Grand Manor Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 3645 Cook Ave, Saint Louis, Missouri 63113
- CMS Provider Number
- 265717
- Inspections on file
- 25
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grand Manor Health Care Center during CMS and state inspections, most recent first.
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.
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.
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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