Estates Of Spanish Lake, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 610 Prigge Road, Saint Louis, Missouri 63138
- CMS Provider Number
- 265776
- Inspections on file
- 27
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Estates Of Spanish Lake, The during CMS and state inspections, most recent first.
The facility did not have an RN on duty for at least 8 hours each day, 7 days a week, as required. The DON was the only RN and was only available on-call, with no RNs scheduled on daily assignment sheets. This affected a census of 140 residents.
The facility did not immediately intervene when a resident with a history of suicidal ideation expressed a desire to commit suicide, resulting in a delay in assessment and supervision. Staff failed to remain with the resident or promptly notify a nurse, and there were gaps in behavioral health follow-up and documentation. Additionally, another resident exhibiting agitation and elopement risk was not appropriately redirected or engaged, contrary to their care plan.
A resident with a history of suicidal ideation and multiple recent suicide attempts did not receive consistent or documented psychosocial support or medically related social services. After returning from hospitalizations, the resident expressed ongoing distress and a desire for counseling, but staff responses were delayed and uncoordinated. Social Services Designees lacked qualifications and training, and the facility had no qualified social worker or outside behavioral health services, resulting in unmet psychosocial needs.
Surveyors found that multiple opened vials and pens of insulin and PPD were not properly labeled or dated, with some medications being expired or improperly stored. Medication refrigerator temperature logs were incomplete, and an Environmental Aide was able to access the medication room unsupervised using keys kept in the nurses' station. These findings indicate failures in medication labeling, storage, and access control.
The facility did not ensure that two residents' code status was properly documented and accurately reflected in their medical records. One resident had no code status or physician's order documented at admission due to the absence of a social worker, while another had conflicting information in the electronic record and code status form regarding DNR status. The DON confirmed that code status should be completed and accurate for all residents, but this was not done in these cases.
Three residents did not receive the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter when their Medicare Part A skilled services ended. Medical record reviews confirmed the absence of these notifications, and staff interviews revealed confusion over who was responsible for issuing them.
The facility did not repair damaged ceilings and water stains in two residents' bathroom, leaving plaster and paint hanging down and a large water stain unaddressed for several days, despite residents and staff being aware of the issue. Additionally, a resident's bedroom door repeatedly slammed shut and would not stay open, causing disturbances, with staff aware of the malfunction but not reporting it to maintenance in a timely manner.
A resident with a history of mental health conditions reported to a CNA that another resident had entered their room and touched their genitalia while they were sleeping. The CNA reported the allegation to a nurse, who documented the resident's account, which included some uncertainty and changes in the details. The facility did not notify the State Survey Agency within the required two-hour timeframe after the allegation was made, as the report was not submitted until several hours later.
A resident with depression and schizophrenia, who was receiving psychotropic medications, did not have a required PASRR Level II evaluation completed after the Level I screening indicated it was necessary. Only the Level I documentation was found in the medical record, and facility leadership confirmed the Level II assessment was missing.
The facility did not update care plans to reflect the current needs of three residents, including one with recent suicide attempts, one receiving dialysis, and one requiring discharge planning. Care plans failed to include recent hospitalizations, dialysis care, and discharge planning, despite staff acknowledging these omissions.
Staff did not transcribe a physician's order for a urine analysis and culture for a resident with a history of UTIs, resulting in the tests not being performed. Additionally, another resident received continuous oxygen therapy without a physician order, despite multiple documented episodes of respiratory distress and staff acknowledgment that an order was required.
Staff failed to consistently assess and document dialysis access sites and vital signs for two residents receiving dialysis, did not complete required communication forms, lacked a physician order for dialysis for one resident, and did not have contracts with dialysis providers. Interviews with nursing staff and the DON confirmed these lapses in following facility policy and documentation procedures.
Two residents did not receive or have properly documented administration of medications, pain and behavior monitoring, weekly skin assessments, and blood pressure checks as ordered. Records showed multiple missed or undocumented doses and assessments, with blanks on the MAR and TAR and no corresponding explanations in progress notes. Staff interviews confirmed that all care should be documented at the time of administration, but facility policies were not followed, resulting in incomplete records.
A facility failed to report an alleged abuse incident involving two residents, leading to a delayed investigation. The Social Service Designee did not inform her supervisor or the Administrator after being told by a CNA about witnessing an inappropriate interaction between the residents, who are siblings with mental health diagnoses. The Director of Social Services assumed the incident was reported, and the Administrator was unaware until questioned by surveyors.
The facility failed to ensure call lights were accessible to residents, affecting five residents who were unable to reach their call lights due to mobility or cognitive impairments. Observations and interviews revealed that call lights were often out of reach, leading residents to yell for help. The facility lacked a call light policy, and staff acknowledged the issue but did not consistently ensure call lights were within reach.
A resident with chronic pain and other conditions did not receive prescribed Lidocaine patches on multiple occasions due to unavailability. Staff failed to reorder the medication or notify the PCP, despite the facility's emergency kit containing the patches. The deficiency in care was identified through interviews and record reviews.
A resident at high risk for pressure ulcers did not receive proper care and documentation, leading to deficiencies in weekly skin and wound assessments and treatment applications. The facility's wound reports were inaccurate, and staff failed to adhere to policies, putting the resident at risk for complications.
A resident with a colostomy experienced complications due to the facility's failure to provide proper care and documentation. Despite the resident's complaints of pain and improper fitting of colostomy bags, the facility lacked a documented care plan and failed to apply prescribed treatments. The resident had to call 911 for assistance, leading to multiple emergency department visits. Interviews revealed that the resident was changing their own colostomy apparatus, contrary to the facility's expectations.
Failure to Provide RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by policy. Review of the daily assignment sheets over a period of more than a month showed that no RNs were scheduled during this time. The Director of Nursing (DON) confirmed in an interview that she was the only RN on staff and was only available on-call as needed, rather than being present in the facility for the required hours. The facility census at the time was 140 residents. The Administrator also acknowledged the expectation to have an RN present for at least eight hours daily, seven days a week, but this was not being met.
Failure to Immediately Intervene for Suicidal Ideation and Behavioral Health Needs
Penalty
Summary
The facility failed to immediately intervene when a resident with a recent history of suicidal ideation and multiple suicide attempts expressed a desire to commit suicide. Despite the facility's policy requiring that residents expressing suicidal tendencies not be left unattended and that staff immediately notify a nurse, there was a significant delay in response. On one occasion, the resident was observed crying and stating a wish to kill themselves, but staff did not remain with the resident or promptly assess their condition. The environmental aide informed the nurse, who was on a phone call and did not immediately check on the resident. The resident remained alone, crying and expressing suicidal thoughts, for over fifteen minutes before a nurse arrived and eventually arranged for hospital transport. The resident had a documented history of depression, anxiety, schizophrenia, and previous suicide attempts, including overdosing and attempting to strangle themselves. The care plan indicated the need for close monitoring and immediate intervention if the resident posed a threat to themselves. However, documentation showed gaps in psychosocial follow-up and a lack of consistent behavioral health services. Staff interviews revealed uncertainty about the frequency and type of behavioral health services provided, and the social services designee admitted to not documenting therapy sessions and being unsure of their own qualifications to provide therapy or assess safety for discontinuing one-on-one monitoring. Additionally, the facility failed to address the behavioral needs of another resident who became agitated and left a secured unit. Staff did not offer alternative activities or explanations, and the resident was left pacing and expressing agitation after being redirected back to the unit. The care plan for this resident identified them as an elopement risk and required interventions to distract and redirect, but these were not implemented during the observed incident. Interviews with the administrator and DON confirmed that staff did not follow expected procedures for managing agitation and supervision.
Failure to Provide Medically Related Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to support a resident with a known history of suicidal ideation, resulting in a lack of appropriate person-centered care to meet the resident's highest practical psychosocial well-being. The resident had a documented history of suicide attempts, including overdosing and attempting to strangle themselves, and was diagnosed with anxiety and schizophrenia. The care plan identified suicide risk and outlined interventions such as monitoring, notification of the physician and power of attorney, and redirection to activities. Despite these documented needs, there were significant lapses in the provision and documentation of social services and psychosocial support. After returning from multiple hospitalizations for suicide attempts, the resident did not receive consistent or documented social services follow-up. Progress notes showed gaps in psychosocial or social services documentation, with no entries between key incidents. The resident expressed ongoing distress, including crying, stating a desire to harm themselves, and reporting a lack of access to group or individual counseling. During an observation, the resident was found in bed, crying, and expressing suicidal ideation, but staff response was delayed and uncoordinated. The Social Services Designee present did not check on the resident and deferred to nursing staff, who also did not provide immediate support or intervention. Interviews with staff revealed that Social Services Designees were not qualified to provide medically related social services and had not received formal training in managing residents with suicidal ideation. The facility had been without a qualified social worker for several months, and outside behavioral health services were no longer available. Staff were unclear about the interventions in place for the resident and did not consistently document or provide the required psychosocial support, resulting in a failure to meet the resident's psychosocial needs as outlined in their care plan.
Medication Labeling, Storage, and Access Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices, specifically regarding the labeling and storage of drugs and biologicals. Observations revealed that several opened vials and pens of insulin (Levemir, Lantus, Lispro) and Tuberculin Purified Protein Derivative (PPD) were found in medication carts and rooms without proper labeling or dating. In some cases, staff were unable to identify the owner of the medication or when it had been opened, and some medications were found to be expired. Additionally, an opened and unlabeled bottle of an over-the-counter antifungal medication was found, and a Lispro insulin pen was improperly stored on a shelf instead of in the refrigerator or medication cart as required. Temperature monitoring of medication refrigerators was also deficient. The temperature log for the medication refrigerator showed multiple dates with missing documentation of temperature readings and staff signatures. The Assistant Director of Nursing (ADON) stated that housekeepers were responsible for monitoring refrigerator temperatures, but acknowledged that they may not have had pens to record the readings, resulting in incomplete logs. This practice deviated from the facility's policy, which required daily temperature documentation by nursing staff. Access to medication rooms was not restricted to authorized personnel. An Environmental Aide (EA) was observed obtaining keys from a nurses' station drawer and entering the medication room unsupervised to retrieve residents' cigarettes. The EA reported that this had been standard practice since employment, with keys always accessible in the nurses' station. The Director of Nursing (DON) confirmed that only nurses and Certified Medication Technicians (CMTs) should have access to medication rooms, and non-licensed staff should not enter these areas.
Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to ensure that residents' code status was properly documented and accurately reflected in their medical records, as required by facility policy. For one resident, who was cognitively intact and had multiple diagnoses including high blood pressure, hemiplegia, traumatic brain injury, and psychiatric conditions, there was no code status indicated in the electronic medical record and no physician's order for code status at the time of admission. The Director of Nursing confirmed that the social worker was responsible for completing the initial code status sheet, but since there was no social worker present during the resident's admission, the code status was not completed. Staff were expected to treat the resident as full code until the code status was clarified and completed. For another resident, also cognitively intact and with significant medical conditions such as heart failure, renal insufficiency, diabetes, and chronic lung disease, there was a discrepancy between the code status documented in different parts of the medical record. The computer system and care plan indicated the resident was full code, while the code status decision form, signed and dated, indicated the resident was DNR (Do Not Resuscitate). An LPN confirmed the inconsistency and stated that, in the event of an emergency, the resident would be treated as DNR based on the form, but also acknowledged the need to clarify the code status order due to the conflicting documentation. The facility's policy requires that code status be determined and documented upon admission, with communication to the interdisciplinary team and regular review during care plan conferences. The Director of Nursing stated an expectation that code status should be completed and accurate for all residents. The failure to complete and accurately document code status for these residents represents a deficiency in honoring residents' rights to make informed decisions about their care.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide required written notification to residents regarding the initiation, reduction, or termination of Medicare Part A benefits. Specifically, three residents who remained in the facility after their Medicare Part A skilled services ended did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter, as mandated by CMS guidelines. Medical record reviews confirmed that for each of these residents, there was no documentation of the SNFABN form being issued at the appropriate time. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing the SNFABN. The MDS Nurse stated that Social Services previously handled the notifications, but she had since assumed responsibility and was unaware that the forms had not been completed for all applicable residents. The Administrator and DON both indicated that they expected the SNFABN to be completed after a resident's discharge from Medicare Part A, but this was not consistently done.
Failure to Maintain Homelike Environment Due to Unrepaired Ceiling Damage and Malfunctioning Door
Penalty
Summary
The facility failed to maintain a homelike environment for its residents by not repairing damaged ceilings and water stains in resident bathrooms over a period of several days. Specifically, two residents' shared bathroom had a damaged ceiling with plaster and paint hanging down, as well as a large water stain on the wall. Both residents reported that the ceiling had been in disrepair for months, and although staff had acknowledged the issue and stated it would be fixed, no repairs had been made. One resident also reported that the ceiling sometimes leaked, and maintenance staff had inspected it but had not completed any repairs. Additionally, the facility did not ensure that a resident's bedroom door was in proper working condition. The door would not remain open and slammed shut loudly, disturbing the resident and their roommate. The resident stated that the door had been malfunctioning for a while, causing sleep disturbances, and staff were aware of the issue but had not addressed it. Staff interviews confirmed awareness of the malfunctioning door, and maintenance leadership stated they had only recently become aware of the problem, despite staff being expected to report such issues.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to notify the State Survey Agency within the required two-hour timeframe after an allegation of sexual abuse was made by a resident. According to the facility's policy, all allegations or suspicions of abuse, neglect, or exploitation must be reported immediately to the Administrator and the State Agency. In this incident, a resident reported to a CNA that another resident had entered their room and touched their genitalia while they were sleeping. The CNA promptly reported the allegation to the nurse, who then documented the resident's account, which included some uncertainty about the details due to the resident's confusion and distress. The resident involved was cognitively intact and able to express themselves clearly, with a history of mental health diagnoses including anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The incident was described as causing the resident significant distress, particularly because it resembled a previous event at another facility. The nurse's documentation noted inconsistencies in the resident's account, as the resident changed details about the incident multiple times before and after emergency services were contacted. Despite the facility's policy requiring immediate reporting, the self-report to the State Agency was not made until the following morning, several hours after the initial allegation was brought to staff attention. The DON confirmed that the report was made within two hours of her being notified, but the initial delay in escalating the allegation to the DON resulted in the facility failing to meet the required reporting timeframe.
Failure to Complete Required PASRR Level II Evaluation for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder received a required DA-124 Level II evaluation (PASRR Level II) after a Level I screening indicated the need for further assessment. The facility's policy states that prior to admission, the DA-124 is completed, and if a Level II is triggered, the assessment should be completed and reviewed to determine if the facility can meet the resident's needs. The Level II/PASRR is then to be placed in the resident's medical record and used to develop an individualized care plan. For the resident in question, who had diagnoses of depression and schizophrenia and was receiving antidepressant and antipsychotic medications, the DA-124 Level I screening indicated a Level II was required. However, upon review, only the Level I documentation was available in the resident's record, and the Administrator confirmed that the Level II evaluation was not present. Both the Administrator and the DON acknowledged that the Level II should have been completed as required.
Care Plans Not Updated to Reflect Resident Needs
Penalty
Summary
The facility failed to ensure that resident care plans were updated and accurate to reflect the current needs of three residents. For one resident with a history of suicide attempts, the care plan did not include information about recent hospitalizations for suicide ideation and self-harming behaviors, despite documented incidents where the resident attempted to harm themselves and required emergency intervention and hospitalization. The care plan remained unchanged after these significant events, and staff interviews confirmed that these incidents should have been reflected in the care plan. Another resident, who was cognitively intact and diagnosed with end stage renal disease, received regular dialysis treatments as ordered by a physician. However, the resident's care plan did not address dialysis care, monitoring of the access site, or emergency procedures related to dialysis. Staff responsible for care plan updates acknowledged that dialysis should have been included as a focus area but was omitted due to oversight. A third resident, with moderate cognitive impairment and multiple diagnoses including schizophrenia and COPD, had no documentation in the care plan regarding discharge planning, despite the need for such planning. Staff interviews confirmed that care plans are expected to be updated quarterly and with significant changes, and that information regarding dialysis, discharge planning, and suicide ideation should have been included for these residents. The care plans in use at the time of the survey did not accurately reflect these residents' current needs.
Failure to Transcribe Physician Orders and Obtain Required Orders for Oxygen Therapy
Penalty
Summary
Staff failed to ensure that services provided met professional standards of care in two separate instances. For one resident with a history of urinary tract infections (UTIs), a physician ordered a urine analysis (UA) and culture and sensitivity (C/S) test after the resident complained of pelvic pain and dysuria. However, the order was not transcribed into the computer system, and there was no documentation that the urine was collected or that the physician was notified of any results. The resident's care plan indicated ongoing antibiotic therapy and monitoring for UTIs, but the required diagnostic tests were not obtained as ordered. In a second instance, another resident who was cognitively intact and had diagnoses including chronic lung disease was observed receiving continuous oxygen therapy via nasal cannula at varying flow rates. Despite this, there was no physician order for oxygen therapy in the resident's medical record. Progress notes documented multiple episodes where the resident experienced respiratory distress and received oxygen, but staff confirmed that no physician order was present for this intervention. Both the LPN and DON acknowledged that a physician order should have been in place for the oxygen therapy.
Failure to Follow Dialysis Care Policy and Documentation Requirements
Penalty
Summary
Facility staff failed to follow their own policy for managing residents receiving dialysis, resulting in multiple deficiencies. Specifically, staff did not consistently assess or document the condition of dialysis catheters or arteriovenous (AV) fistula sites every shift for two residents who were receiving dialysis. Documentation on the Medication/Treatment Administration Record (MAR/TAR) and dialysis communication forms was incomplete, with missing entries for pre- and post-dialysis weights and site assessments. There was also a lack of documentation in progress notes regarding post-dialysis vital signs and site assessments, and no evidence that residents refused these assessments. For one resident, there was no physician order for dialysis, despite the resident receiving dialysis services. The care plan for this resident included monitoring for complications related to end stage renal disease (ESRD) and dialysis, but interventions such as checking for bruit and thrill were not documented as completed. The other resident had a physician order to attend dialysis but lacked documentation of required assessments and communication with the dialysis center. Additionally, the facility did not have contracts in place with the dialysis companies providing services to the residents. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that required documentation and assessments were not consistently performed or recorded, and that physician orders and care plans were not always complete or up to date for residents receiving dialysis.
Failure to Accurately Administer and Document Medications and Assessments
Penalty
Summary
The facility failed to ensure accurate administration and documentation of medications, weekly skin assessments, pain and behavior monitoring, and blood pressure checks as ordered by physicians for two residents. For one resident, who was cognitively intact and had diagnoses including anxiety, depression, asthma, and thyroid disorder, there were discrepancies between the controlled drug log and the Medication Administration Record (MAR) regarding the administration of alprazolam (Xanax). The records showed multiple instances where doses were either not signed out, marked as refused or held without corresponding documentation, or left blank, with no progress notes explaining the omissions. The resident reported not always receiving medications as prescribed, particularly during a hospital transfer, and there was no documentation to clarify whether medications were refused, held, or not administered. For another resident with severe cognitive impairment, multiple dependencies for activities of daily living, and diagnoses such as hypertension, hyperlipidemia, stroke, hemiplegia, dementia, and depression, the MAR and Treatment Administration Record (TAR) revealed several missed or undocumented opportunities for medication administration, pain assessments, skin checks, behavior monitoring, and blood pressure monitoring. Numerous entries were left blank, indicating that either the care was not provided or not documented, with no codes or progress notes to explain the omissions. Orders for artificial tears, senna-docusate, atorvastatin, and routine assessments were not consistently documented as completed. Interviews with staff, including an LPN and the DON, confirmed that all medications and treatments should be documented at the time of administration, and that blanks on the MAR or TAR indicate a failure to document or administer as required. The DON stated that the MAR and control log should match, and any refusals or omissions should be clearly coded and explained in the progress notes. The facility's policies require timely and accurate documentation of all care provided, but these were not followed, resulting in incomplete records and unverified administration of ordered care.
Failure to Report Alleged Abuse Delays Investigation
Penalty
Summary
The facility failed to adhere to its policy on reporting allegations of abuse, resulting in a delayed investigation into an alleged incident involving two residents. The facility's policy mandates that any suspicion or report of abuse must be communicated to the Administrator or a supervisor immediately, and an investigation should be initiated. However, the Social Service Designee, upon being informed by a CNA about witnessing an inappropriate interaction between two residents, did not report the incident to her supervisor or the Administrator. Instead, she only discussed it with the residents' counselor, which led to a delay in addressing the allegation. The residents involved in the incident were siblings, with one being cognitively intact and the other having moderately impaired cognition. Both residents had diagnoses including bipolar disorder and schizophrenia. Despite the serious nature of the allegation, there were no progress notes documenting the incident for either resident. The Director of Social Services only learned of the incident through a rumor and assumed it had already been reported. The Administrator was unaware of the situation until the surveyors' inquiry, and no investigation had been initiated by that time.
Inaccessible Call Lights in Resident Rooms
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents in their rooms, affecting five sampled residents. Observations revealed that call lights were out of reach for residents who were either bedridden or in wheelchairs, making it difficult for them to call for assistance. Interviews with residents and staff confirmed that call lights were often not within reach, and residents had to resort to yelling for help, which was not always effective. Resident #5, who was cognitively intact but had impaired vision and mobility issues, reported that the call light was always out of reach, leaving them to scream for help. Similarly, Resident #11, with moderately impaired cognitive skills and mobility issues, had to lean dangerously over the bed to reach the call light, leading to falls. Resident #12, with severe eyesight impairment and cognitive issues, could not reach the call light from their wheelchair, and the Director of Nursing acknowledged the issue but could not resolve it due to the short length of the call light string. The facility lacked a call light policy, and staff interviews highlighted that call lights were made of thin strings, which could break easily. The Director of Nursing and the Administrator both expressed expectations that call lights should be within reach and functioning, but this was not consistently ensured. The Maintenance Associate noted that rooms with two residents should have two pull cords, but this was not always the case, as seen with Resident #15, who had to rely on a roommate to access the call light.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered for a resident, leading to a deficiency in care. The resident, who was cognitively intact but had an altered level of consciousness, was on a scheduled pain medication regime due to chronic pain from trauma and other conditions such as anxiety, depression, schizophrenia, PTSD, and Parkinson's disease. The Medication Administration Record (MAR) indicated that the resident did not receive the prescribed Lidocaine patch on multiple occasions in August 2024 because it was unavailable. There was no documentation that the facility ordered the missing medication or informed the Primary Care Physician (PCP) about the issue. Interviews with staff revealed that Certified Medication Technicians (CMTs) were responsible for re-ordering medications and notifying nurses if a medication was missing. However, the nurses did not document any actions taken to resolve the issue or notify the PCP. The facility's emergency kit contained Lidocaine patches, but they were not utilized. The Administrator expected staff to follow policies, ensure medications were available, and document any issues and actions taken. The failure to administer the medication as ordered put the resident at risk of increased pain.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident, leading to deficiencies in weekly skin and wound assessments, as well as the application of treatments as ordered. The resident, who was at high risk for pressure ulcers, had a history of heart failure, stroke, diabetes, and other conditions that increased their vulnerability. Despite being admitted with no unhealed pressure ulcers, the resident developed a Stage II pressure ulcer on the buttock and an unstageable ulcer on the left heel, which were not consistently documented or treated according to the facility's policies. The facility's wound reports were inaccurate, lacking essential details such as wound measurements, tissue type, and signs of infection. The Director of Nursing (DON) and other staff failed to complete weekly skin assessments and wound assessments, and there was no documentation of treatments being applied as ordered. The resident's Treatment Administration Record (TAR) showed missing entries for skin assessments and treatments, indicating a lack of adherence to physician orders and facility policies. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin issues. The DON admitted to inaccuracies in wound reports and assessments, which hindered the facility's ability to monitor wound healing effectively. The administrator acknowledged the deficiencies and the potential risks of delayed wound healing and infection due to incomplete and inaccurate documentation. The facility's failure to follow its own policies and procedures for pressure ulcer prevention and management put the resident at risk for further complications.
Failure to Provide Proper Colostomy Care
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, leading to complications and multiple emergency department visits. The resident, who was cognitively intact but had a history of psychiatric conditions, experienced irritation and redness around the colostomy site. Despite the resident's complaints of pain and improper fitting of colostomy bags, the facility did not have a documented care plan for the resident's colostomy care, and there was a lack of documentation for the application of prescribed treatments. The resident's progress notes indicated that the resident had to call 911 due to severe pain and lack of colostomy supplies, resulting in emergency department visits. The facility's staff, including the Director of Nursing, were aware of the resident's issues but attributed the problems to the resident's behavior of removing the colostomy bags. However, the facility did not have a policy on ostomy care, and the nurses failed to document the application of prescribed treatments on multiple occasions. Interviews with the resident and staff revealed that the resident was responsible for changing their own colostomy apparatus, contrary to the facility's expectations. The facility's administrator acknowledged that the nurses were responsible for providing ostomy care and documenting treatments, but there were gaps in documentation and care. The lack of a care plan and proper documentation put the resident at risk of delayed healing and increased skin irritation.
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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