Fountain Care At Sunset Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 10954 Kennerly Road, Saint Louis, Missouri 63128
- CMS Provider Number
- 265331
- Inspections on file
- 40
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fountain Care At Sunset Hills during CMS and state inspections, most recent first.
Surveyors found that staff failed to administer and manage medications according to professional standards for three residents. One resident with ESRD, CHF, and hypertension repeatedly did not receive multiple 8:00 A.M. medications because the CMT documented the resident as sleeping and did not escalate the ongoing refusals to the DON or physician or attempt to adjust administration times. Another resident with dementia and bipolar disorder had a new order for Azithromycin for pneumonia, but the first dose was delayed many hours despite the drug being available in the E‑Kit, and this resident also went several days without amphetamine‑dextroamphetamine and Valium when bubble cards ran out and staff did not timely secure new prescriptions and refills. A third resident admitted with C‑diff did not receive ordered Vancomycin doses for days even though the pharmacy had delivered the medication, and there was inadequate documentation explaining the omissions, demonstrating systemic failures in timely medication administration, communication, and documentation.
A resident was admitted with multiple documented skin issues, including open lesions on the right lower leg and calf, a diabetic foot ulcer on the right great toe, and peri-anal redness. An LPN performed the admission skin check, applied basic dressings and barrier cream, but did not notify the physician, did not obtain treatment orders, and did not enter the skin issues or treatments on the TAR. Other LPNs and the wound care nurse reported that they rely on the TAR to identify residents needing wound assessment and treatment, and the POS and TAR contained no orders or entries for these wounds. As a result, through the time of the resident’s death, the skin issues were not supported by physician orders and were not documented for ongoing monitoring and assessment.
A resident admitted with cognitive impairment, total dependence for care, incontinence, and a high-risk Braden score was found on admission to have an open, reddened coccyx pressure ulcer along with other skin issues. The admitting LPN measured and documented the coccyx ulcer in a progress note and applied barrier cream but did not notify the physician, did not obtain or document any treatment orders, and did not enter the ulcer or a treatment on the POS or TAR. The LPN reported an undocumented attempt to contact the physician on the day of admission and made no further attempts on subsequent worked days, and no other nurses were aware of the ulcer because it was not listed on the TAR. As a result, up to the time of the resident’s death, the coccyx pressure ulcer had no physician orders and was not included in the facility’s ongoing monitoring and treatment system.
A facility failed to communicate care plans and implement proper transfer methods, resulting in a resident sustaining multiple fractures after being transferred without a mechanical lift. Another resident experienced multiple falls and significant swelling, but staff failed to notify the physician of the change in condition. The lack of communication and adherence to care plans led to immediate jeopardy for the residents.
The facility failed to investigate resident-to-resident altercations in a timely manner, involving residents with cognitive impairments and other medical conditions. Staff interviews revealed a lack of communication and understanding of the facility's abuse policy, resulting in delayed investigations and notifications to the state agency.
The facility failed to report resident-to-resident altercations to the Department of Health and Senior Services within the required timeframe. In two separate incidents, residents with cognitive impairments were involved in altercations, but no immediate investigation or report to the state agency was made. Staff members were aware of the incidents but did not initiate an investigation, believing it was management's responsibility. The new Administrator expected the facility's policy to be followed, but the report was delayed.
A resident with severe cognitive impairment and a history of stroke experienced significant weight loss due to the facility's failure to implement a Registered Dietitian's recommendation for a revised g-tube feeding schedule. The recommendation was not communicated to the resident's physician, hospice nurse, or family, leading to continued weight loss. Interviews revealed that facility staff were unaware of the recommendation, and the facility lacked a nutritional policy.
A resident in an LTC facility developed a Stage III pressure ulcer due to inadequate care and prevention measures. Initially, a small breakdown on the buttocks was identified, but it was not staged, and no treatment order was obtained. Weekly skin assessments were not completed, leading to the ulcer's progression. The facility's policies were not followed, and documentation was inconsistent, contributing to the deficiency.
A facility failed to prevent the unauthorized removal of controlled medications by an LPN, who tampered with medication cards for two residents. The LPN was observed on video replacing oxycodone pills with Claritin. Both residents involved were on scheduled pain medication regimens but did not experience a lapse in medication administration.
A facility failed to follow its policy when an injury of unknown origin was discovered on a resident and was not reported, assessed, or investigated. The resident indicated the injury occurred when an aide hit their leg with a wheelchair foot pedal, but no documentation or incident report was initiated. Staff interviews confirmed awareness of procedures, but these were not followed, leading to the deficiency.
A resident with Type 2 diabetes mellitus and diabetic chronic kidney disease sustained a skin tear from an aide hitting their leg with a wheelchair foot pedal. The facility failed to obtain a physician's order for wound care, document the incident, or notify the responsible parties, contrary to their policy.
Failure to Administer and Manage Medications in Accordance With Professional Standards
Penalty
Summary
The deficiency involves multiple failures in medication administration and communication that did not meet professional standards of quality. One resident with ESRD on hemodialysis, CHF, hypertension, atrial fibrillation, and other comorbidities had numerous 8:00 A.M. medications, including cardiac, anticoagulant, renal, and vitamin therapies, documented as not given on multiple days because the resident was sleeping. The electronic MAR showed that on ten separate days in January, eight of eight scheduled 8:00 A.M. medications were not administered, and a weekly vitamin D dose was also missed on two of three scheduled Wednesdays, all coded as the resident sleeping. The CMT who typically passed these medications stated the resident preferred to sleep until around noon and did not want 8:00 A.M. medications, but also stated they had not informed the DON or the physician, had not asked the resident about changing medication times, and had only told a nurse that the resident was not taking the morning medications. The nurse who checked the resident’s blood glucose and administered insulin around 8:00 A.M. reported not being aware of the missed 8:00 A.M. medications and indicated that, if informed, they would have attempted to administer the medications or discuss alternate times with the resident. Another deficiency involved a cognitively intact resident with non‑Alzheimer’s dementia, anxiety, depression, and bipolar disorder who had new orders for Azithromycin for pneumonia and was also prescribed amphetamine‑dextroamphetamine and Valium. A chest x‑ray impression showed focal pneumonia, and a physician order for Azithromycin was obtained that evening. The MAR showed the first Azithromycin dose was not administered until the following day at midday, approximately 15 hours after the order, despite Azithromycin being stocked in the facility’s E‑Kit. The resident reported not feeling well due to pneumonia and stated staff told them the antibiotic had not yet been received. The same resident’s MAR and progress notes documented that amphetamine‑dextroamphetamine and Valium doses were repeatedly not given over several days because the medications were on order or a new prescription was needed. Nursing notes repeatedly indicated the medications were on order or awaiting pharmacy delivery, and that a new script was needed, but one LPN acknowledged not contacting the pharmacy or physician personally and assumed another nurse had done so. Pharmacy records showed that new prescriptions were not received until several days after the medications began running out, and that delivery occurred only after those prescriptions were obtained. A third deficiency involved a newly admitted resident with C‑diff who had a hospital order for Vancomycin 125 mg daily for four days. The facility MAR contained an order for Vancomycin at 6:00 A.M. for four days, but staff documented code 9 (other/see progress notes) for the first two scheduled doses. The progress notes contained no explanation for the missed dose on the first day and documented on the second day that Vancomycin was pending delivery. A pharmacy representative reported that four doses of Vancomycin were delivered to the facility late morning on the first day, but the first dose was not administered until three days after delivery. The DON stated that when medications are delivered, the receiving nurse is responsible for ensuring medications for residents on other halls are promptly distributed, and that if Vancomycin was delivered that morning, she would have expected it to be administered that day. Across these three residents, the survey identified failures to administer ordered medications as scheduled, to use the E‑Kit for timely initiation of antibiotics, to prevent medications from running out by timely reordering and obtaining new prescriptions, and to document and communicate medication refusals and omissions in accordance with facility policy.
Failure to Obtain Physician Orders and Document Treatment for Admission Skin Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and obtain treatment orders for multiple skin issues identified at admission, and to document these issues on the treatment administration record (TAR) for ongoing monitoring. The facility’s Skin Program Policy required that all residents be fully assessed on admission, that residents admitted with skin areas/pressure ulcers have treatment orders initiated upon admission, and that an individualized skin plan of care be developed. The resident was admitted on 12/19/25 with documented dependence in multiple ADLs, cognitive impairment, and incontinence, and the baseline care plan noted current skin integrity issues and referenced a skin assessment. On the evening of admission, an LPN completed a skin check and documented several skin issues in the progress notes: an open lesion on the front right medial lower leg, an open lesion on the right lateral calf, a diabetic foot ulcer on the right great toe, and redness in the peri-anal area. A subsequent admission note the same night described redness to the groin and shearing areas on the front right shin, back of right ankle, and right big toe. However, there was no documentation that the resident’s physician was contacted for treatment orders for these identified skin issues, and the physician order sheet contained no corresponding treatment orders. The TAR for the period from 12/1/25 through 12/23/25 contained no entries to monitor or treat these specific skin issues. In interviews, the admitting LPN stated that dressings were removed, the areas were cleaned with soap and water, and protective dressings and barrier cream were applied, but acknowledged forgetting to place the skin issues and any treatments on the TAR and not documenting attempts to contact the physician. The LPN reported only one undocumented attempt to contact the physician on the day of admission and no further attempts on the following days, despite working that weekend and changing dressings without documentation. Other LPNs and the wound care nurse indicated that they rely on the TAR to know which residents have skin issues requiring assessment or treatment, and that if a treatment is not on the TAR, they would not know to perform it. The DON and wound care nurse both stated that the admitting nurse should have contacted the physician for treatment orders, documented those orders on the POS and TAR, and documented multiple attempts to reach the physician. As of 12/23/25, when the resident died, the facility still had not contacted the physician regarding the identified skin issues, had not obtained treatment orders, and had not documented the skin issues on the TAR for ongoing monitoring and assessment.
Failure to Obtain Physician Orders and Document Treatment for Admission Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and obtain treatment orders for a coccyx pressure ulcer identified on admission, and failure to place the ulcer and its treatment on the Treatment Administration Record (TAR) for ongoing monitoring. The facility’s own Skin Program Policy required that all residents be fully assessed on admission, that residents admitted with skin areas/pressure ulcers have treatment orders initiated upon admission or readmission, and that an individualized preventative and active skin plan of care be developed. The resident was admitted with cognitive impairment, total dependence for mobility and hygiene, constant moisture, chairfast status, friction and shear problems, and a Braden score of 11, indicating high risk for pressure injuries. On the evening of admission, the admitting LPN documented a coccyx pressure ulcer/pressure injury measuring 4.0 cm x 0.3 cm x 0.5 cm, with redness and an open area, along with other skin issues to the groin, right shin, back of right ankle, and right big toe. Despite identifying the coccyx pressure ulcer, the admitting LPN did not obtain or document any physician orders for treatment of this wound and did not enter a treatment on the physician order sheet or TAR. The LPN reported cleaning the ulcer and applying barrier cream but acknowledged forgetting to place the treatment on the TAR and not documenting the care provided. The LPN stated they attempted to contact the physician on the day of admission but did not document this attempt and made no further attempts to contact the physician on the following two days worked, even though the resident remained under their care. There was no documentation in the progress notes that the physician was notified about the coccyx pressure ulcer or that any treatment orders were received. Other nursing staff and the wound care nurse confirmed that, per facility practice, any pressure ulcer or skin treatment should appear on the TAR so that nurses on all shifts know to assess and treat the area. Multiple LPNs stated that if a pressure injury or treatment is not on the TAR, they would not know it existed or required care. The wound care nurse and DON both indicated that the admitting nurse was responsible for completing the admission skin check, notifying the physician, obtaining treatment orders, and documenting the ulcer and orders on the POS, TAR, and in progress notes, including any attempts to contact the physician. As of the date the resident died, there were still no physician orders or TAR entries for the coccyx pressure ulcer, and the ulcer had not been incorporated into the facility’s ongoing monitoring and treatment systems.
Failure to Communicate Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure proper communication and implementation of care plans for residents, leading to significant injuries. In one instance, a resident with a history of stroke and cognitive impairment required a mechanical lift for transfers, as indicated in their care plan. However, an agency CNA, who did not receive a proper report or instructions, attempted to transfer the resident using a gait belt instead of a Hoyer lift. This resulted in the resident falling and sustaining multiple fractures, including to the ribs, legs, and ankle. The incident was not promptly communicated to the resident's physician, and the resident was not transferred to the hospital until several hours later, during which time they became lethargic and hypotensive. Another resident, who was cognitively intact but had a history of falls and multiple medical conditions, experienced several falls over a short period. Despite showing signs of significant injury, including facial swelling and black eyes, the facility staff failed to notify the physician of the resident's change in condition. The resident was left sitting on the toilet for extended periods, refusing care, and eventually required emergency medical attention due to severe swelling and confusion. The lack of timely medical intervention and failure to follow the facility's policy for notifying physicians of changes in condition contributed to the resident's deteriorating health. The facility's policies for change in condition and fall prevention were not adequately followed, as evidenced by the lack of communication and documentation regarding the residents' conditions and care needs. Agency staff did not receive proper orientation or instructions, and there was no system in place to ensure they reviewed the care instructions binder. These deficiencies in communication and adherence to care plans resulted in immediate jeopardy to the residents' health and safety.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to adhere to its abuse policy by not thoroughly investigating in a timely manner allegations of resident-to-resident altercations. The incidents involved two separate pairs of residents. In the first incident, a resident with no cognitive impairment and a history of congestive heart failure, high blood pressure, and dementia was involved in an altercation with another resident who had moderate cognitive impairment and delusions. The altercation was witnessed by a nurse, but there was no documentation of the Administrator, Director of Nursing (DON), or Assistant Director of Nursing (ADON) being notified, and it was unclear if an investigation was initiated. In the second incident, a resident with no cognitive impairment and a history of stroke was assaulted by their roommate, who had severe cognitive impairment and dementia. The assault was witnessed by a nurse and a Certified Medication Technician (CMT), but again, there was no documentation of the Administrator, DON, or ADON being notified. The CMT noted that an investigation should have been started immediately, but it was not until the surveyor's inquiry that any action was taken. Interviews with staff revealed a lack of communication and understanding of the facility's abuse policy. The ADON received a text message about the incident but did not initiate an investigation or report it to the state agency until prompted by the surveyor. The Social Service Director (SSD) also did not start an investigation, citing a lack of knowledge on how to report to the state agency. The DON admitted to not starting the investigations until the day after the surveyor's inquiry, indicating a systemic failure to follow the facility's abuse policy and ensure timely investigations.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to report allegations of abuse to the Department of Health and Senior Services (DHSS) within the required timeframe following resident-to-resident altercations. The facility's policy mandates immediate reporting of such incidents, but this was not adhered to in two separate incidents involving four residents. In the first incident, Resident #15, who had no cognitive impairment but was diagnosed with dementia, was involved in an altercation with Resident #16, who had moderate cognitive impairment and delusions. The altercation involved Resident #15 hitting Resident #16, but no injuries were noted. Despite the incident, there was no immediate investigation or report to the state agency. In the second incident, Resident #10, who had no cognitive impairment but was dependent on activities of daily living due to a stroke, was assaulted by their roommate, Resident #11, who had severe cognitive impairment and dementia. Resident #11 hit Resident #10 in the face, breaking their glasses. Although the residents were separated and sent to the hospital, the incident was not reported to the state agency until the following day when a surveyor inquired about it. Staff members, including a Certified Medication Technician and a Licensed Practical Nurse, were aware of the incident but did not initiate an investigation or report it, as they believed it was the responsibility of management. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the incidents through a group text message, but no immediate action was taken to report the incidents to the state agency. The new Administrator, who had been with the facility for less than 24 hours, expected the facility's policy to be followed, but the report to the state agency was delayed. The lack of timely reporting and investigation of these incidents constitutes a deficiency in the facility's adherence to its abuse, neglect, and exploitation policy.
Failure to Implement Dietitian's Recommendation for Resident with Weight Loss
Penalty
Summary
The facility failed to address a recommendation from the Registered Dietitian (RD) for a resident experiencing significant weight loss. The resident, who had severe cognitive impairment, was dependent on activities of daily living, and had a history of stroke, was at risk for pressure ulcers and had a gastronomy tube (g-tube) for nutrition. Despite the RD's recommendation to change the g-tube feeding schedule to prevent further weight loss, there was no documentation of this recommendation being communicated to the resident's physician, hospice nurse, or family. Consequently, the resident continued to lose weight, dropping from 151.7 lbs to 132.1 lbs over a three-month period, representing a 12.2% weight loss. Interviews with facility staff, including the RD, Hospice Nurse, Wound Nurse Practitioner, Director of Nursing (DON), and the resident's physician, revealed that none were aware of the RD's recommendation. The DON indicated that the previous Assistant Director of Nursing was responsible for following up on such recommendations, but the process was not completed. The facility also lacked a nutritional policy, which contributed to the oversight. The failure to implement the RD's recommendation and communicate it to relevant parties resulted in the resident's continued weight loss and potential impact on their health.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of a Stage III pressure ulcer. Initially, a small breakdown on the resident's buttocks was identified, but it was not staged, and no treatment order was obtained. Despite documentation indicating treatments were provided, licensed nursing staff did not complete weekly skin assessments between mid-June and early July. Consequently, the pressure ulcer progressed to Stage III before being identified and treated. The facility's Skin Program Policy and Procedure, implemented in April 2023, mandates comprehensive skin assessments upon admission and regular follow-ups. However, the resident's Braden skin risk assessment, completed in November 2023, indicated a high risk, yet no further assessments were conducted. The resident's care plan did not include the presence of pressure ulcers, and there was a lack of documentation for treatment orders for the sacrum wound throughout May and June. Interviews with facility staff revealed inconsistencies in skin assessment practices and documentation. The Administrator acknowledged the failure to complete and document skin assessments as ordered, and the wound care company Nurse Practitioner expressed expectations for earlier intervention. The facility's oversight and lack of adherence to its own policies contributed to the resident's pressure ulcer progressing to a more severe stage.
Unauthorized Removal of Controlled Medications
Penalty
Summary
The facility failed to prevent the unauthorized removal of Schedule II controlled medications, specifically oxycodone, for two residents. The incident involved a Licensed Practical Nurse (LPN) who was observed tampering with medication cards. The LPN was seen on video footage using tape to cover missing pills and replacing them with Claritin, an over-the-counter allergy medication. This tampering was discovered during a routine medication count by another LPN. Resident #1, who was cognitively intact and had diagnoses including end-stage renal disease and heart failure, was on a scheduled pain medication regimen. The resident's medication card was found to have been tampered with, although the resident did not experience a lapse in pain medication administration. Similarly, Resident #2, who was also cognitively intact and had conditions such as diabetes and quadriplegia, was on a scheduled pain medication regimen. Their medication card was also found to be tampered with, but they did not experience a lapse in medication. The incident was initially discovered by an LPN who noticed tampering during a shift change. The LPN reported the issue to the Director of Nursing (DON), who then conducted an audit of the medication carts. The DON discovered that several oxycodone pills were missing and had been replaced with Claritin. The facility's investigation revealed that the LPN involved had access to the medication cart keys for several hours during the night shift, which allowed for the tampering to occur.
Failure to Follow Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its policy when an injury of unknown origin was discovered on a resident and was not reported, assessed, or investigated. The resident, who was cognitively intact and required partial to moderate assistance for transfers, was observed with a bandage on their right lower leg. The bandage was dated two days prior, and the resident indicated that the injury occurred when an aide hit their leg with the foot pedal of their wheelchair. However, there was no documentation in the resident's progress notes regarding the injury, assessment, or notification of the responsible party or physician. The Assistant Director of Nursing (ADON) confirmed that there was no documentation available in the resident's medical record regarding the injury. The initials on the resident's dressing belonged to the Director of Nursing (DON), but no incident report or assessment had been initiated. Interviews with various staff members, including Certified Nursing Assistants (CNAs) and nurses, revealed that they were aware of the procedures to follow when discovering an injury of unknown origin, but these procedures were not followed in this case. The Administrator was made aware of the incident by the ADON and acknowledged that the facility's policies were not followed. The Administrator expected the DON to have documented the incident, performed a skin assessment, and notified the appropriate parties. The lack of documentation and failure to follow the facility's Accident and Incident Protocol and Abuse, Neglect, Misappropriation of Resident Property policy led to the deficiency.
Failure to Obtain Physician's Order for Skin Tear
Penalty
Summary
The facility failed to follow its policy by not obtaining a physician's order for a skin tear of unknown origin for a resident, potentially increasing the risk of a negative outcome related to the healing process. The resident, who has a diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease, was observed with a bandage on their right lower leg that was stained and dated two days prior. The resident reported that the injury occurred when an aide hit their leg with the foot pedal of their wheelchair, and they were unsure about the dressing change schedule. Upon review, it was found that there were no physician orders for wound care or treatment documented for the resident. Additionally, there was no documentation in the resident's progress notes regarding the injury, assessment, accident/incident report initiation, or notification of the responsible party or physician. The Assistant Director of Nursing confirmed the lack of documentation and stated that the incident should have been assessed, the physician notified, and an order obtained for treatment, all of which should have been documented. Interviews with staff revealed that the expected protocol for handling such incidents was not followed. The nurse stated that they would have assessed the resident, notified the physician and family, and documented the incident, but this was not done. The Administrator also confirmed that the incident was not documented as expected and that the dressing should have been changed since the initial date. The Administrator indicated that the incident should have been discussed with risk management and the team, and that in-service training should have been completed to prevent such occurrences.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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