Florissant Valley Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 1200 Graham Road, Florissant, Missouri 63031
- CMS Provider Number
- 265112
- Inspections on file
- 24
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Florissant Valley Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple neurological and vascular conditions did not receive a newly prescribed medication for nerve pain after returning from a neurology appointment, as staff failed to follow up on the physician's order and did not add the medication to the resident's regimen until it was brought to their attention by a family member.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with a history of anxiety was not given alprazolam (Xanax) as ordered after admission, due to delays in obtaining a signed prescription and lack of timely communication with the physician and pharmacy. The medication was not administered for several scheduled doses, and staff did not utilize the emergency kit or notify the physician about the missed doses, resulting in increased anxiety and tearfulness for the resident.
The facility failed to ensure that call lights and communication devices were within reach for several residents, leading to a deficiency. Residents with various impairments, including cognitive and physical limitations, were observed with call lights clipped to privacy curtains or placed on furniture out of reach. A nonverbal resident's communication tools were also inaccessible. Staff interviews confirmed the expectation for accessibility, but this was not consistently met.
The facility failed to properly manage the resident trust account, affecting 44 residents. The BOM admitted that there was no consistent cash amount on hand for withdrawals, and no ongoing tracking or monthly reconciliation was conducted. A discrepancy of $50.00 was found between the calculated and actual cash in the cash box. The Administrator expected routine reconciliation and proper tracking to prevent fund misplacement.
The facility failed to provide timely incontinence care, bathing, and repositioning for several residents, leading to potential risks of skin breakdown and urinary tract infections. Residents were left in saturated briefs for extended periods, and some did not receive the minimum of two showers per week. Observations confirmed unkempt hair and beards, and incomplete shower sheets. Residents requiring assistance with repositioning were not turned every two hours, compromising their dignity and health.
A facility failed to provide sufficient nursing staff, resulting in residents being left in bed, meals served cold, and inadequate personal care. Observations and interviews revealed that residents did not receive timely assistance with activities of daily living, such as getting out of bed and receiving showers. Staffing records showed insufficient numbers of CNAs and LPNs on duty, impacting care delivery. Staff confirmed the facility was short-staffed, affecting their ability to provide timely care and services.
The facility failed to deliver meals at safe and palatable temperatures, affecting several residents. Observations showed that warming carts were often left unplugged and open, leading to cold food. Residents with various medical conditions reported dissatisfaction with meal temperatures, and staff interviews confirmed the issue. The administrator acknowledged the problem and identified the need for proper use of warming carts.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, leading to lapses in infection control. Staff did not consistently wear gowns and gloves during care, and hand hygiene practices were inadequate during perineal care. Additionally, the facility neglected TB screening for residents and employees, with missing documentation and tests not read before employment.
The facility did not designate a qualified infection preventionist (IP) with specialized training for its infection control program. The DON had not completed the IP certification, and the previous IP had left a month prior. The Administrator believed the DON had completed the certification and expected a designated person to be trained and certified. The facility's policy outlined responsibilities for infection surveillance, but the deficiency remained unaddressed.
The facility failed to maintain the dignity of three residents by leaving one exposed to the hallway and referring to two others as 'feeders' during meal assistance. A resident was left uncovered and visible from the hallway, while a CNA stood over two residents during meals, using disrespectful language. Staff interviews confirmed these actions violated dignity expectations.
The facility failed to ensure proper assessment and supervision of two residents during medication administration. One resident with severe cognitive impairment and another with moderate cognitive impairment were found with medications left at their bedside without supervision. Facility staff confirmed that residents should be observed during medication administration, but this protocol was not followed, resulting in a deficiency.
The facility failed to complete third party liability (TPL) forms within 30 days for deceased residents with remaining funds, affecting three residents. The Business Office Manager was behind on submissions due to her recent start and learning curve, while the Administrator expected timely compliance with state regulations.
The facility failed to maintain a safe and homelike environment for two residents due to water damage in their shared room. Observations showed water stains, peeling wallpaper, and flaking paint. Staff and family reported ongoing water leaks, with temporary measures like bedspreads used to catch water. Maintenance was aware but delayed repairs, citing a flat roof issue. The Administrator expected timely repairs and a homelike environment.
The facility failed to notify the State LTC Ombudsman of resident transfers and discharges, as required by policy. The SSD, responsible for these notifications, admitted to not sending any since starting in May 2024. The Ombudsman reported not receiving notifications for five to six months, and the Administrator expected monthly notifications. The facility's policies lacked guidance on this requirement.
The facility failed to provide transportation for two residents, resulting in missed medical appointments. One resident with multiple health issues missed appointments due to the need for special transportation, which was not arranged. Another resident with Parkinson's and Alzheimer's missed three neurology appointments. The transportation scheduling process was flawed, with communication and documentation issues noted by staff and residents.
The facility failed to provide proper wound care and skin treatment for two residents. A resident with dementia and diabetes had an undocumented wound on the left flank with no treatment order, while another resident with dry skin and lower extremity issues received ineffective treatment. Staff interviews revealed a lack of awareness and follow-up on treatment plans.
The facility failed to follow physician orders for oxygen administration for two residents, leading to deficiencies in respiratory care. One resident received oxygen at 5L instead of the ordered 2L, without physician notification or documentation of oxygen saturation levels. Another resident received oxygen without the required humidifier, contrary to physician orders. Staff interviews confirmed the expectation to adhere to physician orders, which was not met in these cases.
The facility failed to document and monitor dialysis care for two residents receiving hemodialysis. One resident's care plan lacked documentation of monitoring the dialysis access site, while another's care plan did not reflect the physician's orders for AV fistula checks. Staff interviews indicated a lack of reassessment and documentation upon residents' return from dialysis.
The facility failed to store medications according to professional principles, with expired medications found in medication carts and rooms. Observations showed a FreeStyle Libre sensor kit expired in the South medication room, and Assure Platinum Strip containers in the North and South carts lacked opening dates. Interviews confirmed the need for proper labeling and removal of expired items, as per the facility's policy.
The facility failed to maintain complete and accurate documentation for two residents. One resident left with family and did not return, with no documentation of the discharge circumstances. Another resident's neurological assessments were inaccurately documented by an LPN not on duty. The facility lacked a policy for accurate medical record documentation.
The facility did not employ sufficient staff with the appropriate skills to manage the food and nutrition service after the Dietary Manager was terminated. This failure to designate a new Director of Food and Nutrition Services had the potential to impact all 76 residents.
The facility did not maintain kitchen cleanliness or adhere to cleaning schedules, resulting in unclean equipment and floors. Food was improperly stored, risking cross-contamination, and items were not labeled or dated. These issues potentially affected all 76 residents consuming food from the facility.
The facility was cited for failing to maintain an effective pest control program, leading to the presence of flies and gnats in the kitchen. This issue was identified through observation and interview during a survey, with a census of 76 residents at the time.
The facility failed to employ sufficient staff for food and nutrition services after the Dietary Manager's termination, leading to unsanitary kitchen conditions. Observations showed staff did not maintain cleanliness, proper food storage, or safety, and failed to document necessary logs. Interviews revealed the former DM did not perform required inspections, and the Administrator found the DM's office disorganized, with no sanitation surveys available.
The facility failed to maintain a clean and sanitary kitchen environment, with observations of unclean equipment, floors covered in debris, and improper food storage practices. The kitchen's back hall was cluttered, and the dry storage area was disorganized, making it difficult to rotate stock. Interviews revealed a lack of adherence to cleaning protocols and food safety practices, posing a risk to resident health.
The facility failed to maintain an effective pest control program, leading to the presence of flies and gnats in the kitchen. Observations revealed pests throughout food prep areas, near the walk-in cooler, and around the dishwasher and ice machine. Interviews with staff confirmed the kitchen's dirty condition attracted pests, despite expectations for a pest-free environment.
The facility did not follow its abuse and neglect policy by failing to conduct required background checks and federal indicator checks for a rehired RN. The RN, initially hired and later terminated, was allowed to work a shift without these checks being completed, as confirmed by the Area Director of Operations.
A resident at risk for pressure ulcers was not frequently repositioned or provided timely incontinence care, resulting in new pressure ulcers. The resident was found with soaked bedding and expressed discomfort. A CNA reported the issue, but the Wound Nurse and Physician were unaware until later. The facility's leadership acknowledged unmet expectations for care.
Failure to Follow Physician Orders for New Medication After Outside Appointment
Penalty
Summary
The facility failed to provide services in accordance with professional standards of quality for one resident when staff did not follow physician orders for a new medication. After returning from a neurology appointment, the resident, who had moderately impaired cognition and diagnoses including Wernicke's encephalopathy, muscle wasting, diabetes, and vascular diseases, was prescribed gabapentin 100 mg daily to treat nerve pain. The after-visit summary from the neurologist included this new medication order. However, the facility did not implement the physician's order for gabapentin for 10 days following the resident's return. The medication was not added to the resident's medication list, and staff did not follow up to obtain the necessary paperwork or clarify the order with the physician's office. The omission was only discovered when a family member inquired about the medication, prompting staff to contact the physician and obtain the order for gabapentin.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Administer Ordered Alprazolam and Notify Physician
Penalty
Summary
A deficiency occurred when a resident was not administered alprazolam (Xanax) as ordered following admission from the hospital. The resident had a history of anxiety and was discharged from the hospital with an order for Xanax 1 mg three times daily, which had been administered routinely during the hospital stay. Upon admission, the facility had an order for the same dosage and schedule, but the medication was not given as prescribed due to issues obtaining a signed prescription and pharmacy approval. Facility records show that the medication was not administered for several scheduled doses, with documentation indicating the medication was on hold or not available. There was no evidence that staff contacted the physician or pharmacy in a timely manner to resolve the issue or to access the medication from the emergency kit, which contained lower-dose alprazolam tablets. The physician was not notified that the resident had missed multiple doses, and the pharmacy did not receive any calls from the facility requesting access to the emergency supply. As a result of the missed doses, the resident experienced increased anxiety and tearfulness. The physician confirmed that she was unaware of the missed doses and expected to be notified of any medication issues. The facility's Director of Nursing acknowledged that staff should have verified the medication order and obtained the necessary prescription promptly, and that proper documentation and communication protocols were not followed.
Failure to Ensure Accessibility of Call Lights and Communication Devices
Penalty
Summary
The facility failed to provide reasonable accommodation of individual needs and preferences by not ensuring that call lights were within reach for six residents and a communication device was not accessible for one resident. This deficiency was observed during a survey where multiple residents were found unable to reach their call lights, which were often clipped to privacy curtains or placed on furniture out of reach. For instance, Resident #12, who had severe cognitive impairment and required assistance for various activities of daily living, was observed with a call light clipped to a privacy curtain, making it inaccessible when the resident attempted to get out of bed. Similarly, Resident #23, who was dependent on staff for toileting hygiene and other activities, had a call light positioned on top of a set of drawers, out of reach. Resident #174, who had difficulty swallowing and weakness, was found with a call light under their pillow and later on the floor, both times out of reach. Resident #20, who was cognitively intact but had a self-care performance deficit, expressed difficulty in communicating with staff due to the call light being out of reach. Additionally, Resident #126, who was nonverbal and required an assistive device to communicate, had their communication tools placed on a bedside table approximately four feet away, making them inaccessible. Interviews with staff, including CNAs and LPNs, confirmed that call lights and communication devices should be within reach of residents, but this was not consistently ensured. The facility's administrator also acknowledged the expectation that staff should ensure these items are accessible before leaving a resident's room.
Deficiency in Resident Trust Account Management
Penalty
Summary
The facility failed to adhere to general accounting principles in managing the resident trust account, affecting 44 residents. The Business Office Manager (BOM) revealed that the facility did not maintain a consistent amount of cash on hand for resident withdrawals, and there was no ongoing tracking or monthly reconciliation of the cash. Although a spreadsheet was used to record cash requests and withdrawals, it lacked a running total of the cash available at any given time. During an interview, the BOM calculated that $338.00 should be in the cash box, but upon counting, $388.00 was found, indicating a discrepancy of $50.00. The Administrator expected routine reconciliation and proper tracking of cash to prevent misplacement of funds.
Deficiencies in Incontinence Care, Bathing, and Repositioning
Penalty
Summary
The facility failed to provide timely incontinence care, bathing, and repositioning for several residents, leading to potential risks of skin breakdown and urinary tract infections. Residents were observed to be left in saturated briefs for extended periods, with some wearing double briefs, which is against facility policy. Staff interviews revealed that residents were not being checked for incontinence every two hours as required, and staffing shortages were cited as a reason for inadequate care. Multiple residents reported not receiving the minimum of two showers per week, as outlined in their care plans. Observations confirmed that residents had unkempt hair and beards, and some had not been bathed for weeks. Shower sheets were incomplete, and staff were unaware of residents' specific needs, such as the use of anti-dandruff shampoo. Interviews with staff indicated that showers were often missed due to prioritization issues and staffing shortages. Residents requiring assistance with repositioning were not turned every two hours, as required to prevent pressure ulcers. Observations showed residents remained in the same position for extended periods, and staff interviews confirmed that low air loss mattresses were incorrectly used as substitutes for regular repositioning. The facility's failure to adhere to its policies and care plans resulted in inadequate care for residents, compromising their dignity and health.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, leading to several deficiencies in care. Observations and interviews revealed that residents were left in bed, meals were not delivered timely and were served cold, residents were not changed in a timely manner, and showers were not provided according to residents' needs and preferences. The facility's assessment showed a lack of documentation for specific nurse staffing needs for each shift, contributing to these issues. Multiple residents reported that there was not enough staff across all shifts, resulting in delays in getting out of bed and receiving showers. One resident was observed with white matter on their mouth and oily hair, indicating inadequate personal care. Another resident's call light was out of reach, preventing them from requesting assistance to get out of bed. Staff interviews confirmed that the facility was short-staffed, affecting their ability to provide timely care and services. The facility's staffing records showed insufficient numbers of CNAs and LPNs on duty, which impacted the delivery of care. Staff members reported difficulties in completing tasks such as passing meal trays, assisting residents with transfers, and providing personal hygiene care due to the staffing shortages. The facility's staffing coordinator and administrator acknowledged the staffing issues and the challenges in maintaining adequate care levels, especially when staff called off or were unavailable.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that meals delivered to residents were at a safe and palatable temperature, affecting six residents. Observations and interviews revealed that residents consistently received cold food, with some meals being described as soggy or lacking taste. The facility's food safety and handling policy, which aligns with FDA guidelines, was not adhered to, as evidenced by the cold temperatures of food items such as sausage, waffles, and oatmeal. Multiple residents, including those with conditions such as heart disease, diabetes, kidney failure, and anemia, reported dissatisfaction with the temperature and quality of their meals. Observations showed that warming carts used to transport meals were often left unplugged and with doors open, leading to significant drops in food temperature. For instance, test trays showed sausage at 87.7 degrees Fahrenheit and waffles at 93.2 degrees Fahrenheit, well below the required minimum internal temperature for safe consumption. Interviews with staff, including CNAs, dietary aides, and the dietary manager, confirmed that the warming carts were not consistently plugged in or kept closed, contributing to the issue of cold food. The administrator acknowledged the expectation for food to be delivered at appropriate temperatures and identified the need for warming carts to remain plugged in and closed to maintain food warmth. Staffing issues were also cited as a reason for delayed meal delivery, further exacerbating the problem of cold food.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS. This deficiency was observed in several residents with medical devices such as gastrostomy tubes, wounds requiring treatment, and peripherally inserted central catheters. Staff members were observed not wearing gowns while providing care to residents with these conditions, despite the presence of EBP signage and the availability of personal protective equipment. Interviews with staff, including LPNs and the Assistant Director of Nurses, confirmed that there was an expectation for staff to wear gowns and gloves during such care, but this was not consistently followed. Additionally, the facility failed to ensure proper infection control practices during perineal care for two residents. Observations revealed that staff did not perform hand hygiene after removing soiled gloves and before applying new ones, and they touched clean surfaces and clothing with contaminated gloves. Interviews with staff members indicated an awareness of the correct procedures, but these were not consistently practiced, leading to lapses in infection control. The facility also neglected to provide tuberculosis (TB) screening tests for several residents and employees. Records showed missing documentation of TB tests or results, and some employees began working before their TB test results were read. Interviews with the Assistant Director of Nurses and the Administrator highlighted a lack of adherence to state guidelines for TB testing, with responsibilities for tracking and administering tests not being effectively managed. This oversight in TB screening further contributed to the facility's failure to meet infection control standards.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) with specialized training in infection prevention and control for its infection control program. The facility's policy on Surveillance of Healthcare Associated Infections, reviewed on October 7, 2021, outlined responsibilities for the Director of Nursing (DON), infection control designee, and licensed nurses to conduct surveillance for healthcare-associated infections. However, during an interview on November 20, 2024, the DON admitted she had not completed the IP certification, despite working on it overnight. The previous IP had left the facility about a month prior. In a subsequent interview on November 22, 2024, the Administrator expressed her belief that the DON had completed the IP certification and expected the facility to have a designated person to complete the training and receive certification. The facility census was 83 at the time of the survey.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity of three residents by exposing them to undignified situations. One resident was left exposed to the hallway, lying in bed with no covers and an exposed brief, while staff members walked past without providing privacy. This situation persisted until a Licensed Practical Nurse eventually covered the resident with a sheet and blanket. The resident's baseline care plan did not address their activity of daily living needs, which contributed to the oversight. Additionally, two other residents were subjected to unprofessional behavior by staff during meal assistance. A Certified Nursing Assistant (CNA) stood over these residents while feeding them and referred to them as 'feeders' in the presence of other residents. This behavior was noted as disrespectful and a violation of the residents' dignity. Interviews with staff confirmed that such actions were against the facility's expectations for maintaining resident dignity.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to self-administer medications and that staff adequately supervised residents during medication administration. Specifically, two residents, one with severe cognitive impairment and another with moderate cognitive impairment, were involved in incidents where medications were left at their bedside without proper supervision. The facility's policy requires that residents be observed after medication administration to ensure the dose is ingested, but this was not adhered to in these cases. Resident #26, who has severe cognitive impairment due to conditions such as stroke, Alzheimer's disease, and dementia, was found with a cup containing five medications on their bedside table. There was no documentation in the resident's care plan or medical record indicating an assessment for self-administration of medications. Despite having orders for several medications, the resident was not supervised during administration, as evidenced by the observation of medications left at the bedside. Similarly, Resident #128, with moderate cognitive impairment and diagnoses including stroke, anxiety, and depression, was also found with medications left at their bedside. An assessment dated prior to the incident indicated that the resident was not capable of self-administration. Interviews with facility staff, including a CNA/CMT, LPN, and the ADON, confirmed that residents should be supervised during medication administration and that it is not acceptable to leave medications with residents and walk away. Both residents were identified as needing supervision during medication administration, yet this protocol was not followed, leading to the deficiency.
Failure to Timely Complete TPL Forms for Deceased Residents
Penalty
Summary
The facility failed to ensure that third party liability (TPL) forms were completed within 30 days for the final accounting of residents who had passed away. This deficiency affected three residents who had expired and still had money in their accounts. The facility's Business Office - Resident Trust Fund Policy and Procedure requires that upon the discharge or passing of a resident, funds should be disbursed according to regulatory requirements, particularly for Medicaid residents. These funds must be reported to the State for estate recovery and can only be released by the State or made payable directly to a mortuary for unpaid funeral expenses. The Business Office Manager (BOM) acknowledged her responsibility for submitting the TPL to Medicaid within the required timeframe but admitted to being behind on this task due to her recent start at the facility and the need to learn the procedures for fund reconciliation. The Administrator expressed an expectation for TPLs to be submitted within the state-regulated timeframes and for accounts to be closed out promptly. The report highlights that the TPLs for the three residents were not completed within the 30-day requirement, indicating a lapse in the facility's adherence to its own policies and state regulations.
Failure to Maintain a Safe and Homelike Environment Due to Water Damage
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents sharing a room, as evidenced by water stains on the ceiling, peeling wallpaper, and flaking paint due to water damage. Observations revealed yellow ring stains on the ceiling above the window, and the wall next to the bathroom had bubbled, peeled, and flaked paint. The ceiling near the doorway also showed flaked and bubbled paint. Family members and staff reported that the room had been leaking water for at least a couple of months, with staff placing bedspreads and bath blankets to catch the leaking water. Interviews with staff indicated a lack of timely maintenance response. A CNA mentioned that the room always leaks water, and staff verbally inform maintenance staff about issues. An LPN stated that not all staff have access to place maintenance requests in the computer and was unaware of the water leaking issues. The Maintenance Director acknowledged the ceiling stains and water leaking, attributing it to a flat roof that does not drain well, and was waiting for the walls and ceiling to dry before making repairs. The Administrator expected repairs to be made in a timely manner and for residents to have a homelike environment.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of resident transfers and discharges, as required. The facility's policies on both involuntary and voluntary discharges, revised on 10/7/21, lacked guidance on notifying the Ombudsman. This oversight was identified during a review of the facility's policies and interviews with staff. The Ombudsman reported not receiving monthly notifications of transfers and discharges for approximately five to six months. The Social Services Director (SSD), who began working at the facility in May 2024, was responsible for notifying the Ombudsman but admitted to not sending any notifications since starting her role. The Administrator expected the SSD to send these notifications monthly, but this did not occur. The facility census at the time was 83, indicating a significant number of potential unreported transfers and discharges.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure that transportation was provided for two residents, resulting in missed medical appointments. Resident #66, who has multiple health issues including diabetes, morbid obesity, and obstructive sleep apnea, missed appointments with both a pulmonary doctor and a neurosurgeon. The resident requires a special transportation unit due to their size, which the facility did not arrange. The Social Service Director was unaware of the missed appointments and noted that the transportation company requires at least three days' notice. Similarly, Resident #12, who has Parkinson's disease and Alzheimer's, missed three neurology appointments. The Director of Social Services was not informed of these missed appointments by the nursing staff. The report also highlights systemic issues with the facility's transportation scheduling process. During a group interview, residents expressed that it takes a long time for staff to schedule appointments, and some have missed appointments due to lack of transportation. The transportation driver indicated that nurses are responsible for filling out transportation paperwork and require 24-hour notice. However, the Social Service Director found the transportation logbook empty, indicating a breakdown in communication and documentation. The facility administrator expected timely transportation arrangements, but the current process failed to meet this expectation.
Deficiencies in Wound Care and Skin Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards for two residents, leading to deficiencies in wound care and skin treatment. Resident #14, who has dementia and diabetes, was found to have a wound on the left flank that was not identified or documented in the medical record, and no treatment order was obtained for this wound. Observations revealed a wound dressing on the resident's left flank that was not dated, and interviews with staff indicated a lack of awareness and proper documentation regarding the wound. Resident #66, who is cognitively intact but requires substantial assistance for daily activities, was found to have extremely dry skin with multiple layers of thick flaky skin on the lower legs and feet. Despite having treatment orders for Urea cream and warm towel applications, the resident reported that the treatment was ineffective, and the condition of the skin had not improved. The resident had not received a shower in three weeks, and staff interviews confirmed that the treatment had remained unchanged despite its ineffectiveness. Interviews with facility staff, including LPNs and the ADON, revealed expectations for wound treatments to be in accordance with physician orders and for skin assessments to be accurate and comprehensive. However, there was a lack of follow-up and adjustment of treatment plans when current treatments were ineffective, as well as a lack of understanding of certain documented conditions, such as foot erosion.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents by not adhering to physician orders for oxygen use. Resident #46, diagnosed with acute respiratory failure and hypoxia, had a physician order for oxygen at 2L as needed for shortness of breath. However, observations showed the resident receiving oxygen at 5L without documentation of oxygen saturation levels or physician notification. The resident expressed uncertainty about the correct oxygen setting, and staff confirmed the discrepancy between the physician's order and the administered oxygen level. Resident #14, with diagnoses including dementia and diabetes, had a physician order for oxygen at 2L per nasal cannula as needed, with an additional order for a humidifier. Observations revealed the resident receiving oxygen at 3L initially and later at 2L, but without the required humidifier attached. Staff interviews confirmed the expectation for physician orders to be followed, including the use of a humidifier, which was not adhered to in this case. Interviews with facility staff, including the LPN, ADON, and Administrator, highlighted the expectation that physician orders for oxygen should be followed precisely. The staff acknowledged the inappropriate administration of oxygen at levels higher than ordered and the lack of physician notification when deviations occurred. The facility's failure to adhere to these orders and protocols resulted in deficiencies in providing safe and appropriate respiratory care for the residents involved.
Deficiency in Dialysis Care Documentation and Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for residents receiving dialysis, specifically for two residents out of a sample of 19. Resident #70, who is cognitively intact and diagnosed with end-stage kidney disease, was receiving hemodialysis three times a week. The care plan included interventions such as checking and changing the dressing at the access site daily and avoiding blood pressure measurements in the right arm. However, there was no documentation in the Medication Administration Record/Treatment Administration Record (MAR/TAR) from 11/1/24 to 11/18/24 to show that staff monitored the dialysis access site every shift or reported any absence or weak thrill or bruit to the dialysis provider and primary medical doctor. Similarly, Resident #275, also cognitively intact and diagnosed with kidney failure, was receiving hemodialysis three times a week. The care plan noted the potential for infection, bleeding, and pain related to the internal jugular catheter, but there was no documentation for an AV fistula in the care plan. Physician's orders required checking the AV site for thrill/bruit and signs of infection every shift, but the care plan did not reflect these orders. Interviews with staff revealed that vital signs and weights were taken before dialysis and documented on a communication sheet, but there was a lack of reassessment and documentation upon the residents' return from dialysis.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored in accordance with currently accepted professional principles, as expired medications were found in the nurse medication carts and medication supply rooms. Observations revealed that a FreeStyle Libre sensor kit, which expired on 9/23/23, was still present in the South medication room. Additionally, the North nurse medication cart contained Assure Platinum Strip containers that were not dated when opened, despite having expiration dates of 2/26/26 and 3/20/26. The South nurse medication cart also had an Assure Platinum Strip container without an opening date and a CoaguChek bottle of strips that expired on 10/31/24. Interviews with facility staff, including an LPN and the ADON, confirmed that glucose strip containers should be dated when opened and that expired devices should be removed and discarded. The facility's Medication Storage policy mandates that outdated or expired medications be immediately removed from inventory and disposed of according to procedures. The Administrator also stated that she expected staff to label glucose strip containers when opened and to remove expired medications or equipment from the medication cart and rooms.
Deficiencies in Resident Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of resident records, leading to deficiencies in the handling of two residents' medical records. For one resident, there was no documentation of the circumstances surrounding their discharge from the facility. The resident, who had a history of seizures, diabetes, heart failure, atrial fibrillation, dementia, schizophrenia, and bipolar disorder, left the facility with a family member and did not return. Staff interviews revealed that the resident's leave of absence was not documented, and there was no record of the resident signing out against medical advice or any other documentation regarding the discharge. In another case, a resident with a history of falling had neurological assessments documented as completed by an LPN who was not on duty during the shifts in question. The neurological evaluation flow sheet showed assessments signed with the LPN's initials, despite the LPN not working those shifts. Interviews with staff confirmed that the documentation was inaccurate, as the assessments should have been recorded by the nurse who performed them. The facility lacked a policy related to complete and accurate medical record documentation, as confirmed by the Administrator.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the necessary competencies and skills to manage the food and nutrition service. This deficiency occurred because the facility did not designate a person to serve as the Director of Food and Nutrition Services after the Dietary Manager was terminated. This oversight had the potential to affect all 76 residents in the facility.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen by not adhering to their established cleaning schedules, which included monthly, weekly, and daily tasks. Observations revealed that kitchen equipment was not kept clean, and floors were not free of debris, grease, and grime. Additionally, the facility did not store food in a safe and sanitary manner, leading to potential cross-contamination. Food items were also not labeled and dated properly. These deficiencies had the potential to affect all 76 residents who consumed food from the facility kitchen.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in the kitchen. This deficiency was identified through observation and interview during a survey. The facility had a census of 76 at the time of the survey, indicating the number of residents potentially affected by this issue.
Deficiency in Food and Nutrition Services Management
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to manage the food and nutrition services after the termination of the Dietary Manager (DM) on 7/30/24. This resulted in the absence of a designated Director of Food and Nutrition Services, which affected the cleanliness and safety of the kitchen environment. Observations on 8/12/24 revealed that staff did not maintain kitchen cleanliness, proper food storage, or food safety, and failed to document temperatures and cleaning schedules. Additionally, there was no pest control in the kitchen, which posed a risk of foodborne illnesses to residents. Interviews with the Dietary Cook (DC) and the Administrator highlighted that the former DM had not performed sanitation inspections or maintained a clean and safe kitchen environment. The Administrator, who started on 7/8/24, terminated the DM due to poor job performance and was unsure if any sanitation inspections were completed during the DM's tenure. The facility's Registered Dietician (RD) conducted a sanitation survey on 5/15/24, scoring 61%, but no other surveys were available. The Administrator found the former DM's office disorganized and could not locate prior sanitation surveys, indicating a lack of adherence to facility policies and procedures.
Facility Fails to Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by observations of unclean kitchen equipment, floors covered in debris, grease, and grime, and improper food storage practices. The facility did not adhere to its own cleaning schedules, as there were no monthly, weekly, or daily cleaning task sheets posted, and the kitchen was found to be in disarray. The kitchen's back hall was cluttered with semi-frozen food items on the floor, uncovered trash cans, and dirty mop buckets, all of which contributed to an unsanitary environment. In the dry storage area, food items were improperly stored, with open sacks of rice on the floor and undated boxes of food spilling out. The area was disorganized, making it difficult for staff to rotate stock or determine when items were opened. The kitchen's prep and food service areas were also found to be unsanitary, with sticky, greasy surfaces, dirty equipment, and improperly stored food items. The freezers lacked proper temperature monitoring, and food items were not dated or organized, increasing the risk of foodborne illness. Interviews with the Dietary Coordinator (DC) and the Administrator revealed a lack of adherence to cleaning protocols and food safety practices. The DC admitted to not knowing how to properly monitor freezer temperatures and acknowledged that the kitchen was not a clean or safe environment for food preparation. The Administrator confirmed that the former Dietary Manager was terminated due to poor performance and that the current DC had not implemented necessary cleaning duties or maintained proper food storage and preparation. The facility's failure to follow its own policies and procedures for kitchen cleanliness and food safety posed a significant risk to the health and safety of the residents.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in the kitchen. During an observation on August 12, 2024, at 9:42 A.M., several flies and gnats were noted throughout the food preparation areas, outside the walk-in cooler, and inside the dry food storage room. The pests were also observed in the dishwasher area, outside the ice machine, and swarming over the steam table, dining room pass-through window, and under the disinfecting sinks around the grease trap. Additionally, gnats were found floating in and swarming around a large, clear rectangular container filled with approximately three inches of cloudy water, located underneath a large industrial food steamer. Interviews conducted on the same day revealed that the Dietary [NAME] (DC) acknowledged the kitchen's dirty condition, which attracted the flies and gnats, and expressed an expectation for the kitchen to be free of such pests. The Administrator also stated an expectation for the kitchen to be free of flies and gnats. Despite these expectations, subsequent observations at 11:00 A.M. and 2:00 P.M. confirmed the continued presence of flies and gnats in the same areas, indicating a failure to address the pest issue effectively.
Failure to Conduct Required Background Checks for Rehired Staff
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy regarding employee screening, specifically in the case of a registered nurse (RN) who was rehired after termination. The facility's policy mandates conducting criminal background checks and checking the federal indicator through the state nurse aide registry for all employees, including those returning after termination. However, the facility did not perform these checks for RN A before allowing them to return to work. RN A was initially hired on February 27, 2023, and terminated on April 26, 2024. Despite this termination, RN A worked an overnight shift on June 21, 2024, without the required background and registry checks being completed. During an interview, the Area Director of Operations confirmed that the necessary background checks should have been completed before re-employment. The oversight in conducting these checks represents a failure to follow the facility's established procedures designed to protect residents from potential abuse, neglect, or mistreatment by staff. This deficiency highlights a lapse in the facility's commitment to ensuring the safety and well-being of its residents by not thoroughly vetting returning employees.
Failure to Prevent Pressure Ulcers Due to Inadequate Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for a resident who was at risk. The resident, who was cognitively intact but had impairments in both upper and lower extremities, was always incontinent of bowel and bladder and required substantial assistance for personal hygiene and mobility. Despite these needs, the resident was not frequently repositioned, nor was incontinence care provided in a timely manner, leading to the development of new pressure ulcers. Observations revealed that the resident was left lying on a pressure-reducing mattress with a visibly soaked brief and bedding saturated with urine, which had not been changed since the previous day. The resident expressed discomfort and embarrassment due to the lack of care. A CNA confirmed the resident's condition and noted that it was common for residents to be found wet with urine or feces at the start of their shift. The CNA also reported the issue to supervisors, but the resident's condition was not addressed adequately. The Wound Nurse and Wound Physician were not aware of the resident's new skin issues until they were alerted by the CNA. Upon examination, the Wound Physician identified a Stage II pressure ulcer on the resident's left buttock and coccyx. The facility's leadership acknowledged that staff were expected to follow policies, complete skin assessments promptly, and check on incontinent residents every two hours. However, these expectations were not met, contributing to the resident's skin breakdown.
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Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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