care plan aimed to prevent the wound from increasing in size or showing signs of infection, but the failure to administer the treatment led to the wound showing signs of infection. The facility's policy required that all physician orders be immediately entered into the electronic health record (EHR) by the nurse obtaining the order. However, the order for gentamicin was not entered into the eTAR, and there was no documentation of the treatment being completed or any refusal by the resident. The wound management team noted the presence of multiple wounds, including a pressure ulcer on the scrotum, which was initially unstageable and later showed deterioration with 100% necrotic tissue. Despite the wound management team's recommendations and the nurse practitioner's likely verbal order for gentamicin, the treatment was not consistently documented or administered. Interviews with facility staff, including the wound nurse, nurse manager, and nurse practitioner, revealed a lack of communication and documentation regarding the new treatment orders. The nurse manager expected orders to be documented on the physician order sheet and the eTAR, but this was not done for the gentamicin order. The administrator also expected staff to follow physician orders and complete weekly skin audits, which were not consistently performed. The resident's condition deteriorated, leading to a recommendation for hospital treatment due to the wound's deterioration and signs of infection.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of several residents by leaving them exposed or inadequately dressed, and by not ensuring privacy during care. One resident was left undressed with only a towel covering their genitals, visible from the hallway, despite their preference for a closed door. Another resident was observed in the dining room wearing a hospital gown that exposed their back, contrary to their preference for wearing a shirt during meals. Staff acknowledged that residents should be dressed appropriately and not removed from meals to change clothing, as this could disrupt their eating. Additionally, the facility did not ensure that catheter bags were covered, compromising the dignity of residents with indwelling catheters. Two residents had their catheter bags visible from the hallway, which was against the facility's policy to store collection bags inside a protective dignity pouch. Staff interviews confirmed that catheter bags should be covered to maintain residents' dignity. Furthermore, staff entered residents' rooms without knocking, failing to respect their privacy. One resident reported that a CNA entered their room without knocking, turned off the call light without speaking, and left without addressing their needs. Another resident corroborated this behavior, noting that the CNA often entered without announcing themselves and sometimes slammed the door. The facility's administration acknowledged that staff should knock before entering a resident's room to uphold their dignity and privacy.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide required transfer notices to residents when they were transferred to the hospital. This deficiency was identified for seven residents who were investigated for hospital transfers. The facility's Residents' Rights Policy mandates that residents receive due notice of the reasons for transfer or discharge, but this was not adhered to in the cases reviewed. The residents involved had various medical conditions, including cognitive impairments, heart failure, high blood pressure, and other chronic illnesses, which necessitated multiple hospital transfers. For each of the seven residents, there was no documentation of transfer notices being issued when they were sent to the hospital. The residents experienced multiple transfers and returns between the facility and the hospital, yet the facility did not provide the necessary notifications as required by their policy. This oversight was confirmed during an interview with the Administrator, who acknowledged that no notices of transfer had been issued to residents upon their discharges to the hospital.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their legal representatives at the time of transfer to the hospital. This deficiency was identified for seven residents who were transferred to the hospital. The facility's bed hold policy requires that residents or their representatives be notified in writing at the time of admission, upon discharge, or when transferred to a hospital or during therapeutic leave. However, there was no documentation that this policy was followed for any of the seven residents investigated. The residents involved had various medical conditions, including cognitive impairments, heart failure, high blood pressure, and other serious health issues. For instance, one resident with both long-term and short-term memory loss was transferred to the hospital multiple times without receiving the required written notice. Another resident with severe cognitive impairment and multiple hospital transfers also did not receive the necessary documentation. These omissions were consistent across all seven residents reviewed, indicating a systemic issue in the facility's adherence to its bed hold policy. Interviews with facility staff, including a registered nurse and the administrator, revealed that the bed hold policy was not being issued to residents upon discharge to the hospital. The administrator acknowledged the oversight and mentioned that the issue had been identified in Quality Assurance. Despite this acknowledgment, the deficiency persisted, affecting the residents' rights to be informed about their bed hold status during hospital transfers.
Failure in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs, leading to inaccurate reconciliation. Specifically, the facility did not ensure accuracy and monitoring for controlled substances, as evidenced by a discrepancy in the electronic narcotic count for tramadol. The electronic system showed 120 tablets, while the physical count in the cart was 114 tablets. This discrepancy was noted by a Certified Medication Technician, who reported it to the Director of Nursing, but the issue persisted for several days. Interviews with staff, including a Licensed Practical Nurse and the interim Director of Nursing, confirmed that narcotics should be counted at the beginning and end of each shift, and any discrepancies should be reported and corrected immediately. However, the count remained incorrect for several days, indicating a failure in the facility's medication administration policy and procedures.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 16.67% error rate during the survey. This deficiency was identified through observations, interviews, and record reviews involving four residents. The errors primarily involved the improper administration of insulin using pen devices and the failure to follow physician orders for medication administration. Specifically, insulin pens were not primed before administration, which is a necessary step to ensure the correct dosage is delivered. Resident #50, diagnosed with diabetes and other conditions, had a blood sugar level of 179, but the insulin pen was not primed before administering 17 units of insulin. Similarly, Resident #19, with a blood sugar level of 307, received 18 units of insulin without the pen being primed. In both cases, the registered nurse involved believed that priming was unnecessary, which contradicted the facility's policy and the manufacturer's instructions. Additionally, Resident #74, who was prescribed Advair Diskus for COPD, was not provided with water to rinse their mouth after inhalation, as required to prevent fungal infections. This oversight was observed during medication administration, and the staff involved did not adhere to the physician's orders. Resident #26 also received insulin without the pen being primed, further contributing to the facility's high medication error rate. Interviews with staff, including the interim Director of Nursing, confirmed the necessity of priming insulin pens to ensure accurate dosing.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the 300 Division medication room, expired medications were found, including two bottles of True Metrix Control Solution and an opened bottle of Levetiracetam without a date. Additionally, a bottle of Robitussin had its expiration date blacked out and was not dated when opened. Personal items such as food and drinks were improperly stored in the medication cabinet. Interviews with staff revealed that it was the nurses' responsibility to remove expired medications, and personal items should not be stored in medication rooms. In another instance, a medication cart in the Division 100 was found with an opened bottle of Geri Tussin that had dry residue under the cap and was not dated when opened. The Certified Medication Technician (CMT) was unaware of the requirement to date items when opened, despite the pharmacy's weekly checks. Interviews with the LPN and interim DON confirmed that medications should be dated when opened, expired medications should be removed, and personal items should not be stored in medication areas. The facility's policies on drug storage and pharmacy responsibilities were not adhered to, leading to these deficiencies.
Facility Fails to Maintain Kitchen Cleanliness and Proper Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in the main kitchen, affecting all residents who consumed meals prepared there. Observations revealed that the kitchen floors were consistently dirty, with white specs, dust, grease, and water stains present. The preparation area was cluttered with dirty dish rags, and containers of spices and sauces were found with debris and spillage. Appliances such as the stove, oven, fryer, and tilt skillet were covered in rust, dirt, and grease. The dry storage area was littered with balled-up napkins and outdated food items, including five boxes of cake mix past their use-by date. Additionally, the walk-in freezer contained a bag of chicken and a smoked cigar on the floor, further indicating a lack of proper sanitation practices. Interviews with dietary staff and management highlighted a disconnect between expected and actual cleaning practices. A dietary aide admitted that the kitchen was not clean, with significant build-up on appliances that were supposedly deep cleaned a month prior. The dietary manager acknowledged that while cleaning was expected after each meal service, the kitchen was short-staffed, prioritizing timely meal delivery over cleanliness. The administrator also expressed an expectation for a clean kitchen and the disposal of expired foods, yet these standards were not met, leading to the observed deficiencies.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection control standards, as evidenced by multiple instances of staff neglecting to perform hand hygiene between glove changes and between resident interactions. Specifically, Registered Nurse (RN) A and Licensed Practical Nurse (LPN) E were observed not washing their hands between glove changes while administering insulin and performing blood sugar tests for several residents. This failure to follow hand hygiene protocols was noted during interactions with residents who had various medical conditions, including diabetes, heart failure, and kidney disease. Additionally, the facility did not maintain proper catheter care for a resident, as the catheter bag was observed lying on the floor without a protective barrier. This was contrary to the facility's catheter care policy, which requires catheter bags to be off the floor to prevent infection. Interviews with staff confirmed that catheter bags should not be placed on the floor, highlighting a lapse in adherence to infection control procedures. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a multidrug-resistant organism (MDRO) and an indwelling catheter. Staff were observed not wearing the appropriate personal protective equipment (PPE), such as gowns, during high-contact activities with the resident. Despite the presence of PPE and signage indicating the need for EBP, staff failed to comply with these requirements, as confirmed by interviews with the nursing staff and the Nurse Manager.
Delayed TPL Form Submission 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 sampled residents. These residents had money remaining in their accounts for longer than the stipulated 30 days. Specifically, Resident #301 had an ending balance of $150.13, Resident #302 had $50.00, and Resident #300 had $0.13. The Business Office Manager (BOM) acknowledged that the facility was required to send the TPL forms within 30 days and noted that upon starting her role in April, she observed that some records were not concurrent, with funds lapsing beyond the acceptable timeframe.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to ensure the safe positioning of a resident during a transfer on a shower bed, resulting in a fall and injury. The incident involved a resident with severe cognitive impairment, functional limitations in the lower extremities, and a history of falls. The resident was dependent on staff for transfers and activities of daily living due to an acquired absence of the right leg above the knee and other health conditions. During the incident, the resident was being assisted by a CNA who used a regular lift sling instead of the appropriate shower sling, and the resident fell while being turned on the shower bed. The CNA attempted to turn the resident onto their left side after providing a shower, during which the resident tried to hold onto the wall but fell off the shower bed. The fall resulted in a laceration on the resident's left eyebrow, requiring 14 stitches, and additional bruising and skin tears. The CNA was alone in the shower room at the time of the incident, contrary to the facility's policy that required two staff members to be present during such transfers. The resident was found face down on the floor with significant bleeding and was subsequently sent to the hospital for evaluation and treatment. Interviews with staff revealed that the CNA did not follow the correct procedure by using the wrong sling and not having a second staff member present. The Nurse Manager confirmed that two staff members should be present when a resident is on a shower bed, and it was inappropriate for the resident to be asked to hold onto the wall. The Administrator acknowledged that the procedure was not followed, leading to the resident's fall and injury.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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