Garden View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in O Fallon, Missouri.
- Location
- 700 Garden Path, O Fallon, Missouri 63366
- CMS Provider Number
- 265321
- Inspections on file
- 19
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Garden View Care Center during CMS and state inspections, most recent first.
A resident with significant cognitive impairment and a history of hypersexuality engaged in repeated non-consensual sexual contact with several other cognitively impaired residents, including touching, kissing, and groping. Despite multiple incidents witnessed or reported by staff, the facility did not implement effective interventions or consistently assess capacity to consent, and key leadership was not informed of the ongoing abuse.
Staff failed to report multiple incidents of sexual abuse involving cognitively impaired residents to the state agency and resident representatives, despite facility policy requiring prompt notification. The incidents, which included inappropriate touching and kissing by a resident with a history of such behaviors, were documented in progress notes but not communicated to authorities or families. Interviews revealed confusion among staff about reporting responsibilities and a lack of awareness among leadership regarding the events.
A resident with moderate cognitive impairment reported being stalked and hit by an unidentified individual. Despite consistent accounts of the incident, the facility's administrator did not conduct a formal investigation or report the allegations to the state agency, citing conflicting stories. The facility's policy requires prompt reporting and investigation of abuse allegations, but the administrator and DON did not adhere to this policy, resulting in a deficiency.
A resident with moderate cognitive impairment alleged being hit by a CNA, but the facility failed to conduct a timely investigation or suspend the CNA, contrary to its policy. The resident reported feeling unsafe, but the Administrator dismissed the claims as delusional without notifying the state agency. The facility's inaction led to a deficiency finding.
A resident with a history of trauma and mental health disorders exhibited increased paranoia and reported being hit, but the facility failed to implement a care plan addressing these issues. Staff were unaware of the resident's psychiatric history, and care plans lacked interventions for trauma and behavioral changes. The facility did not provide trauma-informed care or educate staff on PTSD, leading to inadequate support for the resident's mental health needs.
The facility failed to maintain cleanliness and sanitation in the kitchen and nourishment centers, with issues such as soiled surfaces, improper use of hair and beard restraints, and uncovered food items during transport. Ice machines were in poor condition, with buildups of debris and broken doors, exposing ice to contamination. These deficiencies highlight significant lapses in food safety and sanitation standards.
The facility failed to ensure proper hand hygiene during resident care, with staff not washing hands or changing gloves appropriately. Additionally, the facility did not complete required TB tests for new employees and failed to monitor cold water temperatures to prevent Legionella growth. These deficiencies indicate lapses in infection control and employee health screening protocols.
A facility failed to provide adequate incontinence and oral care for two residents. One resident, with severe cognitive impairment, was repeatedly observed with strong urine and fecal odors, indicating a lack of timely incontinence care. Additionally, oral care was often neglected due to time constraints. Another resident, requiring substantial assistance with oral hygiene, reported not receiving help, and observations confirmed the absence of oral care supplies in the room.
The facility failed to ensure resident safety by not following transfer protocols for a resident with severe cognitive impairment, requiring two-person assistance. A CNA assisted the resident alone without a gait belt, leading to an unsafe transfer. Additionally, the facility did not properly document or address a fall incident involving another resident, failing to follow fall protocols and implement new interventions. Staff interviews revealed a lack of communication and documentation regarding the fall.
The facility failed to properly manage oxygen tubing for two residents with COPD, as their care plans lacked directives for changing or dating the tubing. Observations showed undated tubing, and staff interviews revealed inconsistencies in responsibility for changing and documenting the tubing. The facility lacked a policy for this task.
The facility failed to remove expired medications and COVID-19 test kits, with some items remaining for over 100 days past expiration. Medications for a discharged resident were also found 182 days after discharge, and medications without orders were stored for a current resident. The DON admitted to not checking the storage room recently, and the LPN was unaware of the medications' presence.
The facility's pest control program was ineffective, resulting in a roach infestation in the kitchen and dishwashing areas. Observations showed insects crawling near kitchen equipment, and interviews revealed delayed responses to pest sightings due to a billing issue with the pest control company. The facility's policy requires an ongoing pest control program, but recent treatments only addressed the exterior, not the interior.
A facility failed to assess and document the use of bed rails for a resident with a history of falls and mobility issues. The facility did not conduct a risk assessment for entrapment, document alternatives, or obtain informed consent before using bed rails. Despite the resident's care plan indicating the use of side rails, there was no physician's order or necessary documentation. The DON acknowledged the lack of required assessments and documentation, yet the decision to keep the bed rail was made without proper protocol.
A facility failed to perform regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency in identifying potential entrapment hazards. A resident with a history of falls and mobility issues used a half bed rail without documented assessment or consent. The Maintenance Director was unaware of his responsibility to measure bed rails for entrapment zones, and no safety checks were conducted, as required by facility policy.
The facility failed to provide written transfer notices to residents and/or their representatives when six residents were transferred to the hospital. Despite the facility's policy requiring written notice before transfers, there was no documentation of such notices in the medical records of the affected residents. This deficiency was confirmed by the Administrator, who noted that nurses were not providing the necessary notices during transfers.
The facility failed to provide written notice of the bed hold policy to residents or their representatives within 24 hours of hospital transfer, affecting four residents. Despite the policy requiring written communication, staff only discussed it via phone without documentation. The Administrator confirmed that nurses were not providing the policy as required.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from sexual abuse by another resident who exhibited a pattern of inappropriate sexual behaviors. One resident with significant cognitive impairment and a history of hypersexuality was repeatedly observed or reported to have engaged in non-consensual sexual contact with several other residents, all of whom had documented cognitive deficits or dementia and lacked the capacity to consent to sexual activity. Incidents included the resident putting hands down another resident's pants and touching the perineal area, rubbing another resident's breasts, kissing a resident on the mouth, and groping a resident's breast. These events occurred in various locations within the facility, including resident rooms and common areas, and were witnessed or reported by staff on multiple occasions. Despite these repeated incidents, there was no evidence that the facility implemented new or effective interventions to protect the affected residents or prevent further abuse after each event. Documentation showed that staff often redirected the resident or removed them from the situation, but there was no indication of comprehensive assessment, increased supervision, or other protective measures being put in place following the incidents. Additionally, the facility did not consistently notify the families or representatives of the affected residents about the incidents, nor did they document assessments of the residents' capacity to consent to sexual contact, as required by facility policy. Interviews with staff and administration revealed a lack of awareness and communication regarding the ongoing behaviors and incidents. Key leadership, including the DON and Administrator, were not informed of several incidents until much later, and some staff did not recognize the behaviors as abuse, attributing them instead to memory care behaviors. The facility's policies required assessment of capacity to consent and interventions to prevent abuse, but these were not followed. The affected residents all had diagnoses of dementia or other cognitive impairments, and their representatives confirmed that the residents would not have wanted or been able to consent to such contact.
Failure to Report Sexual Abuse Allegations Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report multiple witnessed and documented incidents of sexual abuse involving three residents who lacked the capacity to consent to sexual activity. Staff observed a resident with a history of sexually inappropriate behaviors, including rubbing another resident's breasts, kissing a resident on the mouth, and groping a resident's breast. Despite these incidents being documented in progress notes and discussed among staff, there was no evidence that the events were reported to the state agency or to the residents' representatives as required by facility policy and federal regulations. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, and major depressive disorder with psychotic symptoms, and were documented as having impaired judgment and decision-making abilities. The facility's own policies required prompt reporting of all allegations of abuse to appropriate authorities and to the residents' representatives, as well as evaluation of capacity to consent for any resident involved in sexual activity. However, there was no documentation of such evaluations or notifications in the residents' records, and interviews with representatives confirmed they were not informed of the incidents. Interviews with staff revealed a lack of clarity and follow-through regarding reporting responsibilities. Some staff believed the behaviors were not abuse due to the perpetrator's cognitive status, while others assumed incidents had already been reported or did not recognize the need to report. Leadership, including the DON and Administrator, were unaware of the incidents until much later and acknowledged that the events should have been reported according to policy. The failure to report these incidents constituted a violation of both facility policy and regulatory requirements.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report allegations of physical abuse involving a resident to the state agency. The resident, who was admitted to the facility with moderate cognitive impairment, reported being stalked and hit by an unidentified individual. Despite the resident's consistent account of the incident, the facility's administrator did not conduct a formal investigation or report the allegations to the state agency, citing conflicting stories and the resident's denial of being hit when questioned. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be promptly reported to the appropriate authorities and thoroughly investigated. However, the administrator and the Director of Nursing did not adhere to this policy. The administrator received reports of the resident's allegations from various staff members, including the Social Services Director and Activity Assistant, but dismissed them as delusional without further investigation. Interviews with staff revealed that the resident had expressed fear and distress over the alleged abuse, even leaving a note on their door warning against entry. Despite these clear signs of distress and the facility's policy requirements, the administrator failed to take the necessary steps to ensure the resident's safety and report the incident, resulting in a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation following an allegation of physical abuse made by a resident. The resident, who has moderate cognitive impairment, reported being hit by a young person fitting the description of a Certified Nurse Aide (CNA) working at the facility. Despite the resident's allegations, the facility did not suspend the CNA or conduct a formal investigation, allowing the CNA to continue working, which did not align with the facility's policy for handling abuse allegations. The resident expressed feeling unsafe and reported the incident to various staff members, including an Activity Assistant and the Social Services Director. The Social Services Director reported the incident to the Administrator, but the Administrator dismissed the allegations as delusional without conducting a formal investigation or notifying the state agency. The Director of Nursing (DON) also failed to investigate the CNA as a potential abuser, assuming the resident's claims were delusional. The facility's policy requires immediate suspension of any employee accused of abuse and a thorough investigation, which was not followed in this case. The Administrator acknowledged receiving reports of the allegations but did not take appropriate action, resulting in a failure to protect the resident and ensure their safety. The lack of a formal investigation and failure to report the incident to the state agency contributed to the deficiency identified by the surveyors.
Failure to Address Trauma and Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate care and interventions for a resident with a significant history of trauma and mental health disorders, including major depressive disorder, generalized anxiety disorder, and panic disorder. The resident, who had experienced severe trauma in the past, began exhibiting increased paranoia and reported being hit by an unidentified person. Despite these symptoms, the facility did not have a care plan in place to address the resident's history of trauma or the current behavioral changes. Interviews with facility staff revealed a lack of awareness and understanding of the resident's psychiatric history and the potential impact of past trauma on current behavior. The Licensed Practical Nurse/MDS coordinator and the Social Services Director admitted to not having read the psychiatric notes, which documented the resident's traumatic experiences and ongoing mental health issues. The resident's care plans did not include interventions to address the trauma or the recent behavioral changes, such as paranoia and feelings of being unsafe. The facility's failure to incorporate trauma-informed care and appropriate interventions into the resident's care plan was further highlighted by the lack of staff education on trauma and PTSD. The Director of Nursing and the Administrator acknowledged the need for staff to be aware of the resident's psychiatric history and to implement interventions to manage the resident's paranoia and trauma-related symptoms. The physician also emphasized the importance of recognizing the role of past trauma in the resident's current mental health status and the need for targeted interventions.
Sanitation and Hygiene Deficiencies in Kitchen and Nourishment Centers
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen and nourishment centers, as observed during a survey. Numerous issues were identified, including opened containers of salad dressing and mayonnaise without expiration or use-by dates, soiled lids on bulk flour and sugar bins, and uncovered pans of gelatin in the refrigerator. The kitchen surfaces, including the floor under the freezer and refrigerator, were soiled with debris, and there was a presence of mold-like debris on fan covers in the refrigerator. Additionally, the facility did not ensure proper use of hair and beard restraints by dietary staff, leading to potential contamination of food items. The ice machines in the kitchen and nourishment centers were found to be in poor condition, with heavy buildups of slimy yellow and crusty white debris, and a lack of proper air gaps in the drainage system. The door to the ice machine in the C Wing nourishment center was broken and could not close, leaving the ice exposed to contamination. Despite maintenance attempts, the issue persisted, and staff reported the problem had been ongoing for months. The facility's policy required regular cleaning and maintenance of these machines, but these procedures were not adequately followed. Furthermore, the facility failed to cover food and drink items when transporting meal trays to residents' rooms. Observations showed that while plates were covered, desserts and drinks were left uncovered during transport, increasing the risk of contamination. The dietary manager acknowledged these lapses, noting that all food items should be covered, and staff should adhere to hygiene practices, including wearing appropriate hair and beard restraints. These deficiencies highlight significant lapses in the facility's adherence to food safety and sanitation standards.
Inadequate Infection Control and TB Screening in LTC Facility
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among staff during personal care for four residents. Observations revealed that staff members did not wash their hands or change gloves appropriately between tasks, particularly when moving from soiled to clean tasks. For instance, a CNA was observed cleaning a resident's perineal area and then touching clean supplies without changing gloves or washing hands. This was a common issue across multiple staff members, indicating a systemic failure to adhere to the facility's hand hygiene policy. Additionally, the facility did not complete required Tuberculin Skin Tests (TST) and annual evaluations for tuberculosis for three new employees. The employee files lacked documentation of the necessary two-step TST or any annual TB evaluations. Interviews with the DON/Infection Preventionist revealed a lack of awareness and follow-through on these requirements, leading to non-compliance with the facility's TB screening policy. The facility also failed to monitor cold water temperatures as part of their water management program, which is crucial for preventing the growth of waterborne pathogens like Legionella. The maintenance director admitted to not measuring cold water temperatures and was not fully aware of the risks associated with Legionella growth. This oversight indicates a gap in the facility's infection prevention and control program, as the water management policy was not being fully implemented.
Deficiencies in Incontinence and Oral Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services for incontinence and oral care for two residents. Resident #1, who had severe cognitive impairment and was dependent on staff for personal hygiene, was observed multiple times with strong urine and fecal odors, indicating a lack of timely incontinence care. Despite being incontinent of bowel and bladder, staff did not consistently check or change the resident every two hours as required, leading to the resident being transported to the dining room with soiled clothing. Additionally, Resident #1 did not receive adequate oral care. Observations showed debris around the resident's mouth, and staff interviews revealed that oral care was often neglected due to time constraints. The facility's policy lacked specific documentation on when staff should assist with oral care, contributing to the oversight. Resident #29, who required substantial assistance with oral hygiene, also did not receive proper oral care. The resident reported not receiving assistance, and observations confirmed the absence of oral care supplies in the room. The resident's electronic health record lacked documentation of oral hygiene being provided, highlighting a systemic issue in the facility's care practices.
Failure to Ensure Resident Safety and Proper Fall Protocols
Penalty
Summary
The facility failed to ensure resident safety by not adhering to the care plan and transfer protocols for a resident with severe cognitive impairment and high fall risk. The resident required extensive assistance from two staff members for transfers, as indicated in the care plan. However, during an observation, a CNA assisted the resident alone without using a gait belt, which was against the facility's policy. The CNA acknowledged the need for a second person due to the resident's agitation but proceeded alone due to a lack of available staff. This resulted in an unsafe transfer process, where the CNA used their leg to support the resident, which was deemed inappropriate by the DON. Another deficiency was identified in the facility's handling of a fall incident involving a resident with moderately impaired cognition and a history of falls. The resident fell out of bed and was taken to the hospital, but the facility failed to document the incident comprehensively in the progress notes. Essential details such as the time, location, and activity prior to the fall, as well as injury description and treatment, were missing. The facility's fall protocol was not followed, as there was no documentation of a root cause analysis or implementation of new interventions to prevent future falls. Interviews with staff revealed a lack of communication and documentation regarding the fall incident. The LPN on duty during the fall did not document the incident in the progress notes and failed to implement or communicate any new interventions. The DON confirmed the absence of a fall report and documentation in the electronic health record. Despite the resident's fall, no new interventions were added, as the DON believed they were unnecessary due to the resident's lack of previous falls.
Failure to Properly Manage Oxygen Tubing for Residents
Penalty
Summary
The facility failed to properly store, change, and date oxygen tubing for two residents, leading to a deficiency in respiratory care. Resident #4, who was cognitively intact and used oxygen for chronic obstructive pulmonary disease (COPD), had no directive in their care plan to change or date the oxygen tubing. Observations over several days showed the resident using oxygen tubing without any date or initials, and the resident could not recall the last time the tubing was changed. The facility's records, including the Treatment Administration Record (TAR) and Physician Order Sheet (POS), did not specify when the oxygen tubing should be changed. Similarly, Resident #39, diagnosed with COPD and using continuous oxygen, also had no directive for changing or dating the oxygen tubing in their care plan. Observations showed the resident using undated and uninitialed oxygen tubing over multiple days. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed inconsistencies in understanding and executing the responsibility for changing and documenting the oxygen tubing. The facility lacked a policy for changing and dating oxygen tubing, as confirmed by the administrator.
Expired Medications and Testing Supplies Not Removed
Penalty
Summary
The facility failed to ensure that expired testing supplies and medications not in use were destroyed or returned as per facility policy. Specifically, medications for a discharged resident remained in the facility for 182 days after discharge, and expired COVID-19 test kits were not removed or destroyed, remaining in the facility for up to 132 days past expiration. These items were found during an observation of the medication storage room. Additionally, medications labeled for a current resident were found in the storage room without corresponding physician orders since the resident's admission. These included various medications such as atorvastatin, cyclobenzaprine, and sertraline, among others. The LPN interviewed was unaware of why these medications were in the cabinet, how long they had been there, or who placed them there. It was noted that sometimes families brought medications from home, which the facility could not use, and these were supposed to be taken back by the family. The Director of Nursing (DON) acknowledged responsibility for checking the medication storage room but admitted the last check was two weeks prior. The DON was unaware of the presence of expired COVID-19 tests and medications for the residents in question. The DON stated that expired medications should be placed in a destruction container, and anyone noticing outdated COVID-19 tests could dispose of them. However, these procedures were not followed, leading to the deficiency.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in the kitchen and dishwashing areas. Observations revealed light brown insects crawling along the walls and floors near heated carts, trash cans, and kitchen equipment. The facility's pest control policy, revised in May 2024, mandates an ongoing program to keep the building free of insects and rodents, with services provided by a pest control vendor. However, the pest control company's service summary report from December 2024 only indicated treatment of the facility's exterior for rodents and ants, with no recent interior treatment noted. Interviews with the Dietary Supervisor and Administrator revealed a lack of timely response to pest sightings. The Dietary Supervisor acknowledged a report of a roach in the service hallway on January 11, 2025, but did not act on it as it was not in the kitchen. The pest control company was contacted on January 13, 2025, but a billing issue delayed their response. The Administrator was unaware of the current insect issues in the kitchen until informed by the Dietary Supervisor. The pest control technician confirmed an ongoing issue with roaches, although the volume had decreased, and stated that healthcare facilities are prioritized for pest control services.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for a resident, leading to a deficiency. The facility did not assess the resident for risk of entrapment prior to the placement of bed rails, nor did they document any alternatives attempted before deciding to use bed rails. Additionally, the facility did not complete entrapment zone measurements or obtain written consent from the resident or their guardian before the use of the bed rails. The resident involved had a history of falls, unsteadiness on feet, and required substantial assistance for mobility. The resident's care plan indicated the use of half side rails to maximize independence with turning and repositioning in bed. However, there was no physician's order for the bed rails, and the resident's medical record lacked a bed rail assessment, entrapment assessment, or informed consent documentation. During an interview, the Director of Nursing acknowledged the absence of necessary orders, assessments, consents, or entrapment zone measurements for the resident's bed rail. Despite considering the removal of all bed rails, the facility and the resident decided it was in the resident's best interest to keep the bed rail. This decision was made without the proper documentation and assessments required by the facility's policies.
Failure to Conduct Bed Rail Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which are crucial for identifying potential entrapment hazards. This deficiency was observed in the case of a resident who used a half bed rail for assistance with mobility. The facility's policies required routine inspections and assessments to ensure the safe use of bed rails, but these were not completed. The Maintenance Director, who was responsible for these inspections, was unaware of his duties regarding measuring bed rails for entrapment zones and had not conducted any such assessments since his employment began three months prior. The resident involved had a history of falls and required substantial assistance with mobility due to a recent shoulder fracture. Despite the resident's reliance on the bed rail for safety and mobility, there was no documented assessment, physician order, or informed consent for the use of the bed rail. Interviews with the Maintenance Director and the Director of Nursing revealed a lack of awareness and execution of the necessary safety checks and documentation, contributing to the oversight in ensuring the resident's safety.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notices of transfer to residents and/or their representatives when six residents were transferred to the hospital. This deficiency was identified during a review of 14 sampled residents, where it was found that the facility did not adhere to its own Transfer or Discharge Notice policy. The policy requires that written notice be given as soon as practicable before a transfer or discharge, including details such as the reason for transfer, effective date, location, and appeal rights. However, in these cases, there was no evidence that such notices were provided. For instance, Resident #29 was transferred to the hospital twice, on two separate occasions, due to medical complaints, but there was no documentation of a written notice being provided to the resident's representative. Similarly, Resident #16 was transferred to the hospital with a pulmonary embolism, and Resident #11 was transferred following a fall and subsequent shoulder fracture, yet neither had written notices documented in their medical records. These omissions were consistent across other residents, including Resident #35, who was transferred due to swelling and respiratory issues, and Resident #251, who was transferred due to symptoms related to congestive heart failure. The facility's failure to provide written notices was confirmed during an interview with the Administrator, who acknowledged that the nurses were not sending transfer notices with the residents or providing them to the representatives upon transfer. This oversight indicates a systemic issue in the facility's process for handling transfers and discharges, as evidenced by the lack of documentation in the medical records of the affected residents.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents or their representatives within 24 hours of transfer to a hospital, affecting four residents out of a sample of 14. The facility's policy requires that when a resident is transferred to a hospital, the bed hold policy must be communicated in writing to the resident or their representative. However, in the cases of Residents #11, #16, #35, and #251, there was no evidence that this policy was provided as required. Resident #16 was transferred to the hospital due to elevated fever, decreased oxygen saturation, and increased respiratory effort, and was diagnosed with a pulmonary embolism. Resident #11 was transferred after a fall resulted in a right shoulder fracture. Resident #35 was sent to the hospital with symptoms including periorbital edema, confusion, and shortness of breath. Resident #251, who was their own responsible party, was transferred due to breathing difficulties and suspected weight gain. In all these cases, the facility did not provide the required bed hold policy documentation. Interviews with facility staff revealed that the Admission Director contacted residents or their representatives by phone to discuss the bed hold policy but did not document these discussions. The Administrator acknowledged that the nurses were supposed to provide the bed hold policy upon transfer, but this was not being done. This lack of documentation and communication led to the deficiency identified by the surveyors.
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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