Heritage Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4401 North Hanley Road, Saint Louis, Missouri 63134
- CMS Provider Number
- 265534
- Inspections on file
- 38
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 32 (1 serious)
Citation history
Health deficiencies cited at Heritage Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, bipolar type, impaired judgment, and a documented history of elopement from prior secure facilities was care planned for intensive monitoring but was housed in a room adjacent to an exit door and not reassessed for elopement risk after the guardian requested transfer to a secure unit. On the day of the incident, staff noted the resident missed smoking and dinner, a door alarm sounded and was silenced by a CNA, and an LPN relied on another resident’s report instead of directly confirming the resident’s presence before leaving at shift change. The oncoming LPN found the resident already gone, initiated a search and code white, and later documentation and MAR entries showed missed doses of multiple psych and chronic meds with the resident marked as out of the building, revealing that the resident’s absence had gone unrecognized for several hours despite facility policies requiring elopement monitoring, intensive monitoring, and regular walking rounds.
Two cognitively intact residents with psychotic disorders and schizophrenia became involved in an altercation in which one resident pulled a screwdriver or similar object and attempted to stab the other, with witnesses reporting both verbal and physical fighting. An LPN initially documented that a screwdriver was used, then altered the note to say "object," while a CMT and one resident consistently described a screwdriver and physical contact, and police were notified. Despite facility policies requiring comprehensive incident and abuse investigations, written witness statements, and care plan revisions for resident-to-resident altercations, the facility’s investigation lacked written statements from involved staff and residents, did not include input from maintenance regarding the alleged source of the screwdriver, and failed to update either resident’s care plan or document the incident in one resident’s nursing notes.
The facility did not complete a thorough facility-wide assessment to determine necessary resources and staffing for competent resident care during daily operations and emergencies. The assessment lacked required details on staffing ratios, RN coverage, and staff competencies, and the facility was missing a full-time DON and social worker. The administrator confirmed the assessment was incomplete, with only external contact information documented.
The facility did not maintain a full-time DON who was not also serving as a charge nurse when the census was 105, contrary to policy and regulatory requirements. During the DON's medical leave, the RN Supervisor acted as interim DON but also provided RN coverage, and there was confusion among staff about who was fulfilling the DON role. Corporate RN staff provided intermittent coverage, but the facility lacked a consistent, full-time DON not assigned as a charge nurse.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with multiple resident rooms and shared bathrooms exhibiting unpainted drywall, exposed holes, missing cove base, dirty and sticky floors, and evidence of pests. Maintenance staff reported that repairs were delayed due to slow supply deliveries caused by budget cuts.
A resident with a history of aggression and mental health diagnoses was placed in a head lock by a staff member during an altercation, following an attack on a CNA. The staff member, despite CPI training, did not use approved de-escalation or restraint techniques, resulting in a violation of the resident's right to be free from physical abuse. Staff interviews confirmed improper intervention and a lack of coordinated response during the incident.
A resident's trust funds were withdrawn and used to purchase clothing, furniture, and other items without the resident's consent or required signature. The BOM made these purchases based on staff input rather than direct resident authorization, and the resident later reported not wanting or receiving several of the items. Facility policy requiring resident permission and signatures for withdrawals was not followed.
A resident with terminal diagnoses was not enrolled in hospice services despite hospital discharge orders and care plan interventions indicating hospice care. Staff discovered the lack of hospice enrollment only after a significant decline in the resident's condition, but did not notify the physician of this discovery or document key assessment findings in the medical record. The resident expired without receiving hospice services, and required notifications and documentation were not completed as per facility policy.
The facility did not maintain an accurate accounting system for resident trust fund accounts, failing to complete proper monthly reconciliations and resulting in discrepancies between reported and actual cash on hand. Staff interviews confirmed inconsistent practices in tracking and reconciling petty cash, and expectations for monthly reconciliation were not met.
A resident with severe back pain and multiple comorbidities did not receive a physician-ordered opioid pain medication due to staff failing to transcribe and process the order. Instead, the resident was intermittently given Tylenol, which was reported as ineffective. Staff interviews revealed a lack of awareness of the opioid order, and the order was never sent to the pharmacy, resulting in inadequate pain management.
A deficiency was cited for not ensuring an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The issue remains uncorrected, with references to previous similar citations.
A resident with a history of severe mental health conditions and repeated self-harm incidents was left unsupervised when the assigned 1:1 staff was reassigned due to short staffing. During this unsupervised period, the resident broke a window and used the glass to inflict deep cuts, requiring medical intervention. Facility policy and the resident's care plan required continuous 1:1 supervision, but this was not maintained, leading to the incident.
A cognitively intact resident with a history of sex offender status was transferred from a sister facility and placed on a locked unit without being informed, consulted, or allowed to participate in their care planning. The resident expressed distress and confusion about the transfer and placement, and facility staff confirmed that the process did not include proper communication, assessment, or documentation. The placement decision was made solely based on the resident's sex offender status, without evidence of recent behavioral issues or individualized risk assessment.
A cognitively intact resident was placed on a secured unit solely because of sex offender status, without clinical justification or assessment, and was not informed or given options regarding the transfer. Facility staff confirmed the placement was based on policy rather than individualized evaluation, and documentation lacked evidence of risk assessment or behavioral issues.
The facility did not provide reliable WiFi access for residents, resulting in multiple individuals being unable to use electronic communications such as email, video calls, internet research, or to watch TV. The facility used a business-only internet account for both office and resident use, which violated the provider's policy and led to service suspension. Interviews confirmed that residents were left without internet access for an extended period, and facility leadership was unaware of the full extent and requirements related to resident internet access.
Multiple residents' rooms were found with mice droppings, holes in walls, and food debris, while a common area cabinet contained live and dead roaches with egg sacs. Residents and staff reported frequent sightings of mice, and facility records showed inconsistent pest control services due to a change in vendors, resulting in inadequate pest management.
A resident with a history of mental illness and requiring 1:1 supervision experienced an escalation in aggressive behavior after being told by an LPN to remain at the nurse's station due to staff shortages, rather than being allowed to go to their room as per their care plan. The lack of sufficient and competent staff, along with failure to follow care plan interventions, led to a physical altercation and the resident being sent to the hospital.
A resident was transferred to another facility without receiving the required written notice detailing the reason, effective date, new location, or appeal rights. Documentation of communication with the resident, family, physician, and ombudsman was missing, and staff interviews confirmed that the established discharge process and facility policy were not followed.
A resident with multiple medical conditions was referred for cataract surgery, but after a follow-up eye center visit, unclear discharge paperwork stating only 'return for cataract evaluation' was not clarified by nursing staff. As a result, no further appointment was made and the surgery was not scheduled, despite facility expectations that staff should clarify and act on such instructions.
A resident discharged to another skilled nursing facility did not have a comprehensive discharge summary completed, as required by facility policy. The medical record lacked a final summary of the resident's status, medication reconciliation, and a post-discharge care plan. Additionally, the MDS assessment was incomplete regarding discharge goals and referrals, and there was no discharge order from the physician.
A resident with a mechanical soft diet order was served a regular textured ham sandwich, leading to choking. Staff were unable to clear the airway, and emergency medical staff later dislodged the food. The resident was hospitalized and later expired.
A facility did not follow its abuse and neglect policy by failing to thoroughly investigate an incident where a resident, ordered a mechanical soft diet, was served a regular diet. This error resulted in the resident choking and later dying in the hospital. The incident was part of a sample of 10 residents, with the facility's census at 110.
A resident with a mechanical soft diet order due to swallowing difficulties was served a regular textured ham sandwich, leading to choking and eventual death. The incident was caused by a lack of communication between dietary and nursing staff regarding the resident's dietary needs, resulting in the provision of an inappropriate meal. Despite staff intervention, the resident's airway could not be cleared, leading to hospitalization and death.
A facility failed to investigate a resident's possession of unknown pills and consumption of magnesium citrate, contrary to its abuse and neglect policy. The resident, with no cognitive impairment, was found with foam at the mouth and jerky movements. Staff failed to communicate and act on the incident, with the DON unaware until later. The lack of investigation highlights a breakdown in policy adherence and staff communication.
A facility failed to prevent multiple altercations between two residents, one with moderate cognitive impairment and schizophrenia, and another with no cognitive impairment but exhibiting aggressive behaviors. Despite three incidents, the facility did not update care plans with interventions, nor did it follow its abuse policy to protect residents. Staff interviews indicated that the resident should not have been placed on a hall with more aggressive residents, and the resident was only moved after the third altercation.
During a Covid-19 outbreak, facility staff and visitors failed to comply with the requirement to wear N95 masks, as observed in multiple instances. Despite signage and policy mandates, staff, including CNAs and maintenance workers, as well as external personnel, were seen without masks or wearing them improperly. Interviews confirmed awareness of the requirement, but enforcement was lacking, potentially affecting all 112 residents.
A facility failed to maintain a medication error rate below 5%, resulting in a 22.22% error rate. A CMT administered the wrong inhaler to a resident without instructions and omitted several prescribed medications. Miscommunication after a telehealth visit led to a medication order error, which was corrected after surveyor intervention. The facility's policy on medication administration was not followed.
A significant medication error occurred when a resident received incorrect dosages of Haloperidol due to a transcription failure. The resident was prescribed 5 mg twice a day, but the previous 2 mg three times per day order was not removed, leading to both dosages being administered. The error was identified during a survey, revealing that the CMT did not verify the orders with the Charge Nurse before administration.
A resident with a history of elopement and mental illness symptoms requiring 24-hour monitoring left an LTC facility undetected due to inadequate supervision and malfunctioning exit doors. Staff failed to conduct required hourly checks, and documentation was falsified. The resident was missing for over 24 hours before being found by police. The facility's lack of communication and awareness of the resident's risk contributed to the incident.
Failure to Supervise High-Risk Resident Leading to Unrecognized Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a known history of elopement from prior facilities received adequate supervision and monitoring, resulting in the resident’s absence from the facility going unrecognized for at least 4.5 hours. The resident had diagnoses including schizoaffective disorder, bipolar type, lack of coordination, and muscle weakness, and had a legal guardian. The resident’s care plan identified a problem of elopement risk due to a history of elopement from a prior secure facility, with an intervention for face checks/intensive monitoring per facility protocol. Despite this, the resident’s elopement assessments on two prior dates scored the resident as not at risk for elopement, and no additional elopement risk assessment was completed after the guardian requested that the resident be moved to a secured unit because of prior elopements and recent marijuana use at the facility. On the day of the incident, the resident’s room was located adjacent to an exit door at the end of a hall. Staff accounts showed that the resident was last definitively seen by an LPN between approximately 2:00 P.M. and 2:30 P.M. The resident did not come out to smoke at 11:45 A.M., and later did not come for dinner. Instead of personally checking on the resident, the LPN sent another resident to the room; that resident reported back that the missing resident did not want to be bothered and was asleep, and the LPN did not verify this information before leaving at shift change. The oncoming LPN reported that when the shift began at 7:00 P.M., the resident was already not in the facility, and a CNA informed the oncoming nurse that the resident had not been seen, prompting a search and a code white. The oncoming LPN stated they were unaware of any elopement history for the resident and had not been told the resident might leave. Additional documentation and interviews showed that routine rounds were expected every two hours, primarily by CNAs and CMTs, to ensure residents were present and safe, and that intensive monitoring was understood by some staff to mean constant visual ability to see the resident. However, staff reported that when they believed they knew where residents were, they simply passed that information to the next shift without directly confirming the resident’s presence. The facility’s own investigation noted that a door alarm to the smoking area sounded between approximately 1:15 P.M. and 1:30 P.M., and a CNA obtained a key from the nurse’s station and turned the alarm off, with no documented verification that a resident had exited. The Administrator later stated that the alarm was not reported and that it was unknown whether anyone checked to see if a resident had gotten out. Medication administration records showed multiple scheduled medications, including psychotropic and other chronic medications, were not administered later that day and the following morning, with documentation indicating the resident was out of the building. The resident’s guardian reported that while out of the facility, the resident was not dressed appropriately for the weather, did not have a cell phone or wallet, and later told the guardian that the intent had been to get out for a while, and that the resident was “out of touch” and did not think clearly during this time.
Failure to Thoroughly Investigate Resident-to-Resident Altercation Involving Weapon
Penalty
Summary
Facility staff failed to conduct a thorough investigation of a resident-to-resident altercation in which one resident attempted to stab another with a sharp object, contrary to the facility’s Incidents and Accidents and Abuse and Neglect policies. The policies required use of the electronic risk management system, completion of incident reports for resident-to-resident altercations, obtaining written witness statements, conducting a root cause analysis, and fully investigating all allegations of abuse, including certain resident-to-resident altercations. The policies also required that the facility protect residents during an investigation, document actions taken in the medical record, and revise care plans when residents’ needs or behaviors changed as a result of an incident. In this case, the facility did not follow these procedures after the altercation. Resident #1, who was cognitively intact and diagnosed with a psychotic disorder and schizophrenia, became increasingly violent and aggressive toward staff and another resident on the date of the incident. Nursing documentation initially stated that Resident #1 obtained a screwdriver and attempted to stab another resident, with no physical contact or injury due to immediate staff intervention and initiation of a behavior emergency code. That note was then stricken and rewritten to replace “screwdriver” with “object.” Resident #1 was sent to the hospital for psychiatric evaluation. Resident #2, also cognitively intact and diagnosed with a psychotic disorder and schizophrenia, later reported that Resident #1 pulled a screwdriver from a pocket, tried to “shank” and take Resident #2’s life, and that there was close physical contact, including Resident #2 hitting Resident #1. A CMT who witnessed the event reported that the two residents argued about money, engaged in a physical fight, and that Resident #1 pulled a screwdriver from a back pocket; the CMT stated there was physical contact and that this was also reported to police. Despite these accounts, the facility’s investigation was incomplete and did not comply with policy. The written investigation documented that a behavior code was called for erratic behaviors between the two residents and that staff reported there was almost a resident-to-resident altercation with no harm or physical contact. The Administrator later interviewed Resident #1, who stated that Resident #2 approached after misinterpreting Resident #1’s yelling, and that Resident #1 pulled out a screwdriver and waved it around without making contact, and claimed to have obtained the screwdriver from a maintenance closet. However, the investigation did not include written statements from staff who were involved or witnessed the incident, did not include written statements from either resident, and did not include a statement from the maintenance employee whose cart the screwdriver was allegedly taken from. There was no documentation that either resident’s care plan was updated to reflect the altercation or to add interventions, and Resident #2’s nurses’ notes contained no documentation of the incident. The Administrator acknowledged that an investigation should have been done, that she was not initially aware of the object or attempted stabbing as documented in the progress note, and that no in-service education or comprehensive investigation had been completed prior to the on-site surveyor investigation. The facility’s failure to follow its own incident and abuse policies extended to documentation and care planning. Resident #1’s care plan in use at the time of the investigation contained no documentation or interventions related to the most recent resident-to-resident altercation, and no interventions were added before the on-site investigation. Resident #2’s care plan similarly lacked any documentation or interventions related to the altercation, and there were no nursing notes describing the event for Resident #2. The facility’s Abuse and Neglect policy required investigation of all allegations and types of incidents listed, including certain resident-to-resident altercations, and required that the Administrator or designee complete an administrative investigation with personal statements, root cause, and a plan of action. The Administrator later stated there was no investigation, that she only considered the clinical aspects such as sending the resident out and completing risk management documentation, and that she did not obtain statements from others involved. These omissions demonstrate that the facility did not operationalize its policies for prevention, identification, investigation, and reporting of abuse and resident-to-resident altercations in this incident.
Incomplete Facility-Wide Assessment and Staffing Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not address required staffing ratios per shift, the need for a Registered Nurse (RN) for at least eight consecutive hours daily, or the designation of an RN as the Director of Nursing (DON). Additionally, the assessment lacked documentation regarding the ratios of direct care staff, restorative therapy staff, social services staff, dietary staff, housekeeping, and laundry staff needed on each shift to meet resident needs. There was also no information provided about staff competencies and skill sets required to care for the resident population. The facility's policies and admission agreements indicated that it serves residents with skilled nursing needs, including those with Alzheimer's disease, dementia, and other complex medical and behavioral conditions. The facility's resident matrix showed a diverse population with diagnoses such as Alzheimer's/dementia, hospice care, dialysis, intravenous therapy, PTSD/trauma, and various medication requirements, including insulin, anticoagulants, antianxiety, antipsychotic, antidepressant, and hypnotic medications. Despite these complex care needs, the facility did not have a full-time DON or a full-time social worker or social service designee at the time of the survey. During the survey, the administrator acknowledged responsibility for completing the facility assessment but stated that it was incomplete due to missing maintenance and nursing information. The only documented information in the assessment pertained to contact information for external resources or when to use another facility, rather than a thorough evaluation of internal resources and staffing. As a result, the facility did not have a complete or thorough facility-wide assessment as required.
Failure to Provide Full-Time DON Not Serving as Charge Nurse with Census Over 60
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse when the resident census exceeded 60, as required by both facility policy and federal regulations. At the time of the survey, the census was 105 residents. The facility's policy defined full-time as 40 or more hours per week and specified that the DON may only serve as a charge nurse if the census is 60 or fewer. Review of staffing records and interviews revealed that the DON was on medical leave, and there was uncertainty among staff regarding who was fulfilling the DON role during this period. The RN Supervisor was identified as the interim DON, but also provided RN coverage on several days, which conflicted with the policy prohibiting the DON from serving as a charge nurse when the census is above 60. Further interviews confirmed that on specific days, the facility did not have an interim DON present, and RN staff from corporate provided coverage intermittently. The lack of a consistent, full-time DON who was not also serving as a charge nurse was discussed in the facility's QAPI meeting, and there was consideration of the DON performing some duties remotely. However, at the time of the survey, the facility was not in compliance with the requirement for a full-time DON who was not assigned as a charge nurse, given the census of 105 residents.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and cleanliness of resident areas. Numerous rooms and shared bathrooms had unpainted drywall, exposed holes, missing or damaged cove base, and crumbling drywall. Several rooms had holes in the walls, some with visible mice droppings and black, hairy-like substances protruding. There were also instances of overhead bed light covers missing, exposing light bulbs, and air conditioning units with gaps between the unit and the wall. Shared bathrooms had chipped and cracked paint, brown stains, and sinks pulled away from the wall with cracked paint and caulk. Floors in several rooms and bathrooms were described as dirty and sticky, with baseboards pulled away from the walls and plaster peeling. A broken ceiling tile near the D-hall entrance exposed electrical wires and the space above the ceiling tiles. During interviews, the Maintenance Assistant explained that staff are required to fill out work order sheets for repairs, which are collected daily. However, the Maintenance Assistant stated that due to budget cuts, the supplies needed to make repairs are slow to arrive, contributing to the ongoing issues with the facility's environment. The observations and interviews indicate that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents throughout the building.
Resident Placed in Unauthorized Head Lock During Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident's right to be free from physical abuse was violated after a staff member, Floor Tech N, placed the resident in a head lock during an altercation. The incident began when the resident, who had diagnoses including depression and schizophrenia and was noted to have intact cognition, became physically aggressive. The resident first engaged in a resident-to-resident altercation during a smoke break, after which he was placed on 1:1 supervision. While being escorted back inside by Floor Tech N, the resident attacked a CNA, who was also Floor Tech N's family member, by hitting and pulling hair. In response, Floor Tech N intervened by grabbing the resident from behind and placing him in a head lock, which is not an approved restraint technique according to the facility's policies and CPI training protocols. Multiple staff interviews confirmed that Floor Tech N used a head lock to restrain the resident, and that the proper CPI technique was not followed. The resident reported being choked and stated that Floor Tech N threatened him verbally. Other staff present during the incident indicated that there was confusion and fear among staff, with some not intervening as expected. The Administrator and Staffing Coordinator both noted that Floor Tech N did not de-escalate the situation as directed and did not use the correct CPI-approved restraint methods. The Administrator was also physically attacked by the resident after the restraint was released, and staff struggled to manage the situation safely. The facility's policies require that all residents be protected from abuse, including improper use of physical force or restraint, and that staff use only approved de-escalation and intervention techniques. Despite having completed CPI training, Floor Tech N did not adhere to these protocols, resulting in the use of an unauthorized physical restraint. The incident was further complicated by the involvement of Floor Tech N's family member and the lack of coordinated staff response, which contributed to the violation of the resident's rights and the facility's failure to prevent abuse.
Unauthorized Use of Resident Trust Funds
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's patient trust funds, resulting in unauthorized withdrawals totaling $7,877.01 over a one-week period. The Business Office Manager (BOM) withdrew funds from the resident's account to make purchases, including clothing, furniture, and a recliner, without first obtaining the resident's permission or signature as required by facility policy. The BOM relied on input from Certified Nurse Aides (CNAs) regarding what the resident might need and proceeded with purchases without direct resident involvement or consent. The BOM also admitted to forgetting to have the resident sign the ledger receipt for a cash withdrawal given for shopping with family. The resident, who had no cognitive impairment but diagnoses including schizophrenia, anxiety disorder, depression, and dementia, stated that they did not authorize the purchases and did not want several of the items bought with their funds. Observations confirmed that some purchased items were not present in the resident's room, and some items, such as a recliner, were unwanted by the resident. The facility's policy required resident consent and signatures for all withdrawals, which was not followed in this case.
Failure to Ensure Hospice Enrollment and Timely Physician Notification
Penalty
Summary
A resident with multiple serious diagnoses, including COPD, kidney disease, heart failure, lung cancer, and dementia, was re-admitted to the facility with hospital discharge orders recommending a hospice evaluation and referral. The care plan and physician documentation indicated that the resident had elected hospice services, and interventions were outlined to work cooperatively with hospice to maintain comfort. However, the resident was not actually enrolled in hospice services upon re-admission, and no hospice orders were documented in the re-admission physician orders. Progress notes indicated that the hospice referral was initially made, but the referral was closed and a new referral was to be sent to a different hospice provider. There was no documentation confirming the resident's enrollment in hospice services prior to their decline and subsequent death. On the day of the resident's decline, staff noted a significant change in condition, including low blood pressure, irregular breathing, and low oxygen saturation. The LPN on duty attempted to contact the next of kin and notified the physician of the resident's declining status, but did not inform the physician that the resident was not enrolled in hospice services after discovering this fact. The LPN also failed to document the assessment and vital signs in the medical record, instead writing them on a piece of paper and forgetting to enter them later. The resident expired several hours after the change in condition, and there was no evidence that hospice services were initiated or that the physician was made aware of the lack of hospice enrollment. Interviews with facility staff and the physician confirmed that there was an expectation for the resident to be on hospice services, and that the physician should have been notified if the resident was not enrolled. The physician stated that, had he been informed, he would have considered sending the resident to the hospital for evaluation and treatment. The facility's policy required clinicians to be notified of changes in condition and for all assessments and vital signs to be documented in the medical record, but these procedures were not followed in this case.
Failure to Accurately Reconcile Resident Trust Fund Accounts
Penalty
Summary
The facility failed to maintain an accurate and properly reconciled accounting system for resident trust fund accounts, as required by their own policy and proper accounting principles. Review of facility records showed that monthly reconciliations of the resident trust fund were either not completed or, when attempted, did not match the residents' current balances. Bank statements and reconciliation forms from several months revealed discrepancies, including unexplained differences between the reported cash on hand and the actual cash counted in the safe. For example, the bank reconciliation reports showed significantly higher cash on hand amounts than what was physically present. Interviews with the Business Office Manager (BOM), Activity Director (AD), and Corporate Business Office Manager (CBOM) confirmed inconsistent practices in tracking and reconciling petty cash, which is drawn from the resident trust fund. The BOM and AD described daily and monthly cash counts and receipt tracking, but were unable to explain the discrepancies between the physical cash and the amounts reported on reconciliation forms. The administrator and CBOM both stated expectations that the petty cash and trust fund accounts be accurately reconciled each month, but this was not occurring in practice.
Failure to Administer Physician-Ordered Pain Medication
Penalty
Summary
Facility staff failed to implement an effective pain management regimen for a resident who had a physician's order for Percocet 5/325 mg every four hours as needed for pain. Despite the order being present on the resident's Physician Order Sheet and care plan, staff did not administer the medication at any point during the months reviewed. The Medication Administration Record showed no documentation of Percocet being given, and progress notes did not indicate its use. Instead, the resident received Tylenol intermittently, which was documented as administered on select dates, but the stronger, physician-ordered medication was not provided. The resident, who had diagnoses including high blood pressure, dementia, schizophrenia, and depression, reported experiencing severe back pain that affected mobility and radiated down the leg. The resident stated that Tylenol was not effective and expressed a need for stronger pain relief, but was told by staff that only Tylenol was available. Interviews with staff revealed that the CNA reported the resident's pain to the nurse, and the LPN was unaware of the Percocet order, stating that it was not available on the medication cart and had never been administered. The interim Director of Nurses and the Administrator both confirmed they were unaware of the Percocet order, with the Administrator noting that the order had never been sent to the pharmacy. Facility policy required a systematic approach to pain recognition, assessment, and management, including administering medications as ordered and monitoring their effectiveness. However, the failure to transcribe and process the Percocet order resulted in the resident not receiving the prescribed pain management, despite ongoing complaints of severe pain and repeated communication with pain management providers.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was cited under F689 for failure to ensure that an area of the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The citation remains uncorrected, as referenced in the current and previous survey events. Specific details regarding the actions or inactions that led to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency is ongoing, with references to previous uncorrected citations and supporting documentation in earlier statements of deficiencies.
Failure to Maintain 1:1 Supervision for High-Risk Resident Resulting in Self-Harm
Penalty
Summary
A resident with a documented history of major depressive disorder, anxiety disorder, PTSD, and repeated self-harming behaviors was assessed as high risk for suicide, with multiple recent incidents of self-harm and a high score on the Columbia Suicide Severity Rating Scale. The resident's care plan required 1:1 monitoring and close supervision, defined as staff being within three to five feet of the resident at all times, and removal of items that could be used for self-harm. Despite these interventions, the resident was left unsupervised in their room with the door closed when the staff member assigned to provide 1:1 supervision was reassigned to other duties due to short staffing. During the period the resident was left alone, they broke the window in their room and used a piece of glass to inflict multiple deep cuts on themselves, requiring medical intervention. Staff discovered the incident during routine rounds, and interviews confirmed that the resident was left unsupervised for approximately 15 to 20 minutes. The resident reported taking advantage of the absence of supervision to harm themselves, and staff interviews corroborated that 1:1 supervision was not maintained as required by the care plan and facility policy. Facility policies on supervision and suicide prevention explicitly required that residents at high risk for self-harm not be left alone and that 1:1 supervision be maintained at all times, with staff responsible for ensuring coverage if they needed to leave. Multiple staff and administrative interviews confirmed that the expectation was for continuous supervision, and that the failure to maintain 1:1 supervision directly led to the resident's opportunity to self-harm. The deficiency was identified as Immediate Jeopardy due to the facility's failure to provide adequate supervision and prevent a serious accident.
Resident Not Allowed to Participate in Care Planning During Transfer and Secured Unit Placement
Penalty
Summary
A deficiency occurred when a cognitively intact resident with a history of sex offender status was admitted to the facility and immediately placed on a secured/locked unit without being allowed to participate in the development or implementation of their person-centered plan of care. The resident was transferred from a sister facility without being informed of the transfer, not given any paperwork, and not consulted about their preferences or options for placement. Upon arrival, the resident was visibly upset, expressed not wanting to be at the facility, and reported not understanding why they were placed in a locked unit or why the transfer occurred. Facility policy required sex offenders to be placed on a locked unit, but there was no documentation in the resident's care plan or medical record regarding the rationale for this placement, any assessment of risk, or communication with the resident about the transfer and placement. The resident's medical record showed no evidence of recent or past sexually aggressive or abusive behaviors, and the care plan did not address the secured unit placement. The resident was described as having no unwanted behaviors and was adjusting well, with no documentation of behavioral issues that would warrant such restrictive placement. Interviews with facility staff, including the Social Service Director and Regional Nurse Director of Operations, confirmed that the transfer and admission process was not conducted properly. The resident was not given the opportunity to express their preferences or participate in care planning, and the decision to place the resident on the locked unit was based solely on their sex offender status, contrary to facility policy requirements for individualized assessment and anti-discrimination laws.
Resident Placed on Locked Unit Without Clinical Justification Due to Sex Offender Status
Penalty
Summary
A resident, who was cognitively intact and their own responsible party, was placed on a secured/locked unit within the facility solely due to their status as a registered sex offender. There was no clinical justification, assessment, or documentation indicating that the resident met the criteria for admission to a secured unit. The facility's policy required sex offenders to be placed on the locked unit, but the policy itself stated that placement decisions should be based on risk assessment and not solely on registry status. The resident had no documented history of sexually aggressive or abusive behaviors, and medical records showed no behavioral issues or risk assessments related to sexual abuse. The resident expressed not wanting to be at the facility, was not informed about the transfer, and did not receive any paperwork or options regarding their placement. Interviews with facility staff, including the Social Service Director and the Regional Nurse Director of Operations, confirmed that the resident was transferred from a sister facility without proper discharge or admission procedures. Staff acknowledged that the resident was upset, unaware of the transfer, and not given the opportunity to choose their placement or receive their belongings. Documentation in the resident's care plan and medical record did not address the placement on the secured unit, and there was no evidence of an individualized assessment to justify the restriction. The facility's actions were based on a blanket policy for sex offenders rather than an individualized evaluation, resulting in the resident being confined to a locked unit without appropriate clinical or legal basis.
Failure to Provide Resident Access to Electronic Communications Due to Lack of WiFi
Penalty
Summary
The facility failed to ensure residents had reasonable and reliable access to, and privacy in, their use of electronic communications, including email, video communications, internet research, and television viewing, due to the lack of WiFi services. Documentation showed that the facility was notified by its Internet Provider of a violation of the Acceptable User Policy after sharing its business/office-only internet with residents, which was not permitted under the provider agreement. Despite multiple notifications from the provider, the facility continued to allow residents to use the business internet, resulting in the suspension and eventual disconnection of internet services. At the time of the survey, some residents still did not have internet access. Interviews with residents revealed that they were unable to watch TV, listen to music, or use the internet for an extended period, though they could not specify the exact duration. The Administrator acknowledged being unaware of the length of the issue and stated that the facility did not have the correct internet account to support resident use. The Regional Nurse Consultant also indicated a lack of awareness regarding the requirement to provide WiFi to residents. The Internet Provider confirmed that the facility was in breach of its agreement by sharing the business internet with residents and that a bulk service package was needed for resident use.
Failure to Maintain Effective Pest Control in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of mice, mice droppings, and roaches in multiple resident rooms and a common area. Observations revealed mice feces in the rooms of three residents, with one room also having a visible hole in the wall and separated cove base, and another room containing a chocolate chip cookie on the floor near mice droppings. Residents reported seeing mice in their rooms and noted that staff did not clean areas where droppings were present. Staff interviews confirmed sightings of mice in various areas, including resident rooms and hallways, and one staff member was unaware of a system for reporting pest sightings. In the common/activity area, live and dead roaches with egg sacs were found inside a cabinet, further indicating inadequate pest control measures. Review of facility records showed that the pest control policy required regular services from a qualified vendor, but only two recent invoices were available, with a gap in service after the previous pest company stopped coming. The new pest control company had only recently started, and there was no documentation of consistent pest control services during the interim. The administrator acknowledged the expectation for a pest-free environment, but the facility was unable to provide evidence of ongoing, effective pest management during the period in question.
Failure to Provide Sufficient and Competent Staff for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient and competent staff were available to meet the behavioral health needs of a resident who required 1:1 supervision for safety and behavioral concerns. The resident, who had diagnoses including anxiety disorder, depression, and bipolar disorder, was care planned for close monitoring, avoidance of power struggles, and consistent routines to manage symptoms. On the night in question, the assigned 1:1 staff left before the replacement arrived, leaving the resident without the required supervision. As a result, the resident was brought to the nurse's station and told by an LPN that they would have to remain there until the 1:1 staff arrived or potentially all night. The resident expressed a desire to go to their room to sleep, but the LPN insisted the resident remain at the nurse's station, citing the lack of available staff. This interaction escalated, with the resident becoming increasingly agitated and ultimately aggressive, leading to a physical altercation with the LPN. The situation further deteriorated when the resident attempted to leave, threw objects, and fell from their chair, prompting a call to emergency services and the resident being sent to the hospital. Interviews with staff and review of staffing records confirmed that the facility was short-staffed at the time, and the LPN involved was relatively new and had not effectively implemented the care plan interventions, such as avoiding power struggles and ensuring the resident's needs were met. The failure to provide appropriate supervision and to follow the resident's care plan directly contributed to the escalation of the resident's behavior and the subsequent incident requiring hospital transfer.
Failure to Provide Required Written Notification Prior to Resident Transfer
Penalty
Summary
The facility failed to provide proper written notification to a resident prior to a transfer or discharge, as required by both facility policy and federal regulations. Specifically, the resident, who was cognitively intact and their own responsible party, was transferred to a sister facility without receiving a written notice detailing the reason for the move, the effective date, the new location, or information about the right to appeal the decision. There was also no evidence that the required notifications were sent to the resident representative or the Office of the State Long-Term Care Ombudsman. Record review revealed that the resident's care plan included interventions to address potential relocation stress, but there was no updated documentation reflecting the resident's desires or needs regarding the transfer. Progress notes indicated that the resident was spoken to about relocating and was discharged the following day, but there was no documentation of written notification, family or physician notification, medication reconciliation, or ombudsman notification. Additionally, there was no evidence of referral inquiries or discussions with the resident or prospective facilities about the transfer. Interviews with facility staff confirmed that the established discharge process was not followed. The Social Services Director acknowledged that documentation related to discharge communications and referrals was expected but not present. The Regional Nurse Director of Operations also stated that the process was not followed, the resident was not offered other placement options, and communications with the resident and family were not properly documented. The facility's own policy requires comprehensive written notification and documentation, which was not adhered to in this case.
Failure to Clarify Discharge Instructions Delays Cataract Surgery Scheduling
Penalty
Summary
Facility staff failed to meet professional standards by not clarifying unclear discharge instructions from an eye clinic for a resident who had been referred for cataract surgery. The resident, who was cognitively intact and had diagnoses including diabetes, thyroid disorder, and schizophrenia, was seen by an optometrist and referred to an ophthalmologist for cataract surgery in both eyes. The resident attended a follow-up appointment at the eye center, but the discharge paperwork only stated 'return for cataract evaluation' without specifying a date, location, or procedure, and did not include contact information for further clarification. Upon return to the facility, the assigned nurse did not seek clarification from the eye center regarding the next steps for the resident's care, as the discharge paperwork lacked specific instructions. Interviews with staff revealed that the nurse was responsible for reviewing discharge paperwork and making necessary follow-up appointments, but in this case, no action was taken due to the lack of clear instructions. The medical records staff uploaded the paperwork to the resident's electronic medical record, but also did not follow up, as she was unaware of the need for a return visit to the eye center for surgical evaluation. Multiple interviews with facility leadership, including the Administrator, DON, and medical staff, confirmed that their expectation was for nursing staff to clarify any unclear discharge instructions and ensure appropriate follow-up. However, this did not occur, resulting in the resident's cataract surgery not being scheduled as intended. The failure to clarify and act on the discharge instructions directly led to the deficiency cited in the report.
Incomplete Discharge Summary and Communication at Resident Discharge
Penalty
Summary
Facility staff failed to complete a comprehensive discharge summary for one resident who was discharged to another skilled nursing facility. Review of the resident's closed medical record showed that the discharge summary was incomplete, lacking a final summary of the resident's status, a reconciliation of all pre- and post-discharge medications, and a post-discharge plan of care. The resident's physician order sheet did not contain a discharge order, and the Minimum Data Set (MDS) assessment had unanswered sections regarding the resident's overall goal and whether a referral had been made to the local contact agency. According to facility policy, a discharge summary must be provided upon a resident's discharge, addressing discharge goals, needs, caregiver support, and referrals, and must include a recapitulation of stay and medication reconciliation. The Director of Nursing confirmed that the discharge summary should include information from all departments, medication lists, recapitulation of stay, home health orders, and follow-up appointments, but these elements were missing from the resident's record.
Failure to Serve Correct Diet Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident, who required supervision, was served the correct diet as ordered by the physician. The resident had a physician's order for a mechanical soft texture diet, which is food altered to be soft and easy to chew. However, during lunch, staff served the resident a regular textured ham sandwich. As a result, the resident began to choke, and staff were unable to completely clear the resident's airway. Emergency medical staff eventually dislodged several pieces of regular textured thinly sliced meat, but the resident was hospitalized and subsequently expired.
Failure to Investigate Diet Error Leading to Resident's Death
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy by not conducting a thorough investigation following an incident involving a resident who was served an incorrect diet. The resident, who had an order for a mechanical soft diet, was mistakenly given a regular diet, leading to choking and subsequent death in the hospital. This incident was part of a sample of 10 residents, with the facility having a total census of 110.
Failure to Provide Correct Diet Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident who required supervision was served the correct diet as ordered by the physician. The resident, who had a mechanical soft diet order due to a condition that caused swallowing difficulties, was served a regular textured ham sandwich instead of the prescribed mechanical soft meal. This led to the resident choking, and despite staff intervention, the resident's airway could not be completely cleared, resulting in hospitalization and eventual death. The incident occurred when the resident refused the mechanical soft lunch provided and requested sandwiches. A Certified Medication Technician (CMT) requested sandwiches from the dietary staff but did not specify the need for a mechanical soft consistency. Consequently, the resident was given regular ham and cheese sandwiches, which were not suitable for their dietary needs. The dietary staff did not inquire about the resident's dietary requirements, and the nursing staff failed to communicate the resident's specific diet order. Interviews with various staff members revealed a lack of communication and verification regarding the resident's dietary needs. The dietary manager and staff confirmed that the sandwiches provided were of regular consistency, and the Registered Dietitian emphasized that sliced meat should never be served to a resident on a mechanical soft diet. The Speech Therapist noted that the resident was at risk for aspiration and should have been supervised during meals. The failure to adhere to the prescribed diet and provide adequate supervision directly contributed to the resident's choking incident and subsequent death.
Failure to Investigate Resident's Possession of Unknown Pills and Solution
Penalty
Summary
The facility failed to follow its abuse and neglect policy by not conducting a thorough investigation into an incident involving a resident who was found with unknown pills and allegedly consumed a bottle of magnesium citrate. The resident, who had no cognitive impairment and was independent in activities of daily living, was found on the ground with foam coming from his mouth and exhibiting semi-jerky movements. Despite the resident's claim that the pills and solution were given by a hospital doctor, there was no documentation of an investigation into the origin of these items or the circumstances surrounding their consumption. Interviews with staff revealed a lack of communication and action regarding the incident. A CNA witnessed the resident shaking and called a code blue, but did not see the resident consume any pills or solution. An RN took a picture of the pills and solution and sent it to management but did not initiate an investigation. The LPN who admitted the resident did not inquire about any medications or solutions the resident might have had, and the RCC did not report the incident to the DON, believing it was unnecessary. The DON was unaware of the incident until much later and stated that an investigation would have been initiated had she been informed. The Administrator and Regional Nurse Consultant also expected an immediate investigation. The lack of a timely and thorough investigation into the incident represents a failure to adhere to the facility's policies on abuse and neglect, as well as a breakdown in communication among staff members.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by multiple altercations between two residents. Resident #2, who had moderate cognitive impairment and diagnoses including schizophrenia, was involved in three altercations with Resident #3, who had no cognitive impairment but exhibited physical and verbal behaviors. These incidents occurred on 4/29/24, 8/17/24, and 9/1/24, with Resident #2 being physically assaulted by Resident #3. Despite these altercations, the facility did not update the care plans for either resident with appropriate interventions after each incident. The facility's Abuse and Neglect Policy mandates immediate reporting of abuse allegations and protective measures during investigations. However, the facility did not adhere to these guidelines, as evidenced by the lack of timely intervention and care plan updates following the altercations. The policy also requires that residents who allegedly mistreat others be removed from contact during investigations, but Resident #2 was only moved to another hall after the third altercation on 9/1/24. Interviews with staff, including an LPN and a Hall Monitor, revealed that Resident #2 should not have been placed on a hall with more aggressive residents. The Director of Nursing acknowledged that Resident #2 had aggressive behaviors and expressed that the resident should have been moved sooner. The facility's failure to follow its abuse policy and update care plans contributed to the ongoing risk of resident-to-resident altercations.
Inadequate Enforcement of N95 Mask Usage During Covid-19 Outbreak
Penalty
Summary
The facility staff failed to adhere to infection control practices, specifically regarding the use of N95 masks during an active Covid-19 outbreak. Observations revealed that despite signage at the entrance indicating the presence of Covid-19 and the requirement for all staff and visitors to wear N95 masks, compliance was not maintained. Several staff members, including Certified Nurse Aides and maintenance workers, were observed either not wearing masks or wearing them improperly. Additionally, external personnel such as pest control workers and a soda vendor were seen in the facility without masks, despite acknowledging the signage. Interviews with staff and external workers confirmed awareness of the mask requirement due to the Covid-19 outbreak. However, there was a lack of enforcement or instruction from the facility staff to ensure compliance. The facility's policy on Personal Protective Equipment, updated in June 2024, mandates the use of N95 masks to prevent the transmission of airborne pathogens, yet this policy was not effectively implemented, potentially affecting all 112 residents in the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 22.22% error rate. This deficiency was identified through observation, interview, and record review. During a medication administration observation, a Certified Medication Technician (CMT) administered the wrong inhaler to a resident and failed to provide instructions for its use. Additionally, the CMT did not administer several prescribed medications, including Lasix, Meloxicam, and Sertraline. The CMT acknowledged the errors and reported them to the Charge Nurse after the administration. The errors were compounded by a miscommunication following a telehealth visit, where a Nurse Practitioner was unable to enter a medication order change. The Assistant Director of Nurses (ADON) entered a new order for Haloperidol but failed to remove the previous order, leading to a medication error. The Director of Nursing (DON) confirmed the error and stated that it was corrected after being brought to the facility's attention by the surveyor. The facility's Medication Administration Policy emphasizes the importance of following the six rights of medication administration and reporting discrepancies immediately, which was not adhered to in this instance.
Significant Medication Error Due to Transcription Failure
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was prescribed antipsychotic medication. The error occurred when staff did not correctly transcribe the physician's orders for the resident's medication. The resident was supposed to receive Haloperidol 5 mg twice a day, as ordered on 6/21/24, but the previous order of Haloperidol 2 mg three times per day was not removed from the Medication Administration Record (MAR). This resulted in the resident receiving both dosages, leading to an incorrect total dosage of the antipsychotic medication. The error was identified during a survey when it was observed that the resident was administered both 2 mg and 5 mg doses of Haloperidol. The Certified Medication Technician (CMT) involved reported the medication administration to the Charge Nurse only after administering the medication, rather than verifying the orders beforehand. The Director of Nursing (DON) confirmed that the error stemmed from a failure to update the MAR correctly after a telehealth visit, where the Nurse Practitioner was unable to enter the order change directly and communicated it via email to the Assistant Director of Nurses (ADON), who then failed to remove the outdated order.
Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a history of elopement, hallucinations, and mental illness symptoms requiring 24-hour monitoring. The resident was able to leave the facility without staff knowledge, as staff failed to conduct visual checks and follow up on the resident's whereabouts. The resident was missing for over 24 hours before being located by a local police department. The resident had a documented history of elopement risk, and assessments consistently identified them as at risk. Despite this, the facility's staff did not perform the required hourly face checks, and documentation was falsified to indicate checks were completed when they were not. Additionally, the facility's exit doors were not functioning properly, allowing the resident to leave the premises undetected. Interviews with staff revealed a lack of awareness and communication regarding the resident's risk and recent move from a locked unit to a main area. The resident's family had expressed concerns about the resident's anxiety and desire to leave, but this information was not effectively communicated to the facility. The facility's failure to ensure proper door security and staff supervision contributed to the resident's elopement.
Removal Plan
- Conducted an investigation and in-serviced staff regarding Code white, secured doors, shift reports and rounds, falsifying documentation.
- Completed elopement assessments on all residents to ensure appropriate placement.
- Monitored exit doors one on one until verified all working properly.
- Charge nurses do checks and document.
- Management audits face check documentation.
- Administrator created a department head rotation schedule for completing random rounds in the facility to include evening and night shift.
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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