Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Manor Health Care Center during CMS and state inspections, most recent first.
A resident’s right to choose an attending physician was not honored when the facility changed the resident’s PCP from Physician A to Physician B after discontinuing services with Physician A. The resident was cognitively intact and stated he/she wanted to stay with Physician A but did not have a choice. Social services documented the PCP change and later asked if the resident wanted to return to Physician A when that physician resumed practice at the facility.
A resident with moderate cognitive impairment and a history of falls and returning from leave of absence (LOA) intoxicated signed out in the morning with an expected return time but did not come back for meals or evening medications. Staff on multiple shifts noted the resident’s absence, yet no Code Purple (missing resident) was initiated and no search was conducted, despite facility policies requiring contact attempts and Code Purple procedures when a resident fails to return as expected. Interviews showed staff confusion about Code Purple responsibilities and reliance on assumptions that the resident would return or was with family. The resident’s care plan did not include interventions for the known pattern of returning from LOA intoxicated. The resident remained out all night and was later found unresponsive off-site and subsequently expired at the hospital, leading surveyors to cite the facility for failing to prevent accident hazards and provide adequate supervision.
Staff failed to follow the abuse policy after a resident-to-resident altercation in a common television area where one resident struck another with a cane, causing a cut and bruise under the eye that later led the injured resident to request hospital evaluation. Nursing notes documented the incident and treatment, and the DON, ADON, physician, and families were notified, but the Administrator was not informed, no timely report was made to the state, and no formal administrative abuse investigation was conducted. Required elements such as obtaining staff and resident statements, interviewing a witnessing resident, reviewing both residents’ records, and updating care plans to reflect the altercation and any changes in needs were not completed, despite the facility’s written abuse and neglect policy mandating these actions for all suspected or alleged abuse events.
Staff did not consistently follow standardized recipes when preparing pureed meals, with some meals being prepared without measuring ingredients or referencing the required recipes. Dietary staff relied on personal experience rather than written instructions, and management confirmed that recipes were not always used as expected. This affected residents on pureed diets.
Two residents, both with schizophrenia, were involved in a physical altercation when one charged and struck the other in the arm near the nurse's station. The assaulted resident, who had moderate cognitive impairment, was assessed and found unharmed, while the aggressor exhibited further self-injurious behavior and was later transported to the hospital. Staff intervened to separate the residents and reported the incident according to the facility's abuse and neglect policy.
A resident with hemiplegia and other medical conditions did not receive ordered restorative therapy with weights after discharge from skilled therapy, despite clear care plan and physician orders. The lapse was due to staff turnover and communication failures, resulting in the resident not receiving the recommended exercises to maintain or improve range of motion.
A resident with moderate cognitive impairment and schizophrenia was left unsupervised in an unsecured area during a smoking break, resulting in the resident leaving the facility without staff knowledge. Staff did not immediately notice the absence, and the resident was found the next day after spending the night outside. The incident occurred due to a lack of adequate supervision and oversight during the smoking break.
Staff failed to administer and document medications as ordered for three residents, with multiple instances of blank entries on the MAR and no corresponding progress notes. Residents with conditions such as depression, orthopedic issues, heart failure, and kidney failure reported missed medications, and staff interviews confirmed that facility policy required documentation of all administered or missed doses. The DON and Administrator acknowledged that lack of documentation meant physician orders were not followed.
The facility did not maintain an effective pest control program, as evidenced by multiple residents reporting frequent sightings of mice in their rooms, the presence of dirty sticky traps, and confirmed observations of mice and droppings by staff. Affected residents included those with diabetes, schizophrenia, heart failure, and cognitive impairment. Housekeeping staff reported the issue to supervisors but received no new instructions, and the facility's recent upgrade to pest control services had not yet addressed the ongoing problem.
A resident with multiple chronic conditions was transferred to another facility without receiving written notice of transfer/discharge, and the State LTC Ombudsman was not notified as required. The transfer was initiated due to the resident's sex offender status, but staff did not communicate directly with the resident or provide the mandated notifications, resulting in a deficiency.
A resident with diabetes and a history of substance abuse left the facility without proper notification or supervision, resulting in missed insulin doses and a lack of timely monitoring. Staff failed to notice the resident's absence for several hours, did not complete required sign-out procedures, and did not perform regular rounds to verify the resident's location. Upon return, the resident was found with new skin issues and in an unclean state, highlighting failures in supervision and adherence to facility policies.
The facility failed to prevent negative balances in resident trust accounts, affecting six residents. Despite having a policy to manage resident trust responsibilities, several accounts showed negative balances due to the facility awaiting representative payee status. The BOM and administrator were aware of the issue.
The facility did not complete monthly reconciliations of resident trust accounts for January and April 2024, as required by their policy. The Business Office Manager and Administrator indicated that the previous owners restricted access to bank statements, complicating the reconciliation process. The new ownership began in May 2024, which may have affected access to necessary financial documents.
A facility failed to provide a SNF ABN to a resident after completing Medicare A therapy services, preventing the resident from knowing about remaining Medicare A days. The SSD issued only a Notice of Medicare Non-Coverage, and admitted to being unaware of the requirement to use both forms for residents with available Medicare A days.
A resident with Type 2 diabetes and dementia was transferred to the hospital after missing dialysis sessions, but the facility failed to notify the Ombudsman as required by policy. The resident's moderate cognitive impairment was noted, and interviews with staff confirmed the oversight.
The facility did not provide a bed hold notice to a resident or their representative when the resident was transferred to the emergency room. The resident, who was moderately cognitively impaired and had diagnoses including Type 2 diabetes mellitus and dementia, was sent out due to missing dialysis sessions. The Social Services Director confirmed the absence of a bed hold notice.
The facility failed to manage and monitor the drug regimens of two residents, leading to unnecessary psychotropic medication use. One resident was prescribed multiple antidepressants with incorrect indications and lacked monitoring for adverse effects. Another resident received antidepressants without a psychiatric diagnosis, and there was no evidence of monitoring for side effects. The facility did not adhere to its policy on psychotropic medication use, potentially compromising residents' well-being.
The facility failed to maintain complete medical records for three residents after migrating to a new EMR system, resulting in the absence of current care plans. Additionally, a medication prescription for a resident was inaccurately documented, leading to the administration of the wrong medication. These issues were confirmed by the facility's administration and nursing staff.
A resident's BiPAP mask was found uncovered on the bedside table, contrary to the facility's policy requiring it to be cleaned and stored in a bag when not in use. Despite the resident's confirmation of the lapse and staff acknowledgment of the policy, the mask was not properly stored, indicating a failure in the facility's infection prevention and control program.
A resident with HIV and PML did not receive their prescribed Biktarvy medication due to communication and procedural failures, leading to their hospitalization and eventual death. The facility failed to follow proper medication order processes, and there was inadequate documentation and communication regarding the medication's unavailability.
A resident was abused by another resident who pushed them to the floor, threw an unlit cigarette at them, and tapped their face. The mental health aide left the scene to call for a nurse, allowing further abuse to occur. The facility's failure to adhere to its abuse prevention and protection policies contributed to the deficiency.
Resident Physician Choice Not Honored
Penalty
Summary
The facility failed to honor residents’ right to choose their attending physician when it discontinued services with Physician A, who had been providing care to 30 residents. Three residents from the sample were reviewed, and one resident who was cognitively intact stated a desire to continue care with Physician A. Instead, on 03/25/26, social services informed the resident that the primary care physician would be changed from Physician A to Physician B, and the change-of-PCP paperwork was signed. The resident’s annual MDS dated 03/04/26 showed the resident was cognitively intact. Social service documentation later noted that the resident was told Physician A would be returning to practice in the facility and was asked whether the resident wanted to go back under that physician as PCP; the resident agreed. During interview, the resident stated he/she did not want to change to Physician B and wanted to stay with Physician A, but did not have a choice. The Administrator stated she expected resident rights to be honored and the resident rights policy to be followed as written.
Failure to Initiate Code Purple and Address Intoxication Risk for Resident on Outside Pass
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for supervising a resident on an outside pass and initiating a Code Purple (missing resident) when the resident did not return at the expected time. The resident, who had moderate cognitive impairment and diagnoses including diabetes, acute kidney failure, depression, and hypertension, signed out at 8:30 A.M. to smoke outside with an expected return time of 5:25. The resident did not return for dinner or evening medications, and staff noted that the resident’s breakfast and lunch were still in the room and that the resident was not present for multiple medication passes. Despite this, staff did not initiate a Code Purple or conduct a search when the resident failed to return by the expected time. The facility’s Resident Outside Pass policy required staff to attempt to contact the resident or responsible party when a resident did not return at the stated time and, if unable to contact the resident, to follow Code Purple procedures. The Elopements and Wandering Resident’s policy defined Code Purple as an elopement outside the facility and required staff to search the building and grounds, notify the Administrator or designee, contact police if the resident was not located, and notify the physician and family or legal representative. In this case, staff on the evening and night shifts were aware the resident had not returned, but interviews showed they either believed the resident had signed out with family, assumed the resident would “pop up,” or did not know they were supposed to initiate a Code Purple. The ADON, who was notified between 10:00 P.M. and 11:00 P.M. that the resident was not in the building, instructed the nurse only to document the situation and did not direct staff to initiate a Code Purple. The resident had a history of falls and of returning from leaves of absence intoxicated, including prior incidents where staff had to assist the resident from the ground outside or in the alley behind the facility. Progress notes documented falls associated with alcohol use, with staff noting the resident smelled of alcohol or was intoxicated, and staff sometimes held medications and notified the nurse when the resident was intoxicated. However, the care plan did not include interventions addressing the resident’s pattern of returning from LOA intoxicated or guidance for staff on how to manage this risk. The resident remained out of the facility all night without a Code Purple or search being initiated. According to hospital records, the resident was later found face down, unresponsive, in a puddle of water approximately two miles from the facility, with scattered abrasions, and was admitted in critical condition before expiring at the hospital. Staff interviews revealed inconsistent understanding and implementation of the facility’s policies. Some CNAs and a CMT stated they did not initially know what Code Purple meant or what to do if a resident did not return from LOA, while others stated that when a resident did not return, they were supposed to notify the nurse, administrator, DON, and family, and initiate a Code Purple with a search of the facility and surrounding neighborhood. The Administrator, who was the ADON at the time of the incident, stated that a Code Purple was to be called when a resident did not return from LOA or eloped, but believed it was not initiated in this case because the resident had stayed out overnight before and was his or her own responsible party. The facility’s failure to initiate a Code Purple and conduct a search when the resident did not return as expected, combined with the lack of care plan interventions addressing the resident’s known history of intoxication on return from LOA, led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Report and Investigate Resident-to-Resident Altercation per Abuse Policy
Penalty
Summary
Facility staff failed to follow the facility’s abuse and neglect policy when a resident-to-resident altercation occurred and was not reported to Administration, preventing a thorough abuse investigation. The policy required that all allegations or suspicions of abuse, including resident-to-resident physical abuse and injuries of unknown origin, be reported immediately to the Administrator and appropriate agencies, and that an administrative investigation be completed with staff and resident statements, record review, and care plan updates. On the date of the incident, nursing documentation showed that one resident (Resident #1), who had moderate cognitive impairment, anemia, and ESRD, was sitting in a television area when another resident (Resident #2) was seen hitting him/her with a walking cane, causing a slight bruise/cut under the left eye. The area was cleansed, treated with triple antibiotic ointment, and bandaged, and the DON, ADON, and Resident #1’s family were notified. Nursing notes for Resident #2, who had no documented cognitive impairment or behaviors but carried diagnoses including anemia, CHF, HTN, and Alzheimer’s disease, documented that he/she was seen in the television area hitting another resident with a cane, after which the residents were separated and Resident #2 was taken to the nursing station. A message was left for Resident #2’s family and the DON and ADON were made aware. Two days later, Resident #1 complained of a headache, requested to go to the hospital to be evaluated following the altercation, and was transferred; the family and physician were notified, and the DON was made aware. Despite these events, neither Resident #1’s nor Resident #2’s care plans contained documentation regarding the resident-to-resident altercation. Interviews and record review showed that the facility did not initiate or complete the required administrative abuse investigation. RN A reported overhearing a commotion, hearing another resident (Resident #4, with moderate cognitive impairment) question Resident #2 about hitting Resident #1, and then observing a cut under Resident #1’s left eye; RN A separated the residents, took Resident #2 to the nursing station, and notified the DON, physician, and families, but was not asked to write a statement. Resident #4 later stated that Resident #1 had been watching television when Resident #2 approached and began hitting Resident #1 with a cane without any exchange of words; Resident #4 was not interviewed or asked for a written statement by facility staff. The DON stated she was told that Resident #2 had a fall and that the cane accidentally hit Resident #1, reviewed only Resident #1’s notes, did not review Resident #2’s notes, did not obtain statements, and did not conduct a full investigation. The Administrator reported she was not informed of the altercation, and both she and the DON acknowledged that the incident should have been reported to the Administrator and to the state agency within two hours and investigated thoroughly, as required by the facility’s abuse policy.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that standardized recipes were followed during the preparation of pureed meals for residents requiring such diets. Observations revealed that staff members prepared pureed chicken and potatoes without referencing or using the standardized recipes provided by the facility. One staff member blended diced chicken with an unspecified amount of water and a slice of bread, resulting in a mixture that was not smooth and did not match the facility's recipe, which required specific amounts of chicken, chicken base, and water. The same staff member also prepared pureed potatoes without knowing or measuring the amount of water added. Another staff member prepared pureed carrots with added bread, which was not included in the facility's standardized recipe for that dish. In some instances, recipes were not present during meal preparation, and staff relied on personal experience rather than following written instructions. Interviews with dietary staff and management confirmed that recipes were not consistently used or followed during meal preparation. The Dietary Manager acknowledged that cooks should reference recipes and was unable to locate a recipe for mashed potatoes. The Regional Dietary Manager and the Administrator both stated that recipes are available in the kitchen and are expected to be followed as written to ensure proper nutrition for residents. The facility had eight residents on pureed diets at the time of the survey, and the census was 112.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was physically assaulted by their roommate, who charged and hit them in the arm while the victim was sitting in a chair in the hallway near the nurse's station. The incident was witnessed by staff, and both residents were separated with assistance. The assaulted resident, who had moderate cognitive impairment, diagnoses including anemia, hypertension, and schizophrenia, and required partial to moderate assistance with ADLs, was assessed and found to have no injuries. The resident expressed not knowing why the attack occurred and reported feeling safe at the facility during a subsequent interview. The aggressor in the incident, who also had a diagnosis of schizophrenia and morbid obesity, was observed to have initiated the altercation by running toward and striking the other resident. After the incident, the aggressor exhibited further self-injurious behaviors, including scratching and biting their own arm, and threatened self-harm. The resident was removed from the area, monitored by staff, and eventually transported to the hospital after refusing initial treatment for minor injuries. The aggressor later stated that fear of being watched while sleeping prompted the attack, but denied wanting to harm anyone further. Staff interviews confirmed that the incident was reported and that both residents were separated following the altercation. The facility's abuse and neglect policy defines abuse to include resident-to-resident altercations and requires immediate reporting and intervention. The deficiency was identified due to the failure to protect a resident from physical abuse by another resident, as required by federal regulations.
Failure to Provide Ordered Restorative Therapy for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when the facility failed to provide restorative therapy services as recommended for a resident with a history of hemiplegia, congestive heart failure, and high blood pressure. The resident was discharged from skilled occupational therapy with a recommendation for a Restorative Nursing Program, specifically an active range of motion (AROM) program using bilateral upper extremity weights. The care plan and physician orders specified the use of three to six pound weights for 20 repetitions, three times per session, to be performed three times weekly. However, there was no documentation that these restorative exercises were implemented, and the resident reported not receiving the therapy with weights, despite expressing a desire to participate to improve strength. Interviews with facility staff revealed a breakdown in communication and oversight following staff turnover in the restorative aide position. The restorative aide was unaware of the resident's order for weight exercises, and the Assistant Director of Nursing acknowledged that the order had been overlooked during the transition of responsibilities. The Director of Nursing and Administrator both confirmed that restorative orders are expected to be followed as written, but the lapse was attributed to recent staff changes and oversight.
Resident Elopement Due to Inadequate Supervision During Smoking Break
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, schizophrenia, anemia, and hypertension was left unsupervised in an unsecured outdoor area during a smoking break. The resident required partial to moderate assistance with activities of daily living and had no prior history of wandering or elopement. Despite the facility's policy requiring supervision of residents at risk for elopement, the resident was able to leave the premises without staff awareness or authorization. On the evening of the incident, staff members, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), a receptionist, and a Certified Nurse Aide (CNA), were involved in the resident's care and supervision. The resident was last seen participating in activities and waiting for a smoke break. The resident was given a cigarette by the receptionist and went outside to smoke with other residents and a CNA. After approximately 30 minutes, the CNA and other residents returned inside, but the resident did not. Staff did not immediately notice the resident's absence, and subsequent attempts to locate the resident were unsuccessful. The resident's absence was discovered when the CMT attempted to administer medication and could not find the resident. A search was initiated, and the facility followed its elopement protocol, including notifying the family and police. The resident was found the following morning by activity staff, having spent the night outside. The resident reported feeling "caged" and left the facility during the unsupervised smoking break. The resident sustained a minor burn on the forearm, which was self-reported as unrelated to the incident. The deficiency was due to the failure to provide adequate supervision and oversight, allowing the resident to elope from the facility.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
Staff failed to administer and document medications as ordered by physicians for three residents, resulting in a failure to meet professional standards of quality. Facility policies required that all physician orders be accurately transcribed and followed, and that medication administration be documented on the Medication Administration Record (MAR) immediately after administration. However, review of the MARs for the three residents revealed multiple instances where medications were either not documented as given or left blank, with no corresponding progress notes to explain the omissions. One resident with diagnoses including orthopedic conditions and depression had several medications, such as Duloxetine, Famotidine, and Hydroxychloroquine, that were not documented as administered on multiple dates. The resident reported issues with receiving pain medications, and there was no documentation in the progress notes regarding the missed doses. Another resident with high blood pressure, end stage renal disease, anxiety, and depression also had several medications, including Nortriptyline, Melatonin, and Amlodipine, left undocumented on the MAR for multiple days. This resident reported not receiving their Nortriptyline and was unsure about other missed medications. A third resident with heart failure and acute kidney failure had orders for Hydralazine and Isosorbide Dinitrate, with several doses not documented as administered and no progress notes explaining the omissions. Interviews with staff confirmed that the MAR should be initialed after medication administration and that any missed doses should be documented with reasons. The Director of Nursing and Administrator both stated that the facility's policies required strict adherence to these procedures, and that failure to document indicated the medication was not given as ordered.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice in multiple resident rooms. Despite having a written pest control policy and a contract with an outside pest service, residents consistently reported seeing mice in their rooms, and observations confirmed the presence of dirty sticky traps and, in one case, a dead mouse in a kitchen office trap. Video and photographic evidence submitted to the Department of Health and Senior Services showed mice in resident rooms, including three mice on a glue trap next to a resident's bed. Housekeeping staff reported seeing mouse droppings daily in resident rooms and stated that, after reporting these findings to their supervisor, they were not given any new instructions or guidance on how to address the issue. Residents affected included individuals with diagnoses such as diabetes, depression, schizophrenia, heart failure, acute kidney failure, anemia, and high blood pressure. Some residents had no cognitive impairment, while others had moderate cognitive impairment and required varying levels of assistance with activities of daily living. The Maintenance Director indicated that the facility had only recently upgraded its pest control service to include more comprehensive interior monitoring, but this change had not yet resolved the ongoing rodent problem at the time of the survey.
Failure to Notify Resident and Ombudsman Prior to Transfer/Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident, the resident's representative, and the State Long-Term Care (LTC) Ombudsman prior to a transfer/discharge. The transfer was initiated by corporate staff due to the resident's status as a sex offender, which was not permitted at the facility's location. The Administrator and Social Service Director (SSD) did not issue a written notice of transfer/discharge to the resident or notify the Ombudsman, as required by facility policy and federal regulations. The resident involved had a history of high blood pressure, diabetes, stroke, and seizure disorder, and required partial to moderate assistance with activities of daily living. The resident was cognitively intact, with no noted mood or behavioral issues, and was his/her own responsible party. Documentation showed that the SSD spoke only with the resident's family member about the transfer, who had no objections, but did not communicate directly with the resident regarding the discharge or provide written notice. The Administrator confirmed that she did not speak with the resident, did not issue a discharge notice, and did not contact the State LTC Ombudsman. The transfer was executed by arranging for the resident to be transported by taxi to another facility, accompanied by staff, with medications sent for safety and remaining belongings to follow. The facility's failure to follow its own policy and regulatory requirements regarding notification and documentation led to the deficiency.
Resident Left Facility Unnoticed, Missed Insulin Doses and Supervision
Penalty
Summary
A resident with diagnoses of diabetes and substance abuse, who was their own responsible party, left the facility without proper notification or supervision, resulting in a failure to administer scheduled insulin doses. Staff last observed the resident in their room between 1:00 P.M. and 2:00 P.M., but did not realize the resident was missing until approximately seven hours later. The resident did not sign out with the receptionist or notify nursing staff, and the required information on the Leave of Absence (LOA) form was incomplete, lacking an expected return time and staff initials. Multiple staff members, including CNAs, RNs, and the receptionist, failed to verify the resident's whereabouts during their shifts. The resident was not accounted for during routine rounds, and assumptions were made that the resident was in common areas such as the smoking area. The lack of communication and failure to follow the facility's Resident Outside Pass Policy and Elopement and Wandering Policy contributed to the delay in recognizing the resident's absence. As a result, the resident missed scheduled blood glucose monitoring and insulin administration, as documented by blank entries on the Medication Administration Record (MAR). Upon the resident's return, staff observed that the resident had developed new open areas on the thighs and a sore on the foot, which were not present prior to the absence. The resident was found in an unclean state, indicating a lack of care during the period away from the facility. Interviews with staff revealed gaps in following established protocols for resident supervision, sign-out procedures, and timely medication administration, all of which contributed to the deficiency.
Failure to Prevent Negative Balances in Resident Trust Accounts
Penalty
Summary
The facility failed to maintain a system that ensured residents' individual trust fund accounts did not go into a negative balance. This deficiency affected six residents out of a sample of eight, with the facility managing funds for 61 residents in total. The facility's Resident Trust Policy, dated February 2, 2024, outlined procedures for managing resident trust responsibilities, including preventing negative balances. However, a review of the Resident Trust Transaction History from May 1, 2024, to September 13, 2024, revealed that several residents had negative balances on their accounts. For instance, one resident had a negative balance of $456.23, while another had a negative balance that reached $5,444.00. During an interview, the Business Office Manager (BOM) acknowledged that resident trust accounts should not have negative balances and was aware of the issue. The BOM attributed the negative balances to the facility awaiting representative payee status for some residents, which would resolve the negative balances. The facility's administrator was also aware of and agreed with the BOM's explanation. Despite the policy in place, the facility did not adhere to the procedures, resulting in the cited deficiency.
Failure to Reconcile Resident Trust Accounts
Penalty
Summary
The facility failed to complete and maintain monthly account reconciliations of the resident trust accounts for two months, specifically January 2024 and April 2024. The facility's Resident Trust Policy mandates that a reconciliation of the bank statement module must be completed monthly by the facility's staff accountant, who is responsible for the facility's financials, and not by the Resident Trust Clerk. During an interview, the Business Office Manager (BOM) and the Administrator revealed that the previous owners of the facility no longer allowed access to the bank statements, which contributed to the failure in maintaining the reconciliations. The BOM mentioned that she believed she had copies of the bank statements, but the new ownership took over in May 2024, which may have impacted the access and reconciliation process.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident when he completed his Medicare A therapy services. This oversight prevented the resident from being informed about his remaining Medicare A days. The facility's policy, implemented on 01/01/24, required the use of the SNF ABN, Form CMS-10055, for Part A items and services. However, the Social Services Director (SSD) only issued a Notice of Medicare Non-Coverage, which the resident signed, indicating his last covered day was 08/23/24. The resident remained in the facility and reverted to Medicaid. The SSD admitted during an interview that he was unaware of the requirement to use both forms for residents with available Medicare A days.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a transfer for one of the residents, identified as R84, who was part of a sample of 26 residents. According to the facility's policy on Resident Transfer/Discharge, in cases of emergency or immediate discharge, copies of the transfer notice must be sent to the Ombudsman. R84, who was admitted for long-term care and had diagnoses including Type 2 diabetes mellitus and dementia, was transferred to the hospital on 06/06/24 after missing two dialysis sessions. The resident's most recent Quarterly Minimum Data Set indicated a moderate cognitive impairment with a BIMS score of 11. However, there were no documents in the electronic medical record showing that the transfer information was provided to the Ombudsman. Interviews with the Social Services Director, Administrator, and Director of Nursing confirmed that the transfer notice was not sent to the Ombudsman, and they were unaware of this oversight.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to one of the residents, identified as R84, or their responsible party when the resident was transferred to the emergency room. According to the facility's Bed Hold Policy, revised on 11/06/23, a copy of the policy should be provided to the resident or their legal representative when a resident is discharged to the hospital. R84, who was admitted for long-term care and had diagnoses including Type 2 diabetes mellitus and dementia, was moderately cognitively impaired with a BIMS score of 11. The review of the electronic medical record revealed no documentation of a bed hold form being provided when R84 was sent out on 06/06/24 due to missing two dialysis sessions. An interview with the Social Services Director confirmed that no bed hold notice was given to R84 upon hospital transfer.
Failure to Monitor and Manage Psychotropic Medications
Penalty
Summary
The facility failed to manage and monitor the drug regimens of two residents, R30 and R1, leading to unnecessary psychotropic medication use. For R30, the facility's records showed multiple antidepressant medications prescribed with incorrect indications, such as schizophrenia, and a lack of monitoring for adverse effects. Additionally, R30 was prescribed two antipsychotic medications from the same drug class without clear justification. The Director of Nursing (DON) and Clinical Pharmacist acknowledged these discrepancies, indicating a lack of clarity in medication indications and insufficient monitoring for side effects. R1's case involved the prescription of antidepressant medications without a corresponding psychiatric diagnosis. The resident's records indicated the use of mirtazapine for appetite stimulation, yet it was ordered with an indication for mood disorder. There was no evidence of monitoring for adverse effects of the antidepressant medications in R1's records. The DON confirmed the incorrect indication and the absence of side effect monitoring. The facility's policy on psychotropic medication use emphasizes the necessity of these drugs for specific conditions and the importance of monitoring the resident's response. However, the facility did not adhere to this policy, as evidenced by the lack of appropriate indications for medications and the absence of documented monitoring for adverse effects in both residents' cases. This oversight potentially compromised the residents' mental, physical, and psychosocial well-being.
Deficiencies in Medical Record Maintenance and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accessible medical records for three residents during a recertification and complaint survey. The electronic medical records (EMRs) for these residents did not contain current care plans following the facility's migration to a new EMR system. This deficiency was confirmed by the Administrator and Regional Director of Operations, who acknowledged that the transition to the new system was challenging and that they were still in the process of scanning hard copy chart data. As a result, Certified Nurse Aides were unable to access current Plans of Care to provide appropriate care and services. Additionally, the facility failed to accurately document a medication prescription for one resident. The resident's Medication Administration Record (MAR) showed discrepancies between the prescribed medication and what was administered. The Licensed Practical Nurse (LPN) was observed administering a different medication than what was documented in the EMR. The Director of Nursing (DON) admitted to entering the order incorrectly in the EMR, which led to the pharmacy dispensing the wrong medication. These deficiencies highlight issues with the facility's transition to a new EMR system and the accuracy of medication documentation. The lack of current care plans and incorrect medication orders could potentially impact the quality of care provided to the residents. The facility's policies on medical records and pharmaceutical services were not adhered to, resulting in incomplete and inaccurate documentation.
Improper Storage of BiPAP Mask
Penalty
Summary
The facility failed to ensure proper storage of a resident's BiPAP mask when not in use, as observed during a survey. The facility's policy requires that BiPAP masks be cleaned daily, dried well, and stored in a plastic bag or enclosed in machine storage when not in use. However, during observations on two separate occasions, the BiPAP mask of a resident with a diagnosis of respiratory failure, sleep apnea, and COPD was found lying uncovered on the bedside table. The resident, who had no cognitive impairment, confirmed that the staff had only covered the mask in a plastic bag once and had not done so since. Interviews with the nursing staff, including two LPNs, revealed that they were aware of the policy requiring the BiPAP mask to be stored in a bag, yet the mask was not stored properly. The LPNs acknowledged the oversight, and one of them inquired about the absence of a storage bag. The Regional Director of Operations also confirmed that the masks should be cleaned and bagged when not in use, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Administer Critical HIV Medication
Penalty
Summary
The facility failed to provide a critical medication, Biktarvy, to a resident diagnosed with HIV and progressive multifocal leukoencephalopathy (PML) upon their admission. The resident's discharge paperwork from a previous facility included orders for Biktarvy, but the medication was not administered due to a series of communication and procedural failures. The resident was eventually discharged to the hospital in an unresponsive state and later expired, with the lack of Biktarvy being a contributing factor to their death as per the infectious disease physician's assessment. The facility's process for handling medication orders was not followed correctly. The Charge Nurse did not ensure the Biktarvy order was processed and communicated effectively. The pharmacy flagged the medication order due to its high cost and required approval from the DON or Administrator, which was not obtained. Additionally, there was a lack of documentation and follow-up regarding the medication's unavailability, and the resident's physician was not adequately informed about the delay. The resident's care plan did not include specific interventions for PML, and there was no documentation of the resident's condition worsening due to the lack of Biktarvy. Staff interviews revealed that the resident's paper chart and medication orders were not properly transferred and communicated between facilities. The facility's failure to administer the prescribed medication and properly document and communicate the issues led to a significant medication error, contributing to the resident's decline and eventual death.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse was not violated when one resident was abused by another resident. The incident occurred when Resident #7 pushed Resident #6 to the floor, threw an unlit cigarette at them, and tapped their face three times. The mental health aide who discovered the situation walked away to call for a nurse, leaving Resident #6 on the floor with Resident #7 still present, during which time Resident #7 threw the cigarette at Resident #6. The facility's policy mandates that staff must stay with the resident and immediately inform the charge nurse, which was not followed in this case. Resident #6, who has diagnoses including end-stage renal disease, heart failure, diabetes, and schizophrenia, was found on the floor with no visible injuries but reported being pushed by Resident #7. Resident #7, who has a history of polysubstance abuse and diabetes, admitted to pushing Resident #6 and throwing the cigarette. The altercation was reportedly triggered by a misunderstanding involving food delivered by Resident #7's family member, which Resident #6 shared with another resident. The police were called but did not file charges, and both residents were placed on supervised monitoring to avoid further contact. The facility's investigation revealed that Resident #7 was upset over Resident #6 locking their door and sharing food meant for Resident #7 with another resident. Despite the facility's policies on abuse prevention and protection, the staff's actions were insufficient to prevent the abuse. The mental health aide's decision to leave the scene to call for help, rather than staying with the residents as required, allowed further abuse to occur. The facility's failure to adhere to its own policies contributed to the deficiency in protecting Resident #6 from abuse.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Circle Rehab And Nursing | 0.7 mi | ★★★★★ | 3 | 0 |
| Bernard Care Center | 1.2 mi | ★★★★★ | 31 | 0 |
| Life Care Center Of St Louis | 1.4 mi | ★★★★★ | 14 | 0 |
| Delhaven Manor | 2.6 mi | ★★★★★ | 1 | 0 |
| Beauvais Rehab And Healthcare Center | 2.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.