Ellisville Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellisville, Missouri.
- Location
- 322 Old State Road, Ellisville, Missouri 63021
- CMS Provider Number
- 265766
- Inspections on file
- 30
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Ellisville Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to administer and document ordered medications according to physician orders and professional standards when, on a single morning and afternoon, multiple residents with complex conditions such as CHF, AFib on anticoagulants, COPD, Parkinson’s disease, dementia, seizures, diabetes, depression, and chronic pain did not receive numerous scheduled medications, including anticoagulants, antihypertensives, diuretics, psychotropics, seizure medications, Parkinson’s medications, supplements, inhalers, pain medications, and nutritional supplements. MARs for these residents were left blank with no documented reasons in the MAR or progress notes, while some residents reported that their medications were often late or not given in the morning. Staffing records and interviews showed that a scheduled CMT did not work, another CMT refused to cover the additional hall, and the assigned nurse was expected but failed to ensure all medications were passed and properly documented. In addition, a resident with severe, constant pain did not receive a prescribed hydrocodone-acetaminophen regimen for multiple scheduled doses over two days because the medication was not available, indicating the facility did not reorder the opioid in time to prevent an interruption in pain management.
Staff failed to protect resident privacy and confidentiality when a CNA provided peri-care to a severely cognitively impaired resident while on a multi-person video call, exposing the resident’s genitals and buttocks on camera, including to children present with another CNA at home, and engaging in inappropriate behavior while the resident was on the edge of the bed. In a separate incident, a CNA took a photo of another cognitively impaired resident sleeping in a recliner and shared it in a group chat that included staff and non-staff members, contrary to facility policy prohibiting personal cell phone use and resident photography on nursing units.
A resident with a history of verbal and physical aggression struck another resident in the face, causing scratches and pain. Staff responded after hearing yelling and separated the residents, but the incident resulted in injury and distress. The aggressor had a care plan for behavioral issues, but the measures in place did not prevent the physical altercation, constituting a failure to protect residents from abuse.
Staff failed to follow the care plan and facility policy when a resident with severe cognitive impairment and behavioral symptoms was physically restrained during personal care after refusing and becoming combative. The resident was held down by staff to complete peri care, resulting in a skin tear, bruising, and scratches. The care plan directed staff to allow the resident to calm down and self-soothe, but this was not followed, leading to unnecessary restraint and injury.
The facility did not have a full-time, on-site Administrator as required, with the interim Administrator splitting her time between three facilities and being physically present only two to three days per week. Multiple staff confirmed the lack of consistent administrative leadership, which contributed to ongoing survey citations and complaints. The absence of a full-time Administrator led to challenges in oversight and compliance, affecting the facility's ability to use its resources effectively.
A resident with a full code status experienced a rapid decline and cardiac arrest, but the RN on duty did not follow established emergency protocols. The RN failed to call for additional staff assistance, did not use the AED or provide rescue breaths, and stopped CPR before EMS arrived, despite being trained and certified in BLS. This deficiency had the potential to impact other residents requiring CPR.
A resident with multiple medical conditions and on anticoagulant therapy alleged that a CNA provided rough care, resulting in a hematoma. The facility's investigation was incomplete, as it did not include interviews with all relevant staff or residents, nor did it notify the resident's physician as required by policy. Later interviews revealed similar complaints from other residents about the CNA's care.
A resident with impaired cognition and incontinence alleged that a CNA was rough during personal care, resulting in a hematoma. The facility investigated but did not notify the State Survey Agency within the required timeframe, as the administrator did not believe the injury was caused by abuse. The medical director was also not informed of the allegation, despite assessing the injury. This failure to report the allegation and investigation results constitutes a deficiency in required abuse reporting.
A resident with multiple comorbidities experienced a significant decline, including unresponsiveness and inability to eat, but staff failed to conduct a thorough assessment, document vital signs, provide ordered wound care, or notify a nurse or physician. The resident remained in this state for hours before EMS was called, and was later diagnosed with pneumonia, respiratory failure, and sepsis at the hospital. Staff interviews confirmed a lack of communication, documentation, and adherence to facility protocols.
A resident with severe cognitive impairment and a history of substance abuse left the facility without staff knowledge, and staff failed to follow the facility's elopement policy, including immediate reporting, search procedures, and notification of administration or law enforcement. The resident's care plan did not address elopement or substance abuse risks, and documentation and communication among staff were incomplete, resulting in inadequate supervision and monitoring.
A resident with multiple health issues experienced a significant change in condition, including head and chest pain, nausea, and other symptoms. Despite these signs, the facility staff failed to conduct a thorough assessment, document the changes, or notify the resident's physician. The resident was found unresponsive and later died after resuscitation efforts. Interviews revealed a lack of communication and documentation among staff, contributing to the deficiency.
A resident experienced an unwitnessed fall, and the facility failed to document the necessary assessments and monitoring as per its Fall Protocols Policy. The resident, who was at risk for falls due to cognitive impairment and other conditions, did not have the required neurological checks documented. Interviews with staff confirmed the lapse in documentation and monitoring, and the resident's care plan was not updated to reflect the fall.
The facility failed to properly manage and document resident personal funds, affecting all residents whose funds were handled by the facility. There was a lack of reconciliation of the resident trust fund account and failure to distribute quarterly statements. The Business Office Manager did not have access to previous records and had not reconciled the trust or sent statements since starting. The Administrator expected monthly reconciliations and detailed accounting, but these were not met.
The facility failed to serve food at safe and appetizing temperatures, affecting all residents. Observations showed food temperatures below the required standards, leading to resident complaints. Meals were delivered in nonheated carriers, and staff interviews confirmed ongoing issues with cold food. The Dietary Manager acknowledged the problem, but it persisted.
The facility failed to supervise and assess residents for medication administration and self-administration, leading to unauthorized medications at bedside. Residents were found with medications without proper assessment or physician orders, and staff interviews revealed inconsistencies in policy understanding. The DON and Administrator confirmed no residents were authorized for self-administration, yet observations indicated otherwise.
A resident's request to change a CNA due to unprofessional behavior was ignored, compromising their dignity. Additionally, staff were observed using personal cell phones in resident care areas, against facility policy. The facility's Administrator acknowledged these issues, but the deficiencies persisted.
A resident with type 2 diabetes was switched from a Medicare Advantage plan to a classic plan by the facility without prior notification to the resident or their family. This led to confusion over medication coverage, as the resident's Trulicity was initially reported as not covered. The Business Office Manager admitted to the error, assuming communication had been made. The Administrator acknowledged the oversight, noting that residents should be informed of such changes.
The facility failed to notify the TPL within 30 days for two deceased residents, resulting in a deficiency. One resident had a trust account balance of $5,693.01 and the other $1,077.66 at the time of their deaths. The BOM was preparing TPL letters, but the process was delayed, and the Administrator expected timely final accounting. This inaction led to the deficiency.
A resident receiving hospice care was transferred to the hospital after a fall without notifying hospice services or the family beforehand. The resident, with severe cognitive impairment and dependent on staff, was found with coffee ground emesis and a back fracture. The LPN on duty did not follow the protocol to contact hospice before calling 911, and the family was informed only after the transfer. The facility's Director of Nursing confirmed the lapse in following the notification protocol.
The facility failed to provide complete and individualized care plans for two residents, one at risk of elopement and another who experienced a fall. The care plans did not accurately reflect these risks, despite staff acknowledging the importance of including such information.
The facility failed to implement Enhanced Barrier Precautions for a resident with a Stage four pressure ulcer, as staff did not wear gowns during wound care and transfers. Additionally, an RN prepared medications without hand hygiene and handled them with bare hands. A resident's catheter bag was also observed lying on the floor, contrary to infection control practices. Staff interviews confirmed these deficiencies.
A resident, who was cognitively intact and had multiple medical conditions, was subjected to verbal abuse when a CNA used profanity towards them during an interaction witnessed by the Ombudsman. Despite the incident, the CNA continued to work in the facility and was assigned to the same resident, with no documented reassignment or intervention to prevent further contact.
Failure to Administer and Document Ordered Medications and Timely Refill Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered and documented according to physician orders and professional standards of practice for multiple residents on a specific morning and afternoon. Facility policies required that medications be administered by licensed nurses or authorized staff, following the six rights of medication administration, within one hour before or after the scheduled time, and that any omitted doses be documented in the MAR and progress notes. Policies also required that drugs and biologicals be reordered in a timely manner so refills were available before the last dose was given. On the identified date, numerous scheduled medications for several residents were not administered and the MARs were left blank, with no documentation explaining the omissions. For one cognitively intact resident with a history of stroke, diabetes, CHF, depression, psychotic disorder, and other chronic conditions, multiple daily medications including vitamins, antiplatelet therapy, diuretics, antihypertensives, antidepressants, and pain medications were not given in the morning or midday, and there was no documentation as to why. Similar omissions occurred for other cognitively intact residents with complex medical histories, including those with CHF, AFib on anticoagulants, COPD, dementia, fractures, hypothyroidism, depression, anxiety, Parkinson’s disease, and chronic pain. Their MARs showed that a wide range of medications—such as anticoagulants (Eliquis, apixaban), antihypertensives (lisinopril, losartan, metoprolol, diltiazem, amlodipine), diuretics (furosemide, spironolactone, Lasix), psychotropics (venlafaxine, sertraline, duloxetine, escitalopram), Parkinson’s medications (amantadine), seizure medications (lacosamide, levetiracetam), supplements, inhalers, pain medications, and nutritional supplements—were not administered on the identified morning and midday, with blank MAR entries and no corresponding progress notes. Some residents reported that medications were often late or sometimes not given in the morning, particularly their anxiety, depression, or other routine medications. A resident with severe cognitive impairment and seizure disorder also had multiple essential medications, including anticonvulsants, antidepressants, diuretics, antihypertensives, and GI medications, not administered on the same date, again with no documentation of a reason. Staffing records and interviews showed that on the affected hall, a CMT who was scheduled did not work, and the CMT on the adjacent hall refused to cover the additional medication pass. Staff interviews indicated that when a CMT calls off, the nurse assigned to the hall is expected to pass medications, and that if a medication is not given, it should be documented in the MAR and progress notes. On this date, the nurse assigned to the affected side of the hall was reported by another nurse to have passed medications for some residents, but several residents did not receive their medications, and the DON later acknowledged that blank MARs indicated medications were not given and that she had not been aware of the omissions. Additionally, the facility failed to timely refill a prescribed opioid pain medication for a cognitively intact resident with severe, almost constant pain related to chest pain, muscle spasms, and chronic pancreatitis. The resident’s hydrocodone-acetaminophen 5-325 mg, ordered every six hours for pain, was documented as not available for multiple scheduled doses over a two-day period. The MAR showed missed doses marked as not available at several scheduled administration times before the medication was again given, indicating that the refill was not obtained in time to prevent an interruption in therapy, contrary to the facility’s policy requiring refills to be ordered before the last dose so that medications remained readily available. Interviews with the scheduler, CMTs, LPNs, the nurse manager, and the DON confirmed that there was a CMT scheduled for each floor, that the CMT for the affected hall either called off or was late, and that the nurse on that hall was expected to pass medications when a CMT was unavailable. Staff consistently stated that if the MAR was blank, the medication was not given, and that any omitted medications should have been documented with a reason in both the MAR and progress notes. Despite this, the MARs for multiple residents remained blank for numerous medications on the identified date, and there was no documentation in progress notes explaining the missed doses, demonstrating a failure to provide and document medication administration in accordance with physician orders, facility policy, and professional standards of quality.
Failure to Protect Resident Privacy and Confidentiality During Cell Phone Use
Penalty
Summary
The deficiency involves failure to protect residents’ rights to personal privacy and confidentiality when staff used personal cell phones to record and transmit images and video during care. Facility policy prohibited personal cell phone use on nursing units for any reason and specifically banned taking pictures or videos of residents for personal use or social media, with violations subject to disciplinary action. The facility’s resident rights policy stated that residents had the right to a dignified existence, to be treated with respect and dignity, and to receive care in a safe, clean, comfortable, and homelike environment. One incident involved a resident with severe cognitive impairment, aphasia, hemiparesis, and total dependence on staff for ADLs, who was always incontinent of bowel and bladder. During a video call among a CNA, another CNA, and the scheduler, the first CNA provided peri-care to this resident while on camera. The resident lay in bed wearing a shirt, brief, and socks; the CNA removed the brief, exposing the resident’s genitals and later the buttocks while cleaning. A second CNA joined the call from home with two young children visible on camera, and the children watched the CNA clean the resident’s buttocks before leaving the call. During the call, the resident was rolled to the side, exposed, and at one point held onto the CNA’s buttocks while the CNA moved his/her buttocks in a circle, looked back at the camera, and smiled, while the other CNA laughed. A second incident involved another resident with severe cognitive impairment, dementia, and multiple comorbidities, who used a wheelchair. A CNA took a photo of this resident sleeping in a recliner and sent it to a group chat that included both staff and non-staff members. The DON later identified the resident in the photo. Staff interviewed reported that the group chat was muted and that they did not see the photo, but the Regional Director of Clinical Services stated she was notified of the video and photos by email and that she would have expected staff in the group chat to report the videos when they occurred. Staff involved acknowledged receipt of the resident rights policy, but some reported they had not been oriented on resident rights and personal cell phone policies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with a history of verbal and physical aggression struck another resident in the face, resulting in scratches and pain. The incident took place in a hallway, where staff responded after hearing yelling. Certified Nurse Aides had already separated the residents by the time the nurse arrived. The aggressor had a care plan in place for behavioral issues, which included monitoring and documenting behaviors and attempting to determine underlying causes, but the resident was still able to physically assault another resident. The resident who was struck had no documented behavioral issues and required partial to moderate assistance with activities of daily living. After the altercation, the resident was found to have two scratches on the face, one above the lip and one near the left eye, and reported pain. The resident’s glasses were also bent during the incident. The nurse cleaned the wounds and administered pain medication as needed. The resident expressed not wanting to be hit and reported a prior history of problems with the aggressor, though no previous physical altercations had occurred. Staff interviews revealed that the aggressor was known to be verbally aggressive and could be difficult during care and medication administration. Staff had been inserviced on the facility’s abuse and neglect policy, and the care plan for the aggressive resident included interventions for monitoring and redirection. Despite these measures, the physical altercation occurred, indicating a failure to protect residents from abuse as required by facility policy.
Failure to Prevent Unnecessary Physical Restraint During Personal Care
Penalty
Summary
Staff failed to ensure a resident was free from unnecessary physical restraints during the provision of personal care. When the resident, who had severe cognitive impairment and a history of physical and verbal aggression, refused care and became combative, staff proceeded to hold the resident's wrists and restrain them in order to complete peri care. The resident was observed to be kicking, swinging, and biting during the incident, and staff did not follow the care plan, which instructed them to allow the resident to calm down and self-soothe when agitated or resistive to care. The facility's policies clearly defined physical restraint as any manual method that restricts a resident's freedom of movement, including holding a resident down during care if they are resistive or refusing. The care plan for the resident specified interventions such as giving choices, reducing stimulation, and stepping away to allow the resident to calm down if agitated. Despite these guidelines, staff continued to provide care while physically restraining the resident, rather than stopping and reapproaching later as directed by the care plan and facility policy. As a result of the incident, the resident sustained a skin tear to the chin, bruising on both hands, and scratches on the arms. The event was reported by the CNA involved, who described the nurse's actions in detail, including holding the resident's wrists, flipping the resident, and restraining the resident's legs. The nurse's own statement confirmed that care was provided despite the resident's resistance. The incident was corroborated by interviews and skin assessments, which documented the injuries sustained during the episode.
Failure to Maintain Full-Time On-Site Administrator
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled effective and efficient use of its resources to attain or maintain the highest practicable well-being of each resident. Specifically, the facility did not have an active Administrator on-site on a full-time basis, as required by its own policy and job description. The Administrator position was filled on an interim basis by an individual who also served as Administrator for two other facilities, resulting in her being physically present at the facility only two to three days per week, according to multiple staff interviews. There was no system in place to track the actual time the Administrator spent in the facility, and the job description did not specify whether the position was full-time or remote. Staff interviews consistently indicated that the interim Administrator was not present in the facility five days a week, with most staff reporting her presence only two to three days per week. The Director of Nursing, Assistant Director of Nursing, Human Resources, Social Worker, Admissions Coordinator, Medical Records, LPN, Business Manager, Director of Rehabilitation, Activity Director, and Housekeeping and Laundry Supervisor all confirmed the Administrator's limited on-site presence. The Director of Nursing noted that the facility had experienced multiple citations, including three Immediate Jeopardies, and described the situation as overwhelming due to the lack of full-time administrative support. The Ombudsman also reported receiving complaints from residents and family members about the absence of a full-time Administrator. The interim Administrator herself stated that she worked a 40-hour week but was not present in the facility every day, as she was responsible for two other facilities as well. The lack of a full-time, on-site Administrator led to challenges in leadership, oversight, and compliance with state and federal regulations, as well as difficulties in addressing ongoing survey citations and complaints. The facility census at the time was 123 residents.
Failure to Provide Complete Basic Life Support and CPR Response
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to provide complete basic life support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who experienced a rapid change in condition and subsequently coded. The RN was unable to quickly locate the resident's code status and did not call for additional staff assistance using the facility intercom system. Only the RN and a certified nurse aide (CNA) participated in the response, and the RN did not utilize the automated external defibrillator (AED) located at the nurse's station, nor did they provide rescue breaths during CPR. The RN also did not continue CPR until emergency medical services (EMS) arrived, instead stopping resuscitation efforts before EMS assumed care. The resident involved was cognitively intact and had diagnoses including atrial fibrillation, coronary heart disease, and congestive heart disease. The resident had a documented full code status, with clear orders for CPR to be initiated in the event of cardiac or respiratory arrest. On the day of the incident, the resident was found unresponsive with foaming at the mouth and a bluish/gray color. Vital signs were unobtainable, and oxygen saturation was critically low. Despite these findings and the presence of a signed consent for CPR, the RN did not follow the facility's policy for emergency response, which included using the AED, providing rescue breaths, and ensuring continuous CPR until EMS arrival. Interviews and record reviews revealed that the RN was certified in BLS and had been trained in the use of the AED and AMBU bag. However, the RN reported feeling overwhelmed and did not follow established protocols, such as calling for help or using available emergency equipment. Other staff members, including LPNs and the DON, confirmed that the expected procedure in such situations was to check code status, call for assistance, use the crash cart and AED, and continue CPR until EMS arrived. The failure to adhere to these procedures had the potential to affect multiple residents with full code status in the facility.
Failure to Thoroughly Investigate Abuse Allegation and Notify Physician
Penalty
Summary
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not thoroughly investigating an allegation made by a resident that a CNA provided rough care, resulting in a hematoma on the resident's left inner calf. The resident, who had multiple medical conditions including atrial fibrillation, coronary heart disease, congestive heart failure, high blood pressure, anxiety, and Alzheimer's Disease, was on anticoagulant therapy, increasing the risk of bruising. The incident involved the CNA, who was not typically assigned to the resident's floor, and the resident reported that the CNA was rough and loud during care, particularly after the resident had a bowel movement. The resident expressed fear of the CNA and did not want further care from them. The facility's investigation was incomplete, as it only included interviews with the resident, the roommate, and another resident across the hall. No staff members who worked during the alleged incident, nor residents or staff from the CNA's usual assignment floor, were interviewed. The investigation also failed to notify the resident's physician about the allegation, despite facility policy requiring such notification. The nurse manager who conducted the investigation admitted to not interviewing additional residents or staff due to time constraints and lack of consideration, and only expanded the investigation after being prompted by surveyors. Additional interviews conducted later revealed that other residents had similar complaints about the CNA being rough or not providing adequate care, and some staff were unaware of the importance of reporting such allegations. The medical director confirmed that he was not informed of the abuse allegation, contrary to policy expectations. The initial failure to conduct a thorough investigation and to notify the physician constituted a breach of the facility's abuse prevention policy.
Failure to Timely Report Alleged Abuse and Injury
Penalty
Summary
The facility failed to notify the State Survey Agency within the required two-hour timeframe after a resident alleged that a Certified Nurse Aide (CNA) was rough while providing personal care, resulting in a hematoma on the resident's left inner calf. The facility's abuse policy mandates immediate reporting, but the administrator did not report the allegation, stating they did not believe the injury was caused by abuse. The investigation was completed the same day, but the state agency was not informed of the allegation as required by both facility policy and federal regulations. The resident involved had moderately impaired cognition, was always incontinent of bowel and bladder, and required partial to maximal assistance with personal care and mobility. The resident reported that the CNA was rough and upset while providing care after a bowel movement, and that the CNA had previously ignored or delayed responding to call lights. The resident expressed fear of the CNA and requested not to be cared for by that individual again. The resident's family also reported concerns to the facility after receiving a text from the resident about the incident. Despite the resident's statements and visible injury, the facility's investigation did not substantiate the allegation of abuse, and the administrator decided not to report the incident to the state agency. The medical director, who was also the resident's physician, was not informed of the allegation, although he assessed the hematoma. The facility's failure to report the allegation and the results of the investigation to the appropriate authorities constitutes a deficiency in following required abuse reporting protocols.
Failure to Respond to Change of Condition and Notify Physician
Penalty
Summary
Facility staff failed to appropriately respond to a resident's significant change of condition, which began when the resident exhibited symptoms such as not eating, staring blankly, and being unable to keep their head up. Despite these clear signs of deterioration, staff did not conduct a thorough or documented assessment, nor did they notify a nurse or the resident's physician as required by facility policy. The resident, who had a history of severe cognitive impairment, dysphagia, COPD, Alzheimer's disease, heart failure, and a recent pneumonia diagnosis, was left in a declining state for several hours without proper clinical intervention. Throughout the day, multiple staff members observed that the resident was not acting like themselves, appeared extremely tired, and was not eating meals. Certified nurse aides and certified medical technicians noted the resident's abnormal presentation but did not escalate the situation to a nurse for assessment. There was no nurse assigned to the resident's floor during the day or evening shift, and staff failed to call a nurse from another floor to assess the resident, as required by facility protocol. Vital signs were reportedly taken but not documented, and there was no record of wound care being provided as ordered for several days. The resident remained unresponsive in the dining room for several hours before emergency services were finally called. Upon EMS arrival, the resident was found with their head tilted back, emesis in the airway, and in an unresponsive state. Hospital records confirmed diagnoses of pneumonia, acute hypoxemic respiratory failure, and severe sepsis. Interviews with staff and the resident's physician revealed that no one from the facility notified the physician of the resident's decline or hospital transfer, and there was a lack of documentation and communication regarding the resident's condition and care.
Failure to Prevent Elopement and Inadequate Supervision
Penalty
Summary
Facility staff failed to keep a resident free from hazards and did not provide the necessary monitoring and supervision when the resident left the facility without staff knowledge. The facility did not follow its own Elopement/Missing Person policy after the resident exited the premises, as staff were unaware of the resident's whereabouts or expected time of return. The policy required immediate reporting, search procedures, and notifications to administration, police, and responsible parties, none of which were fully executed in this case. The resident involved had a complex medical history, including severe cognitive impairment, alcoholic dementia, depression with suicidal ideation, a recent right shoulder fracture, and dependence on a wheelchair for mobility. The resident required significant assistance with activities of daily living and had a history of substance use, as evidenced by the discovery of multiple empty alcohol bottles in the resident's room. Despite these risk factors, the resident was assessed as low risk for elopement, and the care plan did not address elopement risk, substance abuse, or the need for enhanced supervision. On the day of the incident, the resident left the facility in a medical transport vehicle without notifying staff, and staff did not know the resident's destination, transportation details, or expected return time. Communication among staff was inadequate, with no follow-up or escalation to administration or law enforcement as required by policy. Documentation was incomplete, and there was no timely reassessment of elopement risk or update to the care plan after the resident's return. Staff interviews revealed a lack of clarity regarding procedures and responsibilities, and no in-service education was provided to address the policy failures after the event.
Failure to Respond to Resident's Change of Condition
Penalty
Summary
The facility staff failed to appropriately respond to a resident's change of condition, which resulted in the resident's death. The resident, who was cognitively intact and had diagnoses including gangrene, peripheral vascular disease, and polyneuropathy, experienced a significant change in condition. Despite the resident's complaints of head and chest pain, nausea, and other symptoms, the staff did not conduct a thorough assessment, document the changes, or notify the resident's physician. The resident was found unresponsive and later died after resuscitation efforts. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. Certified Nurse's Aides and a Certified Medication Technician noted the resident's complaints and symptoms but failed to escalate the situation to a nurse or physician. The Registered Nurse on duty was unaware of the resident's condition due to a lack of communication during shift changes and did not take appropriate action when informed of the resident's distress. The Director of Nursing and other staff members were not informed of the resident's condition until it was too late. The facility's failure to follow its Change of Condition Notification Policy and Procedure, which requires prompt notification of a resident's physician and thorough documentation, contributed to the resident's death. The lack of immediate response and failure to call emergency services in a timely manner were critical factors in the deficiency.
Failure to Document and Monitor Post-Fall Assessment
Penalty
Summary
The facility failed to adhere to its Fall Protocols Policy after a resident experienced an unwitnessed fall. The policy requires that residents be assessed for potential injury and monitored for changes in condition every shift for 72 hours following a fall. However, the facility did not document the necessary assessments and monitoring for the resident who fell. The resident, who was cognitively impaired and at risk for falls due to conditions such as dementia and diabetes, reported the fall to a Certified Medication Technician. Despite this, the resident's medical record lacked comprehensive documentation of the fall incident and subsequent neurological checks. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, confirmed that the required neurological checks were not completed or documented as per the facility's policy. The resident's care plan was also not updated to reflect the fall, indicating a lapse in communication and documentation. This deficiency highlights a failure in the facility's processes to ensure resident safety and proper post-fall assessment and monitoring.
Deficient Management of Resident Personal Funds
Penalty
Summary
The facility failed to maintain proper documentation and management of resident personal funds, affecting all residents whose funds were handled by the facility. The facility did not ensure that access to resident personal funds was transferred to the new management company upon a change in ownership. Additionally, the facility did not reconcile the monies held in the resident trust fund account each month, nor did it distribute quarterly statements to residents or their responsible parties. The facility's policy required that the facility act as a fiduciary of the resident's funds and report at least quarterly on the status of these funds, but this was not adhered to. The review of the facility's resident trust account revealed significant gaps in documentation. From November 2023 to July 2024, there was no documentation of ending balances, bank statements, or receipts. The account showed an ending balance of $118,068.63 in August 2024, $55,189.34 in September 2024, and $50,722.70 in October 2024, none of which were reconciled. Previous trust account records from November 2023 through June 2024 also lacked reconciliations, bank statements, and quarterly statements. This lack of documentation and reconciliation indicates a failure to comply with the facility's policies and procedures regarding the management of resident funds. Interviews with the Business Office Manager (BOM) and the Administrator highlighted further issues. The BOM, who started on September 4, 2024, did not have access to the resident trust accounts and statements maintained by the previous owners until requested by the surveyor. The BOM was responsible for reconciling the resident trust but had not done so, and quarterly statements had not been sent since the BOM started. The Administrator expected monthly reconciliations and detailed accounting for residents, but these expectations were not met. The facility's failure to manage resident funds properly and provide necessary documentation and statements led to the identified deficiencies.
Deficiency in Serving Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature during two observed meal services, affecting all residents who ate meals at the facility. The facility's policy required hot foods to be served at 135 degrees Fahrenheit or higher and cold foods at 41 degrees Fahrenheit or below. However, during observations, food temperatures were significantly below these standards. For instance, during a meal service, the turkey and noodles were served at 102.6 degrees Fahrenheit, and the broccoli at 110 degrees Fahrenheit. Similarly, on another occasion, the baked ham was served at 109.8 degrees Fahrenheit, and the stuffing at 117.5 degrees Fahrenheit. These temperatures were not in compliance with the facility's guidelines, leading to resident complaints about cold food. Residents, including those who were cognitively intact, consistently reported that their meals were served cold, with complaints dating back several months. The Resident Council meeting minutes from October, November, and December indicated ongoing dissatisfaction with meal temperatures. Staff interviews revealed that the food was delivered in nonheated and noninsulated carriers, contributing to the temperature issues. The Dietary Manager, who started in November, acknowledged the problem and mentioned plans to address it, but the issue persisted. The facility's Administrator had different expectations for food temperatures, which were not aligned with the facility's policy, further complicating the situation.
Medication Administration and Self-Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper supervision and assessment of residents regarding medication administration and self-administration. Several residents were observed with medications left at their bedside without proper authorization or assessment to self-administer. For instance, a resident with multiple diagnoses, including hypertension and depression, was found with a medication cup containing pills on their night table, despite no documentation or physician's order allowing self-administration. Interviews with staff revealed inconsistencies in understanding and implementing the facility's policies on medication administration and self-administration. Another resident with COPD insisted on keeping their inhalers in their room, citing the need for immediate access due to short staffing. Despite the resident's cognitive intactness, there was no documented assessment or physician's order permitting self-administration. The resident's insistence on retaining the inhalers highlights a gap in communication and policy enforcement between staff and residents. Observations confirmed the presence of inhalers in the resident's room, contrary to the facility's policy. The facility's staff, including RNs and LPNs, demonstrated a lack of adherence to the facility's medication policies. Interviews with the DON and other staff members revealed a misunderstanding of the policy requirements for self-administration and the necessity of physician orders. The DON and Administrator confirmed that no residents were authorized to self-administer medications, yet observations and interviews indicated otherwise, pointing to a systemic issue in policy implementation and staff training.
Failure to Honor Resident's Request and Inappropriate Cell Phone Use
Penalty
Summary
The facility failed to honor a resident's request for a change in staff assignment, which compromised the resident's dignity and self-determination. A resident, who was cognitively intact and had multiple diagnoses including coronary artery disease and depression, reported that a Certified Nurse Aide (CNA) had yelled at them and was rough during care. Despite the resident's request to not have this CNA assigned to them, the CNA continued to be assigned, causing distress to the resident. The resident's daughter corroborated the resident's account, stating that the CNA was rough and took personal items without permission. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) were aware of the complaints but did not ensure the CNA was reassigned, leading to the CNA's continued interaction with the resident. Additionally, the facility staff were observed using personal cell phones in resident care areas, which is against the facility's policy. During a group interview, several residents reported that staff used their cell phones while providing care, with one resident being told to keep quiet because the staff was listening to music. Observations confirmed that staff were using cell phones inappropriately, including one instance where a staff member was seen walking down a hall and entering a resident's room while looking at their phone. Interviews with staff confirmed that cell phone use in resident care areas was not permitted, yet it was still occurring. The facility's Administrator acknowledged that residents should be treated with dignity and respect, and if a resident was uncomfortable with certain staff, those staff members should not be assigned to them. The Administrator also expected staff to refrain from using cell phones while providing care. Despite these expectations, the facility failed to implement these standards, resulting in the deficiencies observed during the survey.
Failure to Notify Resident of Insurance Change
Penalty
Summary
The facility failed to ensure that residents or their responsible parties were invited to participate in all aspects of person-centered care planning, as evidenced by the case of a resident whose insurance was changed without notification. The resident, who was cognitively intact and diagnosed with type 2 diabetes with a foot ulcer, was switched from a Medicare Advantage plan to a classic plan by the facility. This change was made without prior discussion or permission from the resident or their family, leading to confusion and distress when the resident's medication, Trulicity, was reported as not covered by the new insurance. The Business Office Manager (BOM) admitted to a mistake in switching the resident's insurance, explaining that the change was made to ensure residents could see their medical provider. The BOM assumed that someone had communicated the change to the residents and their responsible parties, but this was not the case for the resident in question. The resident's family expressed concern over the change, particularly regarding the resident's medications and other supplies that were previously covered by the insurance. Interviews with facility staff, including the LPN Manager and the Administrator, revealed a lack of communication and coordination regarding the insurance change. The LPN Manager noted that there was no issue with the resident's medication, as the facility paid for a replacement when it went missing. The Administrator acknowledged that residents and their responsible parties should have been informed of any changes to providers and insurance, typically a responsibility of the social worker. This oversight resulted in the resident and their family being uninformed about significant changes to the resident's care plan.
Failure to Notify TPL and Manage Deceased Residents' Funds
Penalty
Summary
The facility failed to notify the third party liability (TPL) within 30 days when two residents expired, which is a requirement for managing resident funds. This deficiency affected two residents, both of whom had passed away, with one having a trust account balance of $5,693.01 and the other $1,077.66 at the time of their deaths. The facility's policy mandates that a final accounting of resident funds should be completed within 30 days of a resident's death or discharge, and a letter should be sent to the appropriate parties. However, this was not done in a timely manner for the two residents involved. Interviews with the Business Office Manager (BOM) and the Administrator revealed that the BOM was in the process of preparing the TPL letters for one resident, while the other resident, who was private pay and had no estate, had not yet had their funds addressed. The Administrator expressed that it was inappropriate for a deceased resident to still have a trust account with a significant balance and expected staff to ensure timely final accounting. The failure to notify the TPL and manage the residents' funds appropriately led to the deficiency noted in the report.
Failure to Notify Hospice and Family Before Hospital Transfer
Penalty
Summary
The facility failed to notify hospice services and the resident's responsible party before transferring a resident to the emergency room after a fall. The resident, who had severe cognitive impairment and was dependent on staff for self-care and mobility, was receiving hospice services due to severe malnutrition. Despite this, the facility did not update the resident's care plan to reflect hospice services. On the day of the incident, the resident was found with coffee ground emesis and a back fracture, prompting the staff to call 911 and transfer the resident to the hospital without prior notification to hospice or the resident's family. Interviews revealed that the Licensed Practical Nurse (LPN) on duty did not contact the hospice nurse before sending the resident to the hospital and was unsure of the policy regarding such notifications. The resident's responsible party was informed only after the transfer, and they expressed that they would have advised against sending the resident to the hospital. The Hospice Manager confirmed that facility staff were educated to contact hospice before calling 911 or transferring a resident, but this protocol was not followed. The Director of Nursing acknowledged that the facility staff should have contacted the hospice nurse prior to the transfer.
Deficiency in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. This deficiency was observed in the cases of two residents. The first resident, who was cognitively impaired and had a history of wandering, was at risk of elopement. Despite this, the resident's care plan did not reflect the risk of elopement, even though the resident had made multiple attempts to exit the facility. The care plan only addressed the resident's impaired cognitive function and did not include interventions to manage the elopement risk. The second resident, who was also cognitively impaired and at risk for falls, experienced a fall that was not documented in the care plan. The resident's care plan focused on fall prevention strategies, such as keeping the bed in the lowest position and ensuring the call light was within reach. However, after the resident reported a fall, there was no documentation in the care plan regarding this incident, indicating a lack of updating and accuracy in the care plan. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that care plans should be reflective of the residents' needs and specific to each resident. The staff acknowledged that risks such as falls and elopement should be included in the care plans, highlighting the facility's failure to adhere to its own policies and procedures regarding comprehensive care planning.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage four pressure ulcer, as recommended by the CDC and required by CMS. The resident, who was cognitively intact and had diagnoses including heart failure, dementia, and Parkinson's disease, was dependent on staff for transfers and had a significant pressure ulcer. During an observation, staff did not wear gowns while providing wound care and transferring the resident, and there was no EBP sign outside the resident's door. Interviews with staff revealed a lack of consistent understanding and implementation of EBP, with the Infection Control Preventionist acknowledging the absence of EBP for the resident. Another deficiency was observed when a Registered Nurse prepared medications for a resident without performing hand hygiene and handled the medications with bare hands. The resident, who was cognitively intact and had multiple diagnoses including heart disease and stroke, was prescribed several medications. The RN was observed popping medications from bubble cards and pouring them into their bare hands before administering them to the resident. Interviews with staff confirmed that hand hygiene should be performed prior to handling medications and that medications should not be handled with bare hands. Additionally, the facility failed to ensure proper infection control practices for a resident with an indwelling catheter. The resident, who was cognitively intact and had diagnoses including heart disease and end-stage renal failure, was observed with their catheter bag lying directly on the floor on multiple occasions. Interviews with staff, including the CNA and LPN, confirmed that catheter bags should be kept off the floor to prevent contamination. The Director of Nursing and Administrator also acknowledged that catheter bags should not be placed on the floor.
Failure to Protect Resident from Verbal Abuse and Ensure Dignity
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) used profanity towards a cognitively intact resident with multiple diagnoses, including coronary artery disease, hypertension, hyperlipidemia, anxiety, depression, and asthma. The incident took place while the resident was on the phone with the Ombudsman, and the CNA entered the room to assist the resident's roommate. The resident reported that the CNA told them to "shut the fuck up" and, when informed that the Ombudsman was on the phone, responded with further profanity. The Ombudsman, who was on the call, confirmed hearing the CNA use the phrase "mind your fucking business" in response to the resident's inquiry about the CNA's name. The facility's policy states that residents have the right to a dignified existence and to be free from abuse, including verbal abuse. Despite this, the CNA continued to work at the facility and was assigned to the resident after the incident. Documentation and interviews revealed that the CNA denied using profanity but admitted to telling the resident to "mind your business" and refusing to provide their name. The administrator was aware of the incident and acknowledged that the CNA was not removed from duty or reassigned away from the resident. There was no documentation of assignment changes or interventions to prevent further contact between the CNA and the resident. Interviews with facility staff, including the Social Worker and Social Service Coordinator, indicated that it would not be appropriate for a staff member accused of such behavior to continue working with the affected resident. However, the CNA's work records showed continued assignments at the facility, including with the resident. The resident expressed fear for their own and their roommate's safety due to the CNA's behavior and presence. The incident was corroborated by the Ombudsman and was not documented in the resident's progress notes.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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