Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ellisville Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with cerebral palsy, dysphagia, CHF, and seizure disorders developed persistent nausea and vomiting that progressed to dark and then black emesis. Staff obtained an order for Zofran and gave one dose, but the resident kept vomiting, and there was no documented assessment, VS, or timely MD/NP notification when the emesis worsened. The resident later became pale, clammy, hypotensive, and was sent out by EMS after copious black emesis; the resident expired on arrival at the hospital.
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.
Cold meals were served during tray delivery, with surveyors measuring hot foods well below required temperatures and milk above the cold-holding range. Several cognitively intact residents reported that meals arrived cold, tasted bad, and were delayed, including residents with paraplegia, hemiplegia, dysphagia, CKD, HF, DM, and mood disorders. Staff said the warming station and steam table were not being used, and cold drinks were being sent out with the trays.
Failure to Honor Resident Food Preferences and Meal Tickets: A facility did not provide requested alternate foods from the Always Available menu and did not follow meal tickets for several residents. Cognitively intact residents reported repeated denials when asking for substitutes, with the kitchen often saying items were unavailable or not answering calls. Other residents with significant medical conditions, including hospice care, dysphagia, malnutrition, stroke-related deficits, diabetes, and weakness, were observed receiving breakfast items that did not match their orders or stated preferences, such as eggs instead of meat, sausage instead of no sausage, and regular portions instead of requested double portions.
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 facility failed to complete a thorough and immediate investigation after a CNA found a resident with bruising on the neck fold and under the eye. The resident, who was cognitively intact and needed substantial to maximum help with mobility and transfers, later said he/she may have fallen out of bed and woke up on the floor. The DON, nurse manager, and administrator acknowledged the investigation lacked a skin assessment, written staff statements, a summary, and a conclusion, and the resident was later sent to the hospital where a facial contusion was diagnosed.
Care plans were not kept accurate for residents with changing needs. One resident had worsening anxiety, severe depression, weight loss, confusion, wandering, suicidal statements, and increased help needed with eating, but these changes were not reflected in the care plan. Other residents had repeated falls and fall-related injuries, yet the care plans did not include recent fall interventions such as fall mats or other updated safety measures.
A resident with an indwelling Foley and significant urologic history did not receive ordered catheter care and gentamicin bladder flushes on multiple shifts, with several MAR/TAR entries left blank or documented as completed when they were not. Records and staff interviews showed repeated difficulty obtaining the flush medication, catheter changes after failed flushing, blood-tinged urine, and hospital transfers for Foley problems. After a urological procedure, the catheter bag was found at mattress level with tubing lying on the bed, visible blood and sediment in the tubing, and the resident stated no one had provided catheter care since returning.
Failure to Ensure Ordered Nutritional Supplements Were Administered: A resident with paraplegia, quadriplegia, cachexia, malnutrition, weight loss, and wounds had orders for protein oral liquid and Boost, but staff did not consistently provide the supplements or verify consumption. The resident reported missing Boost and meals when leaving for the day program, and a CMT left the protein supplement in the resident’s room and documented it as given without seeing it taken. The DON and Administrator stated the supplement should not have been left in the room and should only be documented as administered if observed.
An agency LPN signed out narcotics and allowed a CMT to administer them to two residents, while documenting the doses as given. In another event, an LPN documented a medication refusal for a resident with severe cognitive impairment, then threw the refused pills into the resident’s trash can instead of handling them through the facility’s medication disposal process.
Failure to promptly document and investigate alleged resident sexual contact: Staff reportedly saw two residents with severe cognitive impairment engaging in close physical behavior, including one resident found in the other resident’s room partially unclothed, but the incident was not immediately documented or investigated. The SW said staff should have documented who witnessed it, while the record showed no timely physician notification or cognitive consent assessment for one resident. Interviews also showed staff were unsure how to handle the situation and relied on administration direction rather than following the abuse and sexual expression policies.
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 Respond to Ongoing Vomiting and Change in Condition
Penalty
Summary
The facility failed to appropriately respond to Resident #35’s change in condition when the resident began vomiting and continued to vomit over several days. The resident had diagnoses including cerebral palsy, muscle weakness, dysphagia, chronic heart failure, epilepsy, and unspecified convulsions. Progress notes showed the resident was warm, clammy, and refused breakfast on 02/26/26, and staff called the NP. A late NP entry stated the resident had nausea and vomiting, that the nausea was improving, and that ondansetron 4 mg as needed should continue, with nursing to monitor for ongoing symptoms. However, the electronic order record did not show an ondansetron order dated 02/26/26. On 02/27/26, the resident complained of nausea and had emesis times four, and staff called the physician exchange for an order for Zofran 4 mg every four hours as needed. The medication was administered that afternoon. The resident continued to vomit after the medication was given. On 02/28/26, staff documented that the resident vomited at lunch and that the emesis was dark in color on the resident’s face and clothing, but there was no documentation of an assessment, vital signs, physician notification, or why medication was not administered that day. The record also showed no blood pressure, respirations, or oxygen saturation documented in February 2026. On 03/01/26, the resident had three episodes of emesis, with the last being a copious amount of black emesis. The resident was pale and clammy, the abdomen was distended, and staff could not obtain blood pressure with standard methods or obtain oxygen saturation because the fingers were cold. A wrist cuff blood pressure was 68/40. Staff notified the ADON, called the on-call physician’s office, contacted the POA, and sent the resident to the hospital by EMS. EMS documented projectile vomiting, cardiac arrest, aspiration concerns, and black emesis during transport. The resident expired upon arrival at the hospital. Interviews with nursing and CNA staff indicated the resident had been vomiting throughout the week, that the vomiting became darker in color, and that staff did not consistently notify the physician or document assessments and medication administration decisions.
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.
Cold Meals Served During Tray Delivery
Penalty
Summary
Food and drink were not maintained at a palatable, attractive, and safe temperature during meal service. The facility’s On Tray Dietary Policies and Procedures required food temperatures to be taken and logged when cooked and again before meal service, with hot foods served at 135 degrees F or higher and cold foods/beverages at 41 degrees F or lower. During observations on the 300 and 400 halls, meal trays were delivered in large metal carts and passed to residents in dining areas and rooms, but the last trays were still being served well after the carts arrived. Surveyors measured biscuits at 102 degrees F, green beans at 106 degrees F, beef stew at 100 degrees F, eggs at 115 degrees F, and milk at 50 to 54 degrees F. Five cognitively intact residents reported that meals were cold and unappetizing. One resident with paraplegia, quadriplegia, kidney calculus, cachexia, chronic pain syndrome, and mild protein-calorie malnutrition said food was always cold and tasted very nasty. Another resident with hemiplegia, diabetes, anemia, dysphagia, and muscle weakness said residents waited up to an hour for food and it arrived cold. Other residents with chronic kidney disease, depression, anxiety, heart failure, high blood pressure, liver disease, heart disease, and major depressive disorder also reported cold meals, including in-room dining. Staff interviews indicated the warming station had recently stopped being used, the steam table had been discontinued while the kitchen was being organized, and cold drinks were being served with the trays rather than kept in ice buckets.
Failure to Honor Resident Food Preferences and Meal Tickets
Penalty
Summary
The facility failed to provide residents with alternate food choices and preferences listed on the Always Available menu, and it also failed to serve foods listed on meal tickets for multiple residents. The report states that the Always Available menu included items such as hamburgers/cheeseburgers, grilled cheese, cold cut sandwiches, chef or garden salad, cold cereal, hot dogs, and peanut butter and jelly sandwiches, but residents reported that requests for alternatives were often denied because the kitchen was too busy, out of the item, or did not answer the phone. A cognitively intact resident reported that when residents asked staff for an alternative, they were told the kitchen was too busy, out of the alternative, or staff did not return. Another cognitively intact resident said he/she did not like the food, repeatedly requested hot dogs for over a month, and was told they were out of them; the resident said only cold meat or peanut butter and jelly sandwiches were sent and that staff were too busy to help. A CNA stated that staff try to order substitutes, but the kitchen is often out of what is requested or does not answer the phone. The report also documented that meal tickets were not followed for several residents. One resident with hospice care, severe anemia, malnutrition, weakness, stroke-related deficits, and dysphagia had an order for meat with breakfast and no eggs, yet was observed served scrambled eggs and no meat on two mornings. Another resident with paraplegia/quadriplegia, cachexia, chronic pain, and mild protein-calorie malnutrition had preferences for double portions and specific breakfast items, but was observed receiving regular portions and different foods than requested. A third resident with hemiplegia, diabetes, anemia, dysphagia, and muscle weakness had orders for bacon and no sausage, but was observed receiving sausage and other foods not matching the meal ticket. The Dietary Manager said the residents' preferences were supposed to be read from the meal tickets and honored, while the Administrator stated the kitchen staff should review the meal tickets and honor resident preferences, but residents reported that the kitchen and nursing staff were not providing the requested items.
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.
Incomplete Investigation of Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough and immediate investigation of an injury of unknown source after a CNA discovered a resident with bruising on the neck fold and under the left eye. The resident was cognitively intact, had lower extremity impairment on one side, and required substantial to maximum assistance with mobility and transfers. His/her diagnoses included stroke, difficulty walking, muscle weakness, and heart disease. The resident later said he/she thought he/she had fallen out of bed and woke up on the floor, but did not remember the details of the event. Facility documentation showed that a nurse manager was notified of the bruises and assessed the resident, but no skin assessment was completed at that time. The resident denied pain and initially refused an x-ray. The resident’s POA was notified later, and the resident was subsequently sent to the hospital after family requested evaluation for bruising and a scalp laceration. The hospital diagnosed a facial contusion, and CT scans of the head and spine were negative. The facility’s investigation consisted of a sheet listing employee names and whether they knew about the fall/bruises, staffing sheets, and handwritten responses. There was no summary, no skin assessment, no written or signed staff interviews or statements, and no conclusion. During interviews, the nurse manager, DON, and administrator acknowledged that the investigation was incomplete and that staff statements in writing, a skin assessment, and more thorough fact-finding should have been completed. The DON also stated she learned of the injury after the POA complained and that staff were asked only whether they knew about the bruise or fall.
Care plans not updated for changing resident needs
Penalty
Summary
The facility failed to keep resident care plans updated and accurate to reflect changes in resident condition for Residents #22, #23, and #24. The comprehensive care plan policy required person-centered care plans with measurable objectives and timeframes, reviewed and revised after assessments and when resident needs changed. In the sample of 11 residents, the survey found that the care plans did not reflect increased eating assistance needs, increased depression, safety concerns, increased confusion, wandering behavior, or recent fall interventions. For Resident #22, the record showed multiple changes in condition that were not reflected in the care plan. The resident had diagnoses including severe protein-calorie malnutrition, weakness, hemiplegia/hemiparesis following stroke, dysphagia, and need for assistance with personal care. The resident was sent to the hospital after making suicidal statements during an anxiety episode, but there was no documentation of follow-up with outside services in the record. Later notes documented continued weight loss, palliative/hospice involvement, severe depression with a PHQ-9 score of 22, increasing confusion, inability to find the room or use the restroom, a Wanderguard placed on the resident after wandering and entering other residents’ rooms, and repeated skin tears from the wheelchair. Observation showed the resident struggling to open food items, needing help with meals, leaving meals unfinished, and becoming tearful and confused. The care plan dated 02/26/26 did not include the increased confusion, Wanderguard, weight loss, suicidal ideations, or increased assistance with eating. For Resident #23, the record showed repeated falls and floor incidents, including being found on the floor multiple times between 12/02/25 and 03/01/26, with one skin tear and other episodes without injury. The resident’s quarterly MDS showed moderate cognitive impairment, wheelchair use, partial/moderate assistance with ADLs and transfers, and falls since admission. The care plan identified fall risk related to impaired cognition, incontinence, and medications, but it did not include the fall mat that was present in the room during observation and was not documented in the care plan. For Resident #20, the record showed a fall with bruising under the eye and on the neck folds, but the care plan still listed older fall risk interventions and did not include new interventions after the recent fall. Observation showed no fall mats in the room and no assist bars on the bed, while the care plan did not reflect the recent fall-related changes.
Missed catheter care and flushes for resident with indwelling Foley
Penalty
Summary
Facility staff failed to provide ordered catheter care and gentamicin bladder flushes for a resident with an indwelling Foley catheter. The resident had a history of paraplegia, quadriplegia, kidney calculus, neuromuscular dysfunction of the bladder, cachexia, chronic pain syndrome, and mild protein-calorie malnutrition. The care plan identified the resident as having an indwelling catheter, with instructions to keep the catheter bag and tubing below bladder level and to change the catheter per physician order. Physician orders included Foley care every shift, peri-care and catheter care twice daily and as needed, and gentamicin solution flushes at bedtime. The record showed multiple missed or undocumented catheter care and flush treatments across several months. The MAR/TAR contained blank or undocumented entries for gentamicin flushes and Foley care on multiple shifts, including instances coded as medication not available or other/see progress notes. Progress notes documented repeated problems obtaining the gentamicin flush from the pharmacy and contacting the urologist, along with catheter changes after inability to flush the Foley. The resident experienced blood-tinged urine, resistance during catheter insertion, penile and scrotal bleeding, and repeated hospital transfers related to Foley catheter problems and urinary issues. On observation after the resident returned from the hospital following a urological procedure, the catheter bag was hooked to the side of the bed at mattress level, and the tubing lay flat on the mattress before curving into the bag. Blood and whitish cloudy gritty sediment were visible in the tubing, and urine flow was blocked about halfway down the tubing. The resident stated no one had provided catheter care since returning from the hospital and said he was in pain and felt something was wrong. Staff interviews confirmed catheter care had not been provided that evening, that the resident had returned from the hospital without documentation of the return time or instructions, and that the MAR/TAR had been signed as completed when it had not been done.
Failure to Ensure Ordered Nutritional Supplements Were Administered
Penalty
Summary
The facility failed to administer and ensure consumption of ordered nutritional supplements for a resident with significant weight loss and wounds. Resident #19 had diagnoses including paraplegia, quadriplegia, cachexia, chronic pain syndrome, and mild protein-calorie malnutrition. The resident was dependent on staff for eating and had ongoing weight loss documented by dietary staff, with orders for protein oral liquid twice daily for wound care and Boost to be sent with the resident to the day program. The record showed repeated concerns about the resident’s nutritional intake and the need to send supplements and snacks to the day program, but documentation was incomplete on some days and the resident reported that staff did not always send Boost or lunch with him/her. On one occasion, a medication administration note stated the resident had to leave so the protein oral liquid was not given. The resident also stated he/she always felt hungry and purchased snacks to take because if breakfast was delayed and he/she had to leave, there would be nothing to eat until dinner. During observation, a cup containing an amber liquid was found on the resident’s dresser. Staff interviews showed the protein supplement had been left in the resident’s room after the resident said he/she was on the way back and would take it there. The CMT documented the supplement as administered even though he/she did not see the resident take it, and acknowledged knowing the resident was supposed to be watched taking medications but did not consider the protein supplement to be medication. The DON and Administrator stated the supplement should not have been left in the room and should be documented as administered only if staff saw the resident take it.
Improper narcotic administration and disposal of refused medications
Penalty
Summary
Pharmaceutical services were not provided in accordance with the facility’s controlled substance and medication administration policies when an agency LPN dispensed narcotics and allowed a CMT to administer them to two residents. The facility’s policy required controlled substances to be stored securely, accounted for, and administered by the person who prepared the medication, with the administering staff member documenting the dose. The medication administration policy also required the nurse to observe the resident consume the medication, sign the MAR after administration, and sign the narcotic book for controlled substances. One resident was cognitively intact and had diagnoses including paraplegia, quadriplegia, kidney calculus, neuromuscular dysfunction of the bladder, cachexia, chronic pain syndrome, and mild protein-calorie malnutrition. The resident had an order for hydrocodone-acetaminophen 10-325 mg every 12 hours as needed for pain, with no order to self-administer or take medication on leave. On the morning of the event, the agency LPN administered the resident’s hydrocodone-acetaminophen on the eMAR, but progress notes and staff interviews showed the LPN had signed out the narcotic and the CMT took the medication and placed it in the resident’s bag for the resident to take out, rather than the LPN administering it. A second resident was cognitively intact and had diagnoses including iron deficiency anemia, severe protein-calorie malnutrition, muscle weakness, unsteadiness on feet, hemiplegia and hemiparesis following stroke, and dysphagia. The resident had an order for MS Contin 15 mg every 12 hours for pain, and the eMAR showed the LPN documented the medication as administered. Interviews with the CMT, nurse manager, DON, and administrator confirmed that the CMT had been allowed to administer narcotics and that the LPN documented administration even though the CMT gave the medication. The DON and administrator stated the nurse who prepared the medication should have been the one to administer it and document it. The facility also failed to follow its medication refusal and destruction process for another resident with severe cognitive impairment and diagnoses of dementia with agitation and depression. The resident refused medications during the night shift, and the nurse documented the refusal but then took the medications from the resident and threw them into the trash can in the resident’s room. Interviews confirmed the nurse routinely disposed of refused medications in the trash, while other staff stated unused medications should not be discarded in a resident’s room and should be placed in the designated disposal container.
Failure to promptly document and investigate alleged resident sexual contact
Penalty
Summary
The facility failed to promptly document and investigate an alleged physical relationship between two cognitively impaired residents after staff reported seeing one resident in the other resident’s room with partially unclothed behavior. The report states that staff observed the residents together and that one resident was reportedly found in the other resident’s room with pants down and the other resident’s hands on him/her, but the incident was not immediately documented or investigated as an allegation of sexual abuse. Staff interviews showed confusion about whether the behavior was a problem, and one CNA said the behavior was not reported because nurses had seen it before. Resident #33 had severe cognitive impairment on the quarterly MDS, unclear speech, and required assistance with dressing and undressing. Resident #39 also had severe cognitive impairment on the quarterly MDS and diagnoses including stroke, dysphagia, aphasia, and cognitive communication deficit. The record for Resident #39 contained no documentation of an assessment of the resident’s cognitive ability to consent to a sexual relationship. Both residents’ care plans were later updated to address a romantic/intimate relationship, but the documentation in the record did not show that the initial allegation had been promptly assessed, documented, or investigated when staff first reported the residents’ physical interactions. The facility’s own policy required documentation of observations of intimacy or sexual activity, notification of social services and the DON, physician notification for clinical and cognitive evaluation of capacity to consent, and care plan meetings as soon as possible after initial notification. Interviews showed the SW was told about the residents’ physical relationship after the fact and stated the staff should have documented the incident and who witnessed it so it could be investigated immediately. The SW also stated he/she did not notify Resident #39’s physician or update the care plan because administration did not direct it. The ADON and Administrator stated they were aware only of the residents holding hands and close interactions, and both said they did not know about the allegation that one resident had been found partially unclothed in the other resident’s room.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ellisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aegis Health And Rehabilitation | 2.1 mi | ★★★★★ | 1 | 0 |
| Delmar Gardens On The Green | 2.9 mi | ★★★★★ | 1 | 0 |
| Lutheran Senior Services At Meramec Bluffs | 3.6 mi | ★★★★★ | 2 | 0 |
| Manchester Rehab And Healthcare Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Garden View Care Center Of Chesterfield | 5.3 mi | ★★★★★ | 1 | 0 |
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