Estates Of St Louis, Llc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 2115 Kappel Drive, Saint Louis, Missouri 63136
- CMS Provider Number
- 265712
- Inspections on file
- 23
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Estates Of St Louis, Llc, The during CMS and state inspections, most recent first.
The facility failed to report an allegation of abuse to the State Survey Agency within the required two-hour timeframe after a physical altercation between two residents in the smoking area, during which one cognitively intact resident with anxiety and depression pulled another severely cognitively impaired resident to the ground and struck the resident, causing a black and purple discoloration under the eye. Facility policy on abuse reporting did not include the federally required immediate/two-hour reporting timeframe, and although nursing staff notified the ADON and the Administrator and documented the injury, leadership delayed reporting while waiting to personally observe the injury, resulting in the incident being reported to the state several days after it occurred.
The facility did not maintain resident personal funds in a separate account from its operating account and failed to provide timely refunds and monthly Social Security/Medicaid allowances to multiple residents. These actions prevented residents and their financial guardians from managing their financial affairs as required.
A resident with chronic hepatitis C did not receive appropriate follow-up care, as the facility failed to complete a clinical referral or initiate treatment despite documented recommendations and active infection. Staff were unaware of the resident's condition and did not obtain ordered labs, and there was no standard process for reviewing and acting on provider orders.
A resident with moderate cognitive impairment and lung cancer underwent lung surgery without the facility notifying the legal guardian (Public Administrator) in advance, as required by policy. Documentation and staff interviews confirmed that the PA was not informed prior to the procedure, and the lack of communication was attributed to administrative changes and missing documentation. The PA only learned of the surgery after the resident called following the procedure.
The facility failed to maintain cleanliness and proper food storage, affecting all 75 residents. Observations showed a sticky kitchen floor, debris, unsealed food, and mouse droppings in the pantry. Nine baking sheets had carbon build-up, and a mixer was rusty. Staff reported cleaning schedules, but pest issues persisted.
The facility did not follow its TB policy, failing to complete required TB screening tests for 10 employees. The DON and Administrator were unaware of the oversight. Additionally, the facility did not implement its water management plan to control Legionella growth, with the MD confirming the absence of necessary measures and documentation.
The facility failed to maintain a pest-free environment, with live mice and droppings found in the kitchen and residents' rooms. Despite regular pest control visits, residents frequently reported sightings of mice, including in their food and personal spaces. The administration acknowledged the issue, but the problem persisted, exacerbated by a shortage of housekeeping staff and inadequate documentation of pest sightings.
The facility failed to conduct CNA registry checks for two newly hired housekeepers, as required by policy. The BOM/HRM admitted oversight, and the Administrator was unaware of the lapse. The facility had hired at least 45 new employees since the last survey, with a census of 78.
The facility failed to provide written transfer or discharge notices to six residents and their representatives, omitting essential information such as the reason and location of the transfer. Interviews with staff revealed a lack of awareness and adherence to policy, with the Social Services Designee not mailing copies of the forms and the Director of Nursing acknowledging incomplete documentation.
The facility failed to provide bed hold notifications to six residents or their representatives within 24 hours of their hospital transfers. The bed hold forms were either blank, unsigned, or not provided, and staff interviews revealed a lack of awareness regarding the notification process. This oversight increased the potential for residents to be unaware of their right to request a bed hold.
The facility failed to ensure interdisciplinary team participation in care conferences for multiple residents, leading to potential unmet care needs. Despite policy requirements, care plan meetings were often attended only by the Social Services Designee and the resident or their family, with no other IDT members present. Interviews revealed that staff were either not invited or did not attend due to time constraints, highlighting a systemic issue in the care planning process.
The facility failed to issue complete and accurate Medicare Part A beneficiary notices for two residents, omitting essential information such as estimated costs and contact details for appeals. The SNFABN and NOMNC forms were not filled out entirely, and residents or their responsible parties did not make informed choices, as required by facility policy.
A resident with moderate cognitive impairment filed a grievance about visitors and rodents. While the visitor issue was addressed, the rodent concern was unresolved. The Administrator signed the grievance form instead of the resident, contrary to policy, and admitted to not following the grievance procedure.
The facility did not report an alleged physical altercation between two residents with severe cognitive impairments to the State Agency, as required by their policy. The incident involved one resident allegedly punching another, with no visible injuries. The Administrator confirmed the incident was not reported, potentially allowing further altercations.
The facility failed to investigate an alleged altercation between two residents with severe cognitive impairments, as required by their policy. One resident allegedly punched the other, but no visible injuries were noted. The incident was not investigated, potentially placing residents at risk of future altercations.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential inaccuracies in care planning and federal reimbursements. A resident's fall was not recorded, another was incorrectly coded as a smoker, a third was inaccurately diagnosed with schizophrenia, and a fourth's fall was omitted from the MDS. The RCN responsible for MDS completion was unavailable for comment.
A resident with severe cognitive impairment and multiple health issues missed a crucial eye appointment due to transportation failure, and the facility did not reschedule the appointment or follow up on routine eye care. The lack of a formal transportation policy and poor communication among staff led to the deficiency in providing timely vision care.
A resident with severe cognitive impairment was observed smoking without a required smoking apron, contrary to the facility's Smoking Policy. Staff interviews revealed a lack of awareness regarding apron requirements, contributing to the deficiency.
A facility failed to maintain an oxygen concentrator for a resident with dementia, as the filter was found covered with a gray substance. Staff were unaware of the maintenance schedule, and no policy existed for cleaning the concentrator. The DON confirmed the issue, and the RCN noted that nurses should check filters when changing tubing, but this was not documented.
The facility failed to maintain cleanliness and organization in medication rooms, leading to potential pest infestation and missing temperature logs. Observations revealed clutter, expired medications, and unsecured tablets. Staff interviews indicated confusion over cleaning responsibilities, and medication carts contained loose pills, showing inconsistent adherence to cleaning schedules.
A resident with severe cognitive impairment and no natural teeth requested dentures but did not receive timely dental care due to inactive benefits and a lack of follow-up. The facility lacked a formal transportation policy, leading to a breakdown in scheduling the necessary dental appointments.
The facility did not maintain a posting of its current survey results. The Administrator kept survey results in a yellow notebook accessible to residents but was unaware of the requirement to post surveys conducted earlier in the year. The facility's survey notebook only contained results from the previous year, despite multiple complaint investigation surveys occurring earlier in the current year.
The facility did not inform residents about the location or content of survey results. Nine residents were unaware of where to find these results, and the Resident Council Meeting Minutes lacked any discussion on this topic. Interviews revealed that the survey results were stored in a yellow notebook, but this was not communicated to the residents, leading to the deficiency.
A resident with severe cognitive impairment and a history of wandering and aggression was not consistently monitored with 15-minute face checks, leading to multiple altercations with other residents. Despite being placed on these checks, there was no documentation for several months. Staff reported challenges in monitoring due to staffing shortages and the resident's quick movements. The facility's interventions, including medication adjustments and the use of an iPad, were inconsistently applied and documented, contributing to ongoing safety issues.
A resident with Alzheimer's disease and known behaviors was not adequately monitored or provided with personalized interventions, leading to multiple altercations with other residents. Despite being on 15-minute checks, documentation was lacking, and the care plan was not updated to reflect incidents or include effective interventions. Staff interviews revealed inconsistencies in monitoring and a lack of training in managing dementia-related behaviors. The facility acknowledged its inability to meet the resident's needs.
The facility failed to ensure staff accurately documented neurological checks for a resident who experienced a fall, resulting in incomplete records and missing critical assessment details. Interviews revealed confusion among staff regarding the documentation process.
A facility failed to report an allegation that a staff member sold drugs to a resident, leading to the resident's overdose. The Administrator did not notify law enforcement when the resident identified the staff member, believing initial police presence was sufficient. The facility's policies lacked guidance on notifying law enforcement in such cases.
Failure to Timely Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the State Survey Agency within the required two-hour timeframe following a resident-to-resident physical altercation that resulted in injury. Facility policy on Abuse, Neglect and Exploitation, dated 4/8/24, defined abuse and outlined general reporting expectations but did not specify that allegations of abuse must be reported to the State Survey Agency immediately, but not later than two hours after the allegation is made, as required by federal regulations. The facility’s Abuse Prevention Plan stated that anyone could report suspected abuse to the abuse agency hotline and that the licensed nurse should respond to the resident’s needs and notify the Administrator and DON, but again did not include the mandated timeframes. The incident involved two residents. One resident, with no cognitive impairment and diagnoses including anxiety disorder and depression, had a care plan problem related to poor impulse control, hitting another resident, and noncompliance with smoking rules. Nursing documentation on the evening of the incident recorded that this resident struck another resident in the eye after an altercation over a cigarette in the smoking area. In a subsequent interview, this resident stated that the other resident drooled on them and tried to take their cigarette, and that they pulled the other resident to the ground and punched them in the nose. The resident was placed on 15-minute checks for behaviors. The other resident involved had severe cognitive impairment and diagnoses including hypertension, stroke, seizure disorder, anxiety, and depression. Nursing notes documented that this resident walked up on another resident trying to take a cigarette, drooled on the other resident, and was then hit in the eye, resulting in a black and purple discoloration under the left eye orbit. The ADON was notified by the charge nurse about the altercation and was told the injured resident had redness under the left eye, but did not review the notes or see the residents until several days later. The Administrator read the nurse’s notes describing the black eye and chose to wait to see the injury before reporting to the Department of Health and Senior Services. The incident occurred on 2/28/26 but was not reported to DHSS until 3/2/26, exceeding the required two-hour reporting timeframe.
Failure to Timely Disburse Resident Funds and Allowances
Penalty
Summary
The facility failed to ensure that resident personal funds were maintained in an account separate from the facility's operating account. Record review showed that personal funds for nine residents were held in the operating account, totaling $19,065.37, and these funds were not credited to the appropriate accounts until two days after the department began a complaint investigation. The Accounts Receivable Manager confirmed that credit balances were created due to various reasons, such as backpay and surplus adjustments, but acknowledged that the credits were not processed in a timely manner. Additionally, the facility did not provide the required Social Security and/or Medicaid monthly allowance to three residents in a timely manner. These residents did not receive their $50 monthly allowance for two consecutive months, and the funds were not refunded until several months later. The Accounts Receivable Manager was unable to explain why the deposits or Social Security payments were missing for those months. These failures prevented residents or their financial guardians from managing their financial affairs as required.
Failure to Provide Follow-Up Care and Treatment for Chronic Hepatitis C
Penalty
Summary
The facility failed to provide services according to acceptable standards of practice for a resident diagnosed with chronic hepatitis C. Upon admission, the resident had a documented diagnosis of chronic viral hepatitis C, with previous recommendations for follow-up at a hepatitis clinic and coordination with a physician regarding a medication regimen. Despite these recommendations and the presence of active infection as indicated by lab results, there was no evidence in the resident's medical record that a referral to a hepatitis clinic was made or that orders for hepatitis C treatment were initiated. Further review of the resident's care plan and medical records revealed that while the care plan acknowledged the hepatitis C diagnosis and outlined approaches such as administering medications as ordered and monitoring for symptoms, there was no documentation that the necessary labs ordered by the ARNP were obtained. Additionally, subsequent history and physical notes failed to list hepatitis C as an active or past medical concern, and there was no follow-up on abnormal lab findings or the need for hepatitis C treatment. The resident's condition progressed to cirrhosis and hepatocellular carcinoma, as documented in hospital and hepatology clinic records. Interviews with facility staff, including an LPN and the DON, indicated a lack of awareness regarding the resident's hepatitis C status and the required follow-up actions. The DON confirmed that there was no standard procedure for ensuring ARNP and physician orders were consistently reviewed and acted upon, and was unaware of the CDC's updated guidance for hepatitis C testing. The absence of a clear process for order review and follow-up contributed to the failure to provide appropriate care and treatment for the resident's chronic hepatitis C.
Failure to Notify Resident's Legal Guardian Prior to Lung Surgery
Penalty
Summary
The facility failed to ensure that a resident's legal guardian, the Public Administrator (PA), was informed in advance of a significant medical treatment—lung surgery to remove the right upper lobe for cancer. According to the facility's policy, the nurse supervisor or charge nurse is required to notify the resident's family or representative within 24 hours of a significant change in condition or the need for hospital transfer, except in emergencies. Documentation and interviews revealed that the PA was not notified prior to the surgery, and there was no evidence in the resident's progress notes of communication with the PA regarding the surgery. The resident in question had moderate cognitive impairment and diagnoses including COPD, lung cancer, bipolar disorder, and a personality disorder. The care plan specified that the PA should be actively involved in care decisions, including being invited to meetings and contacted about concerns. The last documented contact with the PA's office regarding the resident's lung cancer was for consent to a bronchoscope procedure, with no further communication about the subsequent surgery. The PA's office only became aware of the surgery after the resident personally called them following the procedure. Interviews with facility staff, including the ADON, LPNs, and CMT, confirmed that the responsibility for notifying the PA lay with the charge nurse or DON, but none could confirm that notification occurred. Staff cited changes in administration and lack of documentation as contributing factors. The administrator and DON acknowledged that approval from the PA should have been obtained prior to treatment, and that progress notes should reflect such communication, but were unable to verify that this was done.
Facility Fails to Maintain Cleanliness and Proper Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper storage standards in the kitchen and pantry areas, which had the potential to affect all 75 residents. Observations revealed that the kitchen floor was sticky and littered with debris, including dust, paper, and food particles. The freezer contained unsealed bags of donuts and had a sticky substance on its exterior, while the pantry floor was cluttered with a soda can, plastic bag, and mouse droppings. Additionally, mouse droppings were found in a box of chicken noodle soup and on cans of food, with a baby mouse discovered in a drawer labeled 'Applications.' Further observations noted that nine large baking sheets had a build-up of black carbon, and the large stand mixer had a rusty base and chipped paint. The inside of the microwave contained dried food particles, and a large deep dish baking pan also had black carbon build-up. Interviews with the Dietary Manager and a Dietary Aide revealed that the kitchen was supposed to be cleaned between meal preparations and at the end of each shift. However, the presence of mouse droppings and live mice sightings indicated ongoing pest issues, despite staff signing off on cleaning schedules.
Failure to Implement TB Screening and Water Management Plan
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) policy by not completing the required TB screening tests for 10 employees in a timely manner. The policy mandates a two-step TB test upon hire and an annual one-step test for all employees. However, the review of employee files revealed missing documentation for both the initial two-step and the annual one-step tests for several staff members. Interviews with the Director of Nursing (DON) and the Administrator indicated a lack of awareness regarding the incomplete TB tests, with the DON acknowledging responsibility but unable to explain the oversight. The facility recently hired an Assistant Director of Nursing (ADON) to manage the TB testing process. Additionally, the facility did not implement its water management plan to identify and control the growth of Legionella and other waterborne pathogens. The Maintenance Director (MD) confirmed the absence of text and flow diagrams of the water system and acknowledged that no measures were in place to prevent Legionella growth. The Director of Operations (DO) had previously sent the MD an assessment to complete, which included testing for specific organisms, mapping the water system, and monitoring water temperatures, but it was not completed. This lack of action indicates a failure to validate the effectiveness of control measures as outlined in the facility's water management policy.
Pest Infestation in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of live mice and mouse droppings in both the dietary area and residents' rooms. Observations revealed a live mouse and droppings in the kitchen's dry storage pantry, and multiple residents reported seeing mice in their rooms. The Dietary Manager acknowledged the issue, stating that pest control visits the facility twice a month, but confirmed the presence of droppings in the storage area. Despite the pest control efforts, the problem persisted, with residents frequently reporting sightings of mice. Several residents, including those with cognitive impairments and mental health diagnoses, reported seeing mice in their rooms and common areas. Interviews with residents revealed that they had observed mice in various locations, including near dressers, under beds, and in restrooms. Some residents reported finding mouse droppings on their food, leading them to avoid eating meals prepared by the facility. The facility's pest control logs indicated regular visits by a pest control company, but the issue remained unresolved, with residents continuing to express concerns about the rodent problem. The facility's administration and staff were aware of the rodent issue, with the Administrator acknowledging the problem and the Director of Nursing admitting a lack of documentation on pest sightings. The facility had contracted multiple pest control companies, but the problem persisted, exacerbated by a shortage of housekeeping staff. The Resident Council and Ombudsman also noted ongoing complaints about the rodent issue, with residents expressing dissatisfaction with the facility's efforts to address the problem. Despite attempts to control the rodent population, the facility failed to ensure a pest-free environment, compromising the sanitary conditions and potentially exposing residents to health risks.
Failure to Conduct CNA Registry Checks for New Employees
Penalty
Summary
The facility failed to ensure that newly hired employees were properly screened to rule out the presence of a Federal Indicator on the Certified Nurse Aide (CNA) Registry for two staff members. A review of a sample of 10 employee files revealed that two housekeepers, hired on 10/2/23 and 9/18/24, did not have the required CNA registry checks performed. This oversight occurred despite the facility's policy, which mandates background, reference, and credentials checks for all employees prior to or at the time of employment. During interviews, the Business Office Manager/Human Resource Manager (BOM/HRM) acknowledged responsibility for ensuring CNA registry checks for all employees and admitted that these two employees were overlooked. The Administrator also expressed an expectation that the facility's policy be followed and was unaware that the CNA registry checks had not been completed for these employees. The facility had hired at least 45 new employees since the last survey, and the census at the time was 78.
Failure to Provide Proper Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to six residents and their representatives, as required by policy. The notices were supposed to include the reason for the transfer, the location of the transfer, and information on how to appeal the transfer. This deficiency was identified through a review of records, interviews, and policy review, revealing that the facility did not comply with its own standards for notifying residents, their representatives, and the Ombudsman. For Resident 9, the transfer and discharge documents dated March 28 and July 13 did not include the reason or location of the transfer, and copies were not provided to the resident or their representative. Similarly, Resident 13's transfer document dated August 23 lacked the necessary information and was not shared with the resident or their representative. Resident 28 experienced multiple transfers, and none of the documents for these transfers included the required information or were provided to the resident or their representative. Interviews with facility staff, including the LPN, Social Services Designee (SSD), and Director of Nursing (DON), revealed a lack of awareness and adherence to the policy. The SSD admitted to not mailing copies of the transfer/discharge forms to the residents' representatives and only verbally reporting to the Ombudsman. The DON acknowledged that the forms were not being completed correctly and that the expectation was for the forms to be filled out and copies provided to the residents and their representatives.
Failure to Provide Bed Hold Notifications for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed hold notifications to six residents or their representatives within 24 hours of their emergent transfer to the hospital. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy required that a bed hold notification be given upon admission and at the time of transfer to the hospital, but this was not adhered to. For residents R9, R13, R17, R28, R78, and R129, the bed hold forms were either blank, unsigned, or not provided at all during their hospitalizations. Interviews with the Social Services Designee (SSD) and the Director of Nursing (DON) revealed a lack of awareness and communication regarding the requirement to provide these notifications and obtain necessary signatures. The report highlights specific instances where residents were transferred to the hospital without receiving the required bed hold notifications. For example, R9 was transferred to the hospital multiple times without receiving a completed bed hold form. Similarly, R17 was sent to the emergency department on several occasions without the necessary documentation being completed. The SSD admitted to not sending out copies of the bed hold policy upon transfer, and the DON was unaware of this oversight. This failure to provide proper notification increased the potential for residents to be unaware of their right to request a bed hold, potentially affecting their ability to return to the facility.
Lack of Interdisciplinary Participation in Care Conferences
Penalty
Summary
The facility failed to ensure that all Interdisciplinary Team Members (IDT) participated in quarterly care conferences for 12 of 24 sampled residents. This deficiency was identified through interviews, record reviews, and facility policy reviews. The facility's policy, revised on 08/24/24, mandates that care plan conferences should include the interdisciplinary team, the resident, and the responsible party or guardian. However, the review of care plan meeting notes for several residents revealed that only the Social Services Designee (SSD) and occasionally the resident or their family attended these conferences, with no other IDT members present. For instance, Resident 9, who was readmitted with a primary diagnosis of heart failure, had care plan meetings attended only by the SSD and the resident. Similarly, Resident 12, admitted with hemiplegia and hemiparesis following a stroke, also had care plan meetings attended solely by the SSD and the resident. This pattern was consistent across multiple residents, including those with complex medical conditions such as dementia, chronic obstructive pulmonary disease, Alzheimer's Disease, and schizoaffective disorder, among others. The absence of other IDT members in these meetings indicates a systemic issue in the facility's care planning process. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed a lack of clarity and communication regarding the attendance of IDT members at care conferences. Some staff members reported never being invited to these meetings, while others indicated that they were informed but did not attend due to time constraints or staffing issues. The DON acknowledged that all disciplines should attend care conferences but noted that staff often do not show up despite being notified. This lack of participation from the IDT potentially leaves residents with unmet care needs, as the comprehensive input required for effective care planning is not being utilized.
Failure to Issue Complete Medicare Notices
Penalty
Summary
The facility failed to correctly issue Medicare Part A beneficiaries the CMS-10055 Skilled Nursing Advanced Beneficiary Notice (SNFABN) when residents completed therapy or skilled nursing services. This deficiency was identified for two residents, who were not provided with complete and accurate SNFABN and Notice of Medicare Non-Coverage (NOMNC) documents. The documents lacked essential information such as the estimated cost to continue therapy, contact details for the Medicare contractor, and information for the Quality Improvement Organization (QIO) in case of an appeal. Additionally, the residents or their responsible parties did not make a choice on the SNFABN forms, which were signed without selecting an option. The facility's policy required that these notices be delivered at least two calendar days before Medicare-covered services ended. However, the Social Services Designee and the Director of Operations indicated that the forms were not filled out completely and were not provided in a timely manner. The deficiency was further compounded by the lack of clarity on who was responsible for issuing these forms, as there was a discrepancy between the business office and the Social Services Designee regarding their roles in this process.
Failure to Resolve Resident Grievance Timely
Penalty
Summary
The facility failed to resolve grievances in a timely manner for a resident, identified as R23, who had filed a grievance concerning two issues: the number of visitors in his roommate's room and the rodent population within the facility. While the concern regarding the visitors was addressed by the Administrator, the issue related to the rodent population was not resolved, and the grievance form lacked the resident's signature indicating satisfaction with the resolution. Instead, the form was signed by the Administrator, which was against the facility's grievance policy. The resident, R23, who has a moderate cognitive impairment as indicated by a BIMS score of nine out of 15, expressed that the rodent issue remained unresolved months after the grievance was filed. The Administrator admitted to not following the grievance policy and acknowledged signing the form that should have been signed by the resident. The Social Services Director, initially responsible for handling grievances, was overwhelmed, leading the Administrator to take over the process, yet failing to resolve the resident's concerns adequately.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to timely report an alleged physical altercation between two residents to the State Agency (SA), as required by their policy. The incident involved Resident 13 and Resident 17, both of whom have severe cognitive impairments as indicated by their Brief Interview of Mental Status (BIMS) scores. Resident 17 allegedly punched Resident 13 in the eye on November 30, 2024, but there were no visible injuries reported. Despite the incident, Resident 13 did not recall the altercation and expressed no fear of staff or other residents during an interview conducted on December 18, 2024. The facility's policy mandates immediate reporting of any allegations or suspicions of abuse, neglect, or exploitation to the Administrator and other relevant authorities, including the State Survey and Certification agency. However, the Administrator confirmed during an interview on December 18, 2024, that the incident was not reported to the SA. This oversight had the potential to allow continued resident-to-resident altercations, as the facility did not adhere to its own policy for reporting such incidents.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged altercation between two residents, R13 and R17, which was a violation of their Abuse, Neglect, and Exploitation Policy. The policy mandates that any suspicion of abuse must be communicated to the facility's Administrator or designee, who must then initiate an investigation. This investigation should include interviewing all witnesses separately, obtaining signed and dated witness statements, and documenting the investigation chronologically. However, the Administrator confirmed that the alleged incident between R13 and R17 was not investigated as required. Resident R13, who was admitted with a primary diagnosis of dementia, had a severe cognitive impairment with a BIMS score of three out of 15. Similarly, Resident R17 also had severe cognitive impairment with a BIMS score of five out of 15. According to R17's progress note, R17 allegedly punched R13 in the eye, although there were no visible injuries. During an interview, R13 stated he did not recall the incident and was not afraid of any staff or residents. The lack of investigation into this incident had the potential to place residents at risk of future altercations.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four residents, leading to potential inaccuracies in federal reimbursements and care planning. Resident 9 was readmitted with a primary diagnosis of heart failure and had a fall on 07/08/24, which was not recorded in the MDS assessment dated 07/13/24. Resident 37, with a primary diagnosis of pulmonary fibrosis, was incorrectly coded as a smoker in the MDS assessment dated 12/04/24, despite a Smoking Safety Evaluation indicating otherwise. The facility's document on residents who smoke did not include Resident 37. Resident 32 was admitted with a diagnosis of schizophrenia, but interviews with the Regional Corporate Nurse (RCN) and Director of Operations (DOR) revealed that the resident did not have this diagnosis. Resident 19, with diagnoses including intellectual disabilities and dementia, had a fall on 01/16/24, which was not reflected in the MDS assessment dated 02/16/24. The Corporate Director of Operations confirmed that the RCN was responsible for completing the MDS, but the RCN was unavailable for an interview.
Failure to Reschedule Missed Eye Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision due to a series of oversights and miscommunications. The resident, who had severe cognitive impairment and multiple diagnoses including diabetes and dementia, missed a crucial eye appointment for retina surgery and cataract surgery because the transportation did not show up. The staff did not reschedule the appointment after it was missed, and there was no follow-up on the resident's routine eye care. The resident's medical records lacked documentation of the missed appointment and any subsequent actions to address the issue. Interviews with facility staff revealed that there was no formal transportation policy, only a protocol that was not effectively followed. The Administrator was unaware of the missed appointment until the day of the interview and acknowledged that the appointment should have been rescheduled immediately. The resident was not listed for an upcoming eye visit due to missing consent forms, further delaying necessary care. The lack of communication and documentation among the interdisciplinary team and transportation staff contributed to the deficiency in providing timely and appropriate vision care for the resident.
Failure to Ensure Resident Wore Smoking Apron
Penalty
Summary
The facility failed to ensure that a resident identified as requiring a smoking apron wore one while smoking, placing the resident at risk for injury. The facility's Smoking Policy mandates that residents who are supervised smokers and require smoking assistance, such as smoking aprons, must have these needs addressed and care planned for preventative measures. The resident in question, who has severe cognitive impairment and is a smoker, was observed smoking without a smoking apron, despite the care plan indicating the need for one. Interviews with facility staff revealed a lack of awareness and clarity regarding the requirement for smoking aprons. A Certified Nurses Aid (CNA) was unsure of the location of the aprons and which residents required them. The Social Services Designee confirmed that the resident should wear an apron during smoking, and the Director of Nursing admitted uncertainty about how staff were informed of the apron requirements. This lack of communication and adherence to policy contributed to the deficiency observed.
Failure to Maintain Oxygen Concentrator
Penalty
Summary
The facility failed to provide proper maintenance for an oxygen concentrator used by a resident with severe cognitive impairment and a primary diagnosis of dementia. The resident was receiving oxygen therapy as part of their care plan due to ineffective gas exchange. During an observation, it was noted that the oxygen concentrator's external filter was covered with a light gray substance, indicating it had not been cleaned. Interviews with facility staff revealed a lack of awareness regarding the maintenance of the oxygen concentrator, and it was unclear when the filter was last cleaned. The Director of Nursing confirmed the presence of the gray substance on the filter and stated that the hospice agency was responsible for the maintenance of the oxygen concentrator. However, the facility did not have a policy in place for the maintenance or cleaning of oxygen concentrators. The Regional Corporate Nurse mentioned that nurses should check the filter when changing the tubing, but this practice was not documented in a formal policy. This oversight had the potential to impact the effectiveness of the oxygen therapy provided to the resident.
Medication Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness and organization of two medication rooms, which could potentially lead to pest infestation. Observations revealed paper dirt, trash debris, and clutter, including personal belongings, on the countertops. The medication refrigerator lacked a current temperature log for December, and previous months' logs were missing. Interviews with the Director of Nursing and staff indicated that Certified Medication Technicians (CMTs) were responsible for cleaning and maintaining temperature logs, but there was confusion and difficulty due to storage space shortages. Additionally, expired medications and syringes were found on the medication cart, and unsecured tablets were observed. Further observations of the medication carts revealed loose pills in various drawers, indicating a lack of regular cleaning and organization. Interviews with staff, including Licensed Practical Nurses (LPNs) and CMTs, showed a lack of awareness regarding cleaning schedules for the medication carts. The Director of Nursing stated that carts should be cleaned daily or at least weekly, but this was not consistently practiced. The presence of loose pills and expired items on the carts highlights the facility's failure to adhere to its policy on medication storage and labeling.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to provide necessary dental care services to a resident who requested dental services. The resident, who has severe cognitive impairment and is fully edentulous, expressed interest in obtaining full dentures. Despite having impressions completed for dentures, the process was halted due to the resident's dental benefits not being active at the time. The resident's benefits became effective in January 2025, but the facility did not schedule a dental appointment to continue the denture process. The deficiency was further compounded by a lack of a formal transportation policy, which led to a breakdown in communication and follow-up. The transportation staff responsible for scheduling appointments was out of work, and interim arrangements failed, resulting in the resident not being placed on the dental appointment list. The facility's administrator acknowledged the oversight and indicated that the dental appointment was being scheduled after the issue was identified.
Failure to Post Current Survey Results
Penalty
Summary
The facility failed to maintain a posting of its current survey results, as required. An interview with the Administrator revealed that the survey results are kept in a yellow notebook accessible to residents. However, the Administrator admitted to only maintaining the state and life safety survey results and was unaware of the requirement to post surveys conducted earlier in the year. A review of the facility's survey notebook showed it only contained the recertification/complaint survey results from the previous year, despite the Missouri Department of Health and Senior Services website indicating multiple complaint investigation surveys had occurred earlier in the current year.
Failure to Inform Residents of Survey Results
Penalty
Summary
The facility failed to inform and review with residents the results of the facility's surveys. During a group meeting, nine residents expressed that they were unaware of the location of the survey results and that these results were never discussed with them. The review of the Resident Council Meeting Minutes, provided by the Activity Director, did not show any discussion of past survey results or their location. This indicates a lack of communication between the facility administration and the residents regarding survey outcomes. Interviews with the Administrator and the Activities Director revealed that the survey results were kept in a yellow notebook outside the copier room, but this information was not communicated to the residents. The Administrator assumed that the residents were informed about the survey results' location during discussions of residents' rights, which was not the case. The Activities Director confirmed that while residents' rights are discussed monthly, the survey results and their location have never been addressed. This oversight led to the residents being uninformed about the survey results, contributing to the deficiency.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure residents were free from physical abuse and did not follow its policies to prevent resident-to-resident abuse. This was evident when staff failed to consistently monitor a resident during 15-minute face checks, an intervention for wandering. This oversight contributed to multiple resident-to-resident altercations, affecting the safety and privacy of other residents on the secured unit. The facility's policies on abuse, neglect, and exploitation, as well as supervision and management of residents with behaviors, were not adequately implemented. The resident involved had a history of severe cognitive impairment, Alzheimer's disease, depression, and anxiety, with documented behaviors of wandering and physical aggression towards others. Despite being placed on 15-minute checks due to these behaviors, there was no documentation of these checks for several months. The resident was involved in multiple altercations with other residents, resulting in injuries and hospital evaluations. The facility's failure to document and consistently perform the 15-minute checks contributed to these incidents. Interviews with staff and the resident's Power of Attorney revealed that the facility's interventions were insufficient and inconsistently applied. Staff reported difficulties in monitoring the resident due to staffing shortages and the resident's quick movements. The facility attempted various interventions, such as medication adjustments and the use of an iPad for engagement, but these were not consistently effective or documented in the resident's care plan. The lack of consistent monitoring and documentation, along with inadequate staffing, contributed to the ongoing safety issues.
Failure to Manage Resident with Dementia Leads to Altercations
Penalty
Summary
The facility failed to ensure a resident with Alzheimer's disease and known behaviors attained or maintained their highest practicable mental and psychosocial well-being. The staff did not provide increased behavioral monitoring or update the resident's care plan with identified triggers, personalized interventions, and meaningful activities focused on the resident's preferences. This failure resulted in a resident-to-resident altercation. The resident had a history of severe cognitive impairment, physical behavioral symptoms directed towards others, and wandering, which were documented in their Minimum Data Set (MDS) assessment. The resident's progress notes indicated multiple incidents of wandering into other residents' rooms, leading to physical altercations. Despite being placed on 15-minute face checks due to wandering, there was no documentation of these checks for several months. The facility's investigation into a resident-to-resident altercation revealed that the resident's care plan was not updated to reflect the incident or include specific interventions such as 1:1 supervision. Interviews with staff and the resident's Power of Attorney (POA) highlighted a lack of communication and effective interventions to manage the resident's behaviors. The facility's policies on supervision and management of residents with behaviors, care planning, and communication documentation were not effectively implemented. Staff interviews revealed inconsistencies in monitoring and documenting the resident's behavior, as well as a lack of training in managing dementia-related behaviors. The facility's attempts to use interventions such as an iPad and signage were not successful, and the resident continued to wander and engage in altercations. The facility acknowledged its inability to meet the resident's needs and was seeking alternative placements for the resident.
Failure to Document Neurological Checks
Penalty
Summary
The facility failed to ensure staff completely and accurately documented neurological checks for a resident who experienced a fall. The facility's Fall Policy mandates that staff perform and document frequent neurological assessments for a minimum of 72 hours following a fall, especially if the fall was unwitnessed or if the resident hit their head. However, the documentation for the resident in question was incomplete, with missing times and lack of documentation for pupil size and reactivity, which are critical components of the neuro checks. The resident, who had severe cognitive impairment and diagnoses including high blood pressure, Alzheimer's Disease, and depression, was found on the floor with a bleeding cut under their right eye. The resident was alert and responsive but was taken to the hospital for further evaluation. Upon return to the facility, the resident's neuro checks were supposed to be documented as per the Fall Policy, but the records showed significant gaps and omissions in the required assessments. Interviews with the facility staff revealed confusion and lack of adherence to the Fall Policy. One LPN admitted to not filling out the neuro check form because the resident was not in the facility at the time, while another LPN stated that they started the neuro checks upon the resident's return from the hospital. The facility's Administrator and Regional Director of Operation acknowledged that the Fall Policy was not followed as written and emphasized the importance of accurate documentation to ensure the resident's stability and to monitor for any changes in condition.
Failure to Report Allegation of Staff Providing Drugs to Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to law enforcement as required. The resident alleged that a Certified Medication Technician (CMT) sold them a pill containing cocaine and Fentanyl, which led to the resident becoming unresponsive and requiring emergency medical intervention. The facility's Administrator did not report this allegation to the police, believing that the initial police presence during the emergency response was sufficient. However, the facility's investigation did not include notifying law enforcement when the resident identified the staff member who provided the drugs. The facility's policies on abuse, neglect, and exploitation did not include guidance on when to notify law enforcement, and the drug and alcohol policy did not address the specific situation of a drug overdose or the involvement of staff in providing illicit substances. The resident, who had a history of psychotic disorder and meth abuse, was found unresponsive in their room and required administration of Narcan by staff before being transported to the hospital by EMS. The resident later disclosed that they had purchased the drugs from the CMT and consumed them, leading to the overdose. During interviews, the Administrator acknowledged that the police should have been notified when the resident provided the staff member's name. The facility's investigation confirmed that the resident tested positive for cocaine and Fentanyl but did not show that law enforcement was notified about the staff member's involvement. The facility's failure to report the allegation to law enforcement as required constitutes a deficiency in their handling of the situation.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
