Hidden Lake Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 11728 Hidden Lake Drive, Saint Louis, Missouri 63138
- CMS Provider Number
- 265735
- Inspections on file
- 22
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hidden Lake Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and mobility limitations, who required two-person Hoyer lift transfers per care plan, was improperly transferred by staff—once with a gait belt instead of a lift, and later with a Hoyer lift operated by only one CNA. These actions, contrary to facility policy and training, resulted in the resident sustaining a head hematoma and a fractured tibia, as confirmed by hospital evaluation.
A resident with a right foot fracture did not receive proper investigation or family notification by the facility. The staff failed to follow the facility's guidelines for incident investigation and did not fully implement hospital care instructions. Confusion over physician orders led to incorrect treatment, and the family was not promptly informed of the resident's condition. Interviews revealed a lack of adherence to policies and procedures, contributing to the deficiency in care.
A resident with multiple medical conditions, including unhealed pressure ulcers, did not receive proper wound care as per physician orders and facility policy. The resident was observed without required heel protector boots and dressing, and staff interviews revealed a lack of awareness of updated wound care orders. The facility's administrator emphasized the importance of reviewing orders and progress notes, but the deficiency occurred due to non-compliance with these expectations.
The facility failed to segregate resident funds from its operating account, affecting 26 residents. A review revealed that significant amounts of personal funds were improperly held, totaling $164,763.34. The Business Office Manager acknowledged some funds as valid credits needing refunds, while others required further investigation. The Administrator was unaware of these credit balances.
The facility failed to maintain a sufficient surety bond to protect resident funds. A review showed an average monthly balance of $19,158.19 in the Resident Trust Bank Statements, while the Accounts Receivable Aging Report indicated a balance of $164,763.34. The facility only had an approved bond of $30,000, insufficient by $246,000. The Administrator was unaware of the credit balances and stated that corrections would be made.
Two residents experienced unsafe transfers due to staff failing to follow safe practices, respond to requests for assistance, and properly use gait belts. One resident fell from a raised bed and sustained multiple injuries after a CNA attempted to move them alone on a low air loss mattress, despite the resident's request for a second staff member. Another resident, unable to support their own weight, was transferred by two CNAs using a loose gait belt and improper lifting techniques. Staff interviews revealed confusion and inconsistent documentation regarding required assistance levels and transfer status.
The facility did not provide timely access to its EMR system for a state Surveyor during an on-site investigation and also failed to grant hospice providers access to a resident's medical records, despite documented consent and contractual agreements. The hospice team was repeatedly denied both electronic and printed records, impacting their ability to coordinate care for a resident with severe cognitive deficits and multiple diagnoses.
The facility failed to monitor and report changes in condition for two residents and one closed record. A resident with congestive heart failure experienced unreported weight gain and respiratory changes, leading to hospitalization. Another resident showed confusion and motor issues, with critical labs not communicated to the physician timely, resulting in hospitalization for acute kidney failure and UTI. Additionally, a urinalysis was not ordered for a resident who later developed a kidney infection.
A resident readmitted with a Stage II pressure ulcer experienced worsening of the condition due to the facility's failure to conduct wound measurements, transcribe hospice orders, and notify the physician. The resident, at high risk for pressure injuries, developed additional wounds that were not properly documented or treated. Staff failed to follow protocols, leading to a progression of the ulcer to Stage III.
The facility failed to maintain proper food safety standards, with walk-in cooler temperatures exceeding safe limits and dishwashing equipment out of order, leading to potential cross-contamination. The kitchen and kitchenette areas were unclean, with food items improperly labeled and stored, affecting all residents consuming food from the facility.
The facility did not develop or implement a QAPI program, potentially affecting all 53 residents. The Administrator, who started in March 2024, acknowledged the absence of a facility-specific QAPI plan and cited emergency issues as a reason for the delay. A planned QAPI committee meeting in July 2024 was not organized.
The facility failed to maintain a safe and homelike environment, with issues such as inadequate lighting, chipped paint, torn drywall, and strong urine odors in resident rooms. Staff interviews revealed a lack of awareness and communication regarding maintenance issues, with the DON and Administrator unaware of the extent of deficiencies. The Housekeeping Supervisor acknowledged the odor problem and initiated a deep cleaning program, but systemic issues with communication and maintenance processes were evident.
The facility failed to encode and transmit MDS assessments within the required 7 days for several residents. The MDS Coordinator faced challenges with the electronic medical record system, which delayed the transmission process. Interviews with the DON and Administrator revealed they were unaware of the transmission issues, and the Coordinator had to manually verify each resident's MDS status, leading to non-compliance with federal and state regulations.
The facility failed to ensure proper dialysis care and documentation for two residents requiring dialysis. One resident lacked communication records with the dialysis center and had no orders for pre or post-dialysis assessments. Another resident had no orders specifying dialysis days or location. The facility also lacked a policy for assessments, monitoring, and communication with dialysis centers.
The facility failed to conduct comprehensive risk-benefit assessments for siderail use for seven residents, leading to potential safety risks. Residents with conditions such as dementia and hemiplegia had siderails installed without documented assessments. Interviews with staff revealed a lack of awareness and systems for assessing and maintaining siderails, indicating a systemic issue in the facility's approach to siderail safety.
The facility did not maintain the required RN coverage for 8 consecutive hours daily, 7 days a week, as revealed by the PBJ staffing report for Q2 2024. The report showed multiple days with no RN hours, resulting in a one-star staffing rating. The administrator indicated that the previous DON might not have recorded their RN hours correctly, contributing to the deficiency.
The facility failed to properly contain waste, with trash cans in the kitchen and SNF dish room left uncovered and overflowing. Flies were observed in food preparation areas, and an insect light was off due to incorrect bulbs. The Administrator and ADM acknowledged the issue, noting that trash cans should be covered to prevent flies.
The facility failed to offer and document influenza vaccinations for two residents, despite CDC guidelines. One resident with severe cognitive impairment and another who was cognitively intact did not receive the vaccine, and there was no documentation of education or refusal. The infection control nurse admitted that several residents were not offered the vaccine or the option to decline, revealing a lapse in the facility's vaccination program.
The facility failed to provide the required SNF-ABN or denial letters for two residents upon discharge from Medicare Part A services. Staff interviews revealed a lack of awareness and responsibility for issuing these notices, with the SSD and MDS Coordinator both unaware of their distribution. The Administrator was also unaware of the deficiency.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately listed Alzheimer's as the only diagnosis, omitting other conditions like vascular dementia and hypertension. Another resident's MDS left the dialysis treatment section blank, despite receiving hemodialysis thrice weekly. The administrator expected accurate MDS documentation.
A facility failed to implement a baseline care plan for a newly admitted resident within the required timeframe. The resident had several physician's orders, including hospice evaluation and wound care treatments, which were not incorporated into a baseline care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the completion of baseline care plans, despite expectations from the MDS Coordinator, DON, and Administrator for timely completion.
The facility failed to provide complete and individualized care plans for residents, leading to deficiencies in addressing ADL needs, dietary preferences, and accurate medical orders. A resident with severe cognitive impairment lacked a care plan for ADL needs, another resident's vegetarian diet was not accommodated, and a third resident's care plan contained outdated information. Staff interviews confirmed the care plans were not reflective of current needs.
A resident with dementia and other conditions was allowed to smoke outside in a nonsmoking facility, due to lack of staff awareness and training. The resident had cigarettes and a lighter, supplied by a family member, and was unsupervised by an untrained Activity Aide. The facility lacked a written nonsmoking policy, and key staff were unaware of the resident's smoking activities.
A resident with a history of stroke and dysphagia was administered the wrong enteral nutritional supplement due to a failure to verify the physician's order. The RN did not check the supplement before administration, and the DON was unaware of the stock issue, highlighting a lack of policy for physician orders.
The facility failed to properly label and store medications, as home medications not in use were found in the medication room. Staff interviews revealed confusion over responsibility for monitoring medication storage, with a CMT and LPN unaware of the presence of these medications. The DON indicated that the charge nurse should oversee medication rooms, but this was not effectively implemented.
A facility failed to ensure timely communication and documentation of critical lab results for a resident with chronic conditions, leading to delayed treatment. Despite multiple attempts, a urine sample was delayed from May 2 to May 7 without proper documentation or physician notification. Critical blood test results collected on June 7 were not communicated promptly, delaying emergency care until June 10. Staff interviews revealed inconsistencies in lab result handling, contributing to the deficiency.
A resident with severe cognitive impairment and a preference for a vegetarian diet was not provided with adequate vegetarian meal options. The facility failed to address the resident's dietary preferences in their care plan, and staff interviews revealed a lack of appropriate vegetarian alternatives, relying instead on the resident's family to supply meals.
A facility failed to document hospice orders and integrate a hospice plan of care into a resident's overall care plan. Despite the resident being admitted to hospice services, necessary orders and treatments were not documented in the ePOS, and the care plan did not reflect hospice services. Interviews revealed a lack of communication between the facility and hospice provider, contributing to the deficiency.
A facility failed to resolve a grievance concerning a resident's transfer method. The resident, with severe cognitive impairment, experienced pain from a stand-up lift. Despite a grievance suggesting an evaluation for a Hoyer lift, the facility did not conduct the assessment. The Director of Therapy did not evaluate the resident, and the care plan lacked specific transfer instructions. The resident was discharged without resolution, leading to a deficiency.
The facility did not notify the State LTC Ombudsman of resident transfers and discharges. The Ombudsman had not received a monthly transfer report since March 2024. The Social Services Director, new to the role since April 2024, had not sent the reports, intending to organize first. The Administrator assumed the reports were being sent as before.
A resident with a history of aggression pushed another resident to the ground during an argument over a walker, resulting in a fractured femur. Despite the escalating situation, staff present did not physically intervene to separate the residents. The facility's abuse prevention policy lacked specific guidance on intervention, and many staff had not attended relevant training.
A resident with a history of aggression entered another resident's room and demonstrated physical aggression, but the incident was not reported to the Administrator, physicians, or responsible parties as required by the facility's policy. The lack of immediate reporting and intervention led to a delayed investigation and further incidents of aggression.
A LTC facility failed to document specific behaviors of a resident with dementia, leading to insufficient information for the IDT to determine effective interventions. The resident exhibited aggressive behaviors, including physical aggression towards others. Another resident expressed fear after being pushed down, resulting in a fractured femur, but did not receive adequate psychosocial follow-up. Staff were unsure of the aggressive resident's triggers and interventions, and documentation was inadequate.
Failure to Provide Adequate Supervision and Safe Transfer Assistance
Penalty
Summary
Staff failed to provide adequate supervision and assistance to prevent accidents for a resident with severe cognitive impairment, limited mobility, and a history of repeated falls. The resident required a Hoyer lift with two staff for all transfers, as documented in the care plan and facility policy. However, one CNA, unaware of the resident's transfer requirements, used a gait belt instead of the Hoyer lift to transfer the resident from bed to wheelchair. This method was not in accordance with the resident's care plan or facility policy, which mandates mechanical lifts and two-person assistance for residents needing such support. Later, another CNA observed the resident sliding out of a wheelchair and, unable to locate a second staff member, used the Hoyer lift alone to transfer the resident back to bed. This action was also contrary to facility policy and training, which require two staff members for Hoyer lift transfers to ensure resident safety. Multiple staff interviews confirmed that all were trained to use two people for Hoyer lift transfers and to wait for assistance if a second person was not immediately available. Following these improper transfers, the resident was found with a hematoma on the back of the head and a swollen leg. The resident was sent to the hospital, where imaging revealed a closed fracture of the proximal left tibia. Documentation and interviews indicated that the improper transfer methods directly preceded the discovery of these injuries, and staff statements confirmed deviations from established transfer protocols.
Failure to Investigate Injury and Notify Family
Penalty
Summary
The facility failed to meet professional service standards by not investigating an injury case for a resident who sustained a right foot fracture. The staff did not notify the resident's family about the change in condition, nor did they fully transcribe or clarify orders from the hospital emergency room. The resident, who had a history of stroke, dementia, unspecified psychosis, and high blood pressure, was found to have an acute non-displaced fracture of the fifth metatarsal bone in the right foot. Despite the hospital's instructions for care, including the use of a boot, ice packs, and elevation, these were not fully implemented or documented in the resident's care plan. The facility's Accident and Incident Investigation Guidelines were not followed, as there was no evidence of a thorough investigation into the cause of the injury. The staff failed to secure witness statements or inspect the environment for causative factors. Additionally, there was confusion among the staff regarding the physician's orders, particularly concerning the taping of the resident's toes, which led to incorrect treatment. The lack of communication and documentation resulted in the resident not receiving the appropriate care and monitoring as prescribed. Interviews with facility staff revealed a lack of understanding and adherence to the facility's policies and procedures. The staff did not notify the family or physician promptly about the resident's condition, and there was a misunderstanding about the facility's ability to handle STAT orders. The administrator acknowledged the need for clarification and education regarding STAT orders and emphasized the importance of notifying families about changes in residents' conditions. The failure to investigate the injury and communicate effectively with the family and physician contributed to the deficiency in care provided to the resident.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with pressure ulcers, as staff did not adhere to physician orders and facility policy. The resident, who had multiple medical conditions including hemiplegia, aphasia, and unhealed pressure ulcers, was observed without the required heel protector boots and dressing on the left heel. The resident's medical record indicated orders for Prevalon boots to be worn at all times while in bed and for a foam dressing to be applied daily to the left heel. However, during an observation, the resident was found with both heels flat on the bed, without the protective boots or dressing, and with a visible black and deep purple spot on the left heel. Interviews with facility staff revealed a lack of awareness and adherence to the updated wound care orders. A CNA confirmed the absence of a dressing and boots, while an LPN admitted to not being aware of the change in orders to apply a dressing, having only used skin prep on the heel. The LPN acknowledged that all orders should be verified prior to treatment, but had not done so since the order change. This oversight resulted in the resident not receiving the prescribed wound care, which was confirmed by the observation of the resident's heel condition. The facility's administrator stated that nursing staff are expected to review all orders before administering treatments and medications, and to check progress notes for continuity of care. Despite these expectations, the failure to follow the updated wound care orders led to the deficiency, as the resident did not receive the necessary treatment to promote healing of the pressure ulcer.
Failure to Segregate Resident Funds from Operating Account
Penalty
Summary
The facility failed to ensure that resident funds were placed in an account separate from the facility's operating account, affecting 26 residents. The Accounts Receivable Aging Report revealed that significant amounts of personal funds were held in the facility's operating account, totaling $164,763.34. During email correspondence, the Business Office Manager acknowledged that some of these funds were valid credits and should be refunded, while others required further investigation to verify their validity. The Administrator admitted that the facility was unaware of these credit balances in the Accounts Receivable Account.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to protect resident funds. A review of the facility's Resident Trust Bank Statements from June 2024 to November 2024 showed an average monthly balance of $19,158.19. However, the Accounts Receivable Aging Report dated November 22, 2024, indicated that the facility held a balance of resident funds amounting to $164,763.34. Despite this, the facility only had an approved bond of $30,000, which was insufficient by $246,000. During an interview, the Administrator admitted that the facility was unaware of the credit balances in the Accounts Receivable Account and stated that the credits would be corrected or the bond increased.
Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for two residents, resulting in significant injuries and unsafe transfer practices. In the first incident, a resident with multiple impairments, including debility, dementia, diabetes, and impaired mobility, was dependent for all bed mobility and required maximum assistance. During perineal care, a CNA attempted to move the resident alone on a low air loss mattress, despite the resident's requests for a second staff member and the increased risk associated with the mattress type. The CNA did not secure the bed wheels and failed to obtain additional help, leading to the resident falling from the raised bed and sustaining three spinal compression fractures, a tooth avulsion, and facial contusions. Interviews and documentation revealed that staff were unclear about the resident's required level of assistance for bed mobility, and this information was not consistently documented in the care plan or Kardex prior to the incident. In the second incident, another resident, who was severely cognitively impaired and required maximal assistance for bed mobility and transfers, was observed being transferred by two CNAs using improper gait belt technique. The resident was unable to support their own weight or respond to directions, yet the CNAs placed a loose gait belt around the resident's waist and lifted the resident by the shoulders and the back of the pants, rather than using the gait belt as required by facility policy. The resident's feet did not touch the floor during the transfer, and the resident did not participate in the movement. Both CNAs admitted to not following safe gait belt practices, and one CNA was unsure of the resident's transfer status, indicating a lack of clear communication and training regarding safe transfer procedures. Interviews with staff and administrators confirmed that there was confusion and inconsistency in how transfer status and required assistance levels were communicated and documented. Therapy staff, nursing staff, and CNAs provided conflicting accounts of how transfer status was determined and relayed, and there was no clear documentation specifying whether one or two staff were required for certain residents. The facility's policies required individualized, resident-centered approaches to safety, but these were not consistently implemented, leading to unsafe practices and preventable accidents.
Failure to Provide Timely EMR Access to Surveyor and Hospice Providers
Penalty
Summary
The facility failed to provide timely access to its electronic medical records (EMR) to both a state Surveyor and hospice care providers, resulting in a deficiency related to safeguarding and maintaining resident-identifiable information in accordance with professional standards. On the day of the survey, the Surveyor arrived at 8:00 A.M. and requested EMR access, but was not provided with functional access before the end of the workday. Multiple attempts were made by the Director of Nursing (DON) to provide passwords, but these either did not work or only allowed partial access. The issue was not resolved before the Surveyor had to leave, and the Administrator acknowledged the lack of access but did not provide a solution during the surveyor's visit. For a resident receiving hospice care, the facility also failed to provide the hospice team with access to the resident's EMR, despite the resident's documented consent and a contract between the facility and the hospice provider. The hospice nurse and director reported repeated refusals by the Administrator to release the resident's medical records, either electronically or in printed form, even after multiple requests and the provision of necessary documentation. The Administrator required the hospice team to attend care plan meetings before granting access and refused to send records to the email address provided by the hospice nurse, citing concerns about the address not being specific to the company. The hospice team was unable to access the resident's EMR onsite or offsite and could only obtain limited information by requesting printed records from facility staff, which was also restricted by the Administrator's instructions. The lack of access to the EMR affected the hospice team's ability to coordinate care, as they could not verify medication orders, treatments, or make necessary changes to the plan of care. The resident in question had severe cognitive deficits, kidney failure, and dementia, and was actively receiving hospice services at the time of the deficiency.
Failure to Monitor and Report Changes in Resident Conditions
Penalty
Summary
The facility failed to thoroughly and accurately assess, document, and notify the physician of a change in condition for two residents and one closed record. Resident #44, diagnosed with congestive heart failure and a history of fluid retention, experienced weight gain and respiratory changes that were not monitored or reported to the physician. This oversight led to the resident being transported to the hospital and administered intravenous Lasix. Resident #306 exhibited symptoms of confusion and an inability to use a motorized wheelchair. Despite receiving orders for lab work, critical lab results were not communicated to the physician until several days later, during which the resident's condition worsened, including an inability to use utensils and increased confusion. The delay in notifying the physician resulted in the resident being transported to the hospital with acute kidney failure and a urinary tract infection. Additionally, the facility failed to order a urinalysis for Resident #36, who later went to the hospital with a kidney infection. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to, leading to inadequate monitoring and delayed medical intervention for the affected residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident who was readmitted with a Stage II pressure ulcer on the coccyx, which subsequently worsened to a Stage III pressure injury. Upon readmission, the facility did not conduct necessary wound measurements, transcribe hospice wound care orders, or notify the physician about the wound. This lack of action led to the resident developing additional wounds and the existing wound increasing in severity, with slough present, indicating a progression to a Stage III pressure injury. The resident, who had moderate cognitive impairment and required substantial assistance with daily activities, was at high risk for developing pressure injuries due to conditions such as heart failure, diabetes, and paralysis. Despite these risk factors, the facility's staff did not follow the established protocol for wound care. The resident's care plan included interventions for skin integrity, but these were not effectively implemented. The resident's wounds were not documented in the facility's wound report, and there was no record of wound care orders or assessments in the medical records. Observations revealed that the resident had multiple open wounds on the buttocks, which were not properly treated or reported by the staff. The CNA and LPN involved did not ensure that the wounds were assessed or that the physician was notified. The facility's Director of Nursing was unaware of the resident's condition until several days after readmission, highlighting a breakdown in communication and documentation. The hospice provider had given verbal wound care orders, but these were not transcribed into the medical records, leading to a delay in treatment.
Facility Fails to Maintain Food Safety and Cleanliness Standards
Penalty
Summary
The facility failed to maintain proper time/temperature controls for safety food, which is essential to limit the growth of pathogens and prevent foodborne illnesses. Observations revealed that the walk-in cooler door was repeatedly propped open, causing the internal temperature to rise above the safe threshold of 41 degrees Fahrenheit. Several food items, including pureed meat, ham, and cottage cheese, were found to be stored at temperatures exceeding this limit. Additionally, the facility lacked thermometers for staff to monitor food temperatures, and the walk-in freezer's external thermometer indicated a temperature of 10 degrees Fahrenheit, although the food remained frozen solid. The facility's dishwashing equipment was not in working order, with the main kitchen's dishwasher out of service since May and the SNF dish room's machine in poor condition. Staff were observed washing dishes by hand in a three-compartment sink without proper sanitization due to a lack of a functioning sanitizer sink. This inadequate dishwashing process posed a risk of cross-contamination. Furthermore, the handwash sinks in the first-floor kitchenette and SNF dish room were not operational, preventing staff from washing their hands and increasing the potential for cross-contamination. The overall cleanliness of the kitchen and kitchenette areas was substandard, with food scraps, grease, and dust accumulating on floors, walls, and equipment. Open food items were not properly labeled, dated, or sealed, and scoops were improperly stored, increasing the risk of cross-contamination. These deficiencies had the potential to affect all residents who consumed food prepared in the facility, as the census was 53 at the time of the survey.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program, which is a requirement under the Affordable Care Act of 2010. This deficiency had the potential to affect all 53 residents in the facility. The Administrator, who started in March 2024, acknowledged during an interview that while the facility possesses the CMS QAPI at a glance guide, no facility-specific QAPI plan has been initiated. The Administrator was unaware of any existing plan prior to her tenure and cited several emergency issues that have prevented her from implementing a corrective plan. Although a QAPI committee meeting was planned for July 2024, it was not organized.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. Lighting issues were prevalent, with the spa room and men's restroom on the first floor having inadequate lighting. The dining room had chipped paint and duct tape on the floor, and several resident rooms exhibited various environmental concerns, such as torn drywall, unfinished ceilings, and missing privacy curtains. Additionally, strong odors of urine were noted in some rooms, indicating a lack of cleanliness and maintenance. Interviews with staff revealed a lack of awareness and communication regarding maintenance issues. A CNA reported that the lighting problems had been ongoing and reported to maintenance, while an LPN was unaware of the non-functional restroom light and did not know the proper procedure for reporting maintenance issues. The DON and Administrator were also unaware of the extent of the deficiencies, including missing privacy curtains, strong urine odors, and the need for repairs and painting in several areas. The Housekeeping Supervisor, who had recently assumed the position, acknowledged the strong urine odor in specific rooms and indicated that a deep cleaning program was underway. However, the report highlights a systemic issue with communication and maintenance processes, as staff were unclear about reporting procedures, and significant environmental concerns had persisted without resolution.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data within the required 7 days after completing a resident's assessment for seven residents. The Minimum Data Set (MDS) assessments for these residents were either showing as 'in progress' or 'ready to export' but had not been transmitted. This issue was identified during a review of the facility's compliance with the MDS encoding and transmission requirements, as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. The MDS Coordinator, who had been in the role since April, acknowledged that there were alerts in the electronic medical record system to notify when an MDS was due. However, she faced challenges with the system, which was different from what she was accustomed to, and encountered glitches that delayed the transmission process. The Coordinator had to manually find each resident's MDS for transmission, which was time-consuming. She also mentioned that the residents who did not have transmitted MDS assessments were from before her tenure, and she was not aware of any issues with transmitting the MDS when she started. Interviews with the Director of Nursing (DON) and the Administrator revealed that there were expectations for the MDS to be accurate and submitted timely, but they were not aware of the transmission issues. The MDS Coordinator was able to pull up validation reports to check if assessments were rejected or accepted, and most were rejected. The facility's electronic medical record system indicated 'exported' or 'export ready,' but the Coordinator had to correlate this information manually. The deficiency was highlighted by the failure to transmit the MDS assessments within the required timeframe, impacting the facility's compliance with federal and state regulations.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for two residents requiring such services. Resident #107, who has diagnoses including stroke, end-stage renal disease, and diabetes, was observed to have no documented communication between the facility staff and the dialysis center. The resident's care plan indicated dialysis treatments on specific days, but there were no physician orders to assess or monitor the resident before or after dialysis treatments. Additionally, there was no policy in place to address assessments, monitoring, and communication with dialysis centers. Resident #106, who is cognitively intact and has diagnoses including heart failure, diabetes, cerebral palsy, and end-stage renal disease, also lacked proper documentation and orders related to dialysis care. The resident's care plan noted hemodialysis three times a week, but there were no orders specifying the days or location of dialysis. The facility administrator acknowledged the absence of necessary orders and policies, indicating a lack of documentation for communication between the dialysis center and the facility.
Failure to Conduct Risk-Benefit Assessments for Siderail Use
Penalty
Summary
The facility failed to conduct comprehensive risk-benefit assessments for the use of siderails for seven residents, which is a critical step in ensuring resident safety. The absence of these assessments means that the facility did not evaluate the potential risks of entrapment or injury against the benefits of siderail use for each resident. This oversight was observed in residents with various medical conditions, including dementia, history of falls, hemiplegia, and severe cognitive impairment, all of whom had siderails installed without documented assessments. For instance, Resident #43, diagnosed with dementia and a history of falls, had a quarter-length siderail attached to their bed without a comprehensive risk-benefit assessment or a care plan. Similarly, Resident #20, with multiple diagnoses including dementia and hemiplegia, had bilateral U-rails on their bed without any orders or assessments documented. Observations revealed that these siderails were not used by the resident, indicating a lack of individualized assessment and planning. Interviews with facility staff, including the Administrator, Director of Therapy Services, and Director of Nursing, revealed a lack of awareness and systems in place for assessing and maintaining siderails. The Director of Therapy Services admitted to not completing specific siderail assessments, and the Director of Nursing was unaware of any systems for siderail assessment and maintenance. The Administrator acknowledged the absence of a monitoring system and the need for assessments prior to siderail use, highlighting a systemic issue in the facility's approach to siderail safety.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the facility's payroll-based journal (PBJ) staffing report for the second quarter of 2024, covering January 1 to March 31. The report highlighted multiple dates where no RN hours were recorded, triggering a one-star staffing rating and indicating a lack of RN coverage on specific days. During an interview, the administrator suggested that the previous Director of Nursing (DON) might not have properly recorded their hours when working as an RN, or they may not have known how to update the PBJ file, leading to the absence of recorded RN hours.
Improper Waste Containment in Kitchen and Dish Room
Penalty
Summary
The facility failed to properly contain waste and refuse, leading to the potential harboring and feeding of rodents and pests. Observations on multiple occasions revealed that trash cans in the main kitchen and skilled nursing facility (SNF) dish room were uncovered and overflowing with trash, including cans. Flies were observed in the kitchen, particularly in areas where food was prepared, and an insect light was found to be turned off due to having the wrong bulbs. During an interview, the Administrator and Assistant Dietary Manager acknowledged that trash cans should be covered when not in use and that the uncovered trash cans contributed to the presence of flies. The facility census at the time was 53.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to offer and provide the influenza vaccine to two residents, as per the CDC guidelines. Resident #44, who had severe cognitive impairment and diagnoses including heart failure, dementia, and seizure disorder, did not receive the influenza vaccine. The medical record indicated that the vaccine was offered and declined, but there was no documentation of education regarding the benefits and potential side effects of the vaccine, nor was there a documented refusal. Similarly, Resident #1, who was cognitively intact and had diagnoses including heart failure, dementia, weakness, and kidney disease, also did not receive the influenza vaccine. The record showed the vaccine was offered and declined, yet lacked documentation of education and refusal. During an interview, the infection control nurse acknowledged that neither resident received the influenza vaccination and that they were not offered the declination form. The nurse had conducted an audit and found that several residents did not receive the influenza vaccination or the option to decline it. The facility's policy was to offer the vaccine from October through March, with forms sent to residents and families around September. The nurse, who had been at the facility since the last influenza season, assumed all residents had been offered the vaccinations, highlighting a lapse in the facility's vaccination program.
Failure to Provide SNF-ABN Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents who remained in the facility after their Medicare Part A services were discharged. This deficiency was identified for two residents, one whose last covered day of Medicare Part A service was on March 18, 2024, and another on May 30, 2024. In both cases, the facility initiated the discharge from Medicare Part A services before the benefit days were exhausted, yet did not provide the necessary SNF-ABN form CMS-10055 or an alternative denial letter to the residents or their legal representatives. Interviews with facility staff revealed a lack of awareness and responsibility regarding the issuance of SNF-ABNs. The Social Service Director (SSD) acknowledged handling only the Notice of Medicare Provider Non-Coverage (NOMNC) and was not aware of SNF-ABNs being distributed in the facility. The Minimum Data Set (MDS) Coordinator, who also dealt with Medicare A discharges, confirmed that SNF-ABNs should be provided but was unaware of their distribution. The facility Administrator was also unaware that staff were not providing the SNF-ABNs, despite knowing they should be issued.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to deficiencies in the documentation of their medical conditions. For one resident, the admission and quarterly MDS assessments inaccurately listed Alzheimer's disease as the only active diagnosis, despite the resident having multiple other diagnoses, including vascular dementia, psychotic disturbance, mood disturbance, anxiety, and hypertension. The staff also failed to mark the section indicating no other active diagnoses within the last seven days, which further contributed to the inaccuracy of the resident's assessment. Another resident with end-stage renal disease, who was receiving hemodialysis three times a week, had an incomplete quarterly MDS assessment. The section for Special Treatments and Programs, which should have included dialysis, was left blank. This omission failed to accurately reflect the resident's treatment needs and care plan focus, which included checking the dialysis catheter site every shift. The facility's administrator acknowledged the expectation for MDS assessments to accurately represent the residents' conditions.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident, identified as Resident #305, within the required timeframe. The facility's policy mandates that a preliminary care plan be developed within 24 hours of admission to address the resident's immediate care needs. However, upon review, it was found that no baseline care plan was documented for Resident #305, who was admitted on an unspecified date. The resident had several physician's orders, including hospice evaluation, topical antibiotic application, nutritional supplements, and wound care treatments, which were not incorporated into a baseline care plan. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of baseline care plans. The Minimum Data Set (MDS) Coordinator acknowledged that the baseline care plan for Resident #305 was not completed and mentioned that either the admitting nurse or another nurse could have done it. The Director of Nursing (DON) and the Administrator both expected the baseline care plan to be completed within 24-48 hours of admission. Despite these expectations, the necessary care plan was not developed, indicating a lapse in the facility's adherence to its own policies and procedures.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #28, the care plan did not address the resident's Activities of Daily Living (ADL) needs, despite the resident having severe cognitive impairment, being a fall risk, and requiring assistance with most activities. Observations showed the resident attempting to stand from a wheelchair unsafely, and interviews with staff confirmed the resident's need for reminders, cues, and assistance with transfers and personal care. Resident #44's care plan did not address dietary preferences, even though the resident had severe cognitive impairment and practiced a vegetarian lifestyle. The resident expressed dissatisfaction with the facility's food options, indicating that staff did not take their dietary preferences seriously. Progress notes indicated that the resident's dietary preferences were known to the facility, yet they were not reflected in the care plan. For Resident #106, the care plan included outdated and inaccurate information, such as a fluid restriction and dietary orders that were not present in the current physician's orders. Additionally, the care plan mentioned smoking supervision, although the facility was smoke-free. Interviews with staff highlighted the expectation that care plans should be up-to-date and reflect the resident's current needs, which was not the case for these residents.
Failure to Enforce Nonsmoking Policy Leads to Resident Smoking Incident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident who was allowed to smoke during an outside activity, despite the facility being a nonsmoking environment. The resident, who has diagnoses including dementia, anxiety, impaired balance, and major depressive disorder, was observed smoking a cigarette outside with other residents present. The resident had a lighter and a package of cigarettes in their possession, which were supplied by a family member. The Activity Aide present was unaware of the facility's nonsmoking status and had not received training on supervising a smoking resident. No ashtray was available, and the nearest fire extinguisher was located inside the facility. The facility's staff, including the Registered Nurse, Social Worker Director, Director of Nursing, and Administrator, were not fully aware of the resident's smoking activities or the existence of a smoking order. The facility had transitioned to a nonsmoking status earlier in the year, but there was no written nonsmoking policy, only verbal communication and information in the resident handbook. The Administrator and Director of Nursing were not informed of the resident's smoking activities until after the incident occurred, indicating a lack of communication and enforcement of the nonsmoking policy.
Administration of Incorrect Enteral Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as evidenced by the administration of the wrong enteral nutritional supplement to a resident with a feeding tube. The resident, who had a medical history including stroke, dysphagia, and hemiplegia affecting the right side, had a physician's order for Glucerna 1.5 Cal oral liquid nutritional supplement to be administered via gastrostomy tube if less than 50% of a meal was consumed. However, during an observation, a registered nurse administered Glucerna 1.2 instead of the prescribed Glucerna 1.5. The registered nurse admitted to not verifying the nutritional supplement with the physician's order before administration. Additionally, the Director of Nursing was unaware that the facility did not have Glucerna 1.5 in stock and acknowledged that a physician's order should be obtained before substituting a nutritional supplement. The facility's lack of a policy and procedure for physician orders contributed to this oversight, as confirmed by the Administrator during an interview.
Deficiency in Medication Storage Practices
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the 200-unit medication room, it was found that two separate gallon Ziploc bags contained home medications for residents that were not in use at the facility. These medications were not from the facility pharmacy and included various drugs such as Lasix, carbidopa/levodopa, Farxiga, Metoprolol, and others. The facility's pharmaceutical storage policy mandates that drugs should be stored in a safe, sanitary, and orderly manner, and only those prescribed for individual residents should be kept on the premises. However, the home medications were still present in the medication room despite the residents having been at the facility for several months. Interviews with facility staff revealed a lack of clarity and responsibility regarding the monitoring of medication rooms for unused or home medications. A Certified Medication Technician (CMT) acknowledged that home medications should no longer be in the medication room, while a Licensed Practical Nurse (LPN) admitted to not knowing who was responsible for monitoring the medication room. The Director of Nursing (DON) stated that the charge nurse should monitor the medication rooms for expired and home medications, and that home medications should be returned to the family once the facility pharmacy delivers the ordered medications. This lack of oversight and adherence to policy led to the deficiency in medication storage practices.
Failure to Timely Communicate and Document Critical Lab Results
Penalty
Summary
The facility failed to ensure timely communication and documentation of critical laboratory results for a resident, leading to a delay in treatment. The resident, who had a history of hypertension, chronic kidney disease, and other conditions, was admitted with symptoms that warranted a urinalysis (UA) with culture sensitivity (CS). Despite multiple attempts to obtain a urine sample from the resident, there was a significant delay from May 2 to May 7, during which no documentation was made regarding the inability to collect the sample or notify the physician. The urine sample was eventually collected on May 22, and the results, indicating an abnormal E. coli infection, were not reported until May 27, with treatment starting on May 30. Additionally, the facility did not manage the communication of critical blood test results effectively. On June 6, the resident exhibited increased confusion and other symptoms, prompting a request for lab work. The blood samples were collected on June 7, and the results, which included critical low glucose and high BUN levels, were reported on the same day. However, there was a failure in ensuring these critical results were communicated to the physician in a timely manner, as the resident was not sent to the emergency room until June 10, after the physician was finally notified of the critical lab results. Interviews with facility staff revealed inconsistencies in the process of receiving and handling lab results. There were multiple methods for receiving lab results, including fax, email, and an online portal, but there was no clear protocol ensuring that critical results were promptly communicated to the appropriate medical personnel. The lack of a formal process for timely lab result management and the absence of documentation regarding the delays contributed to the deficiency in care provided to the resident.
Failure to Accommodate Vegetarian Dietary Preferences
Penalty
Summary
The facility failed to provide a resident with a nourishing, well-balanced diet that accommodated their vegetarian preferences. The resident, who had severe cognitive impairment and required supervision for certain activities, expressed dissatisfaction with the food options provided, stating that they did not eat meat and had been given limited vegetarian alternatives, such as cheese sandwiches and occasionally fish. The resident's care plan did not address their dietary preferences, and the facility relied on the resident's family to bring in vegetarian meals. Interviews with staff, including a Certified Nurse Aide, a Registered Dietician, and a Licensed Practical Nurse, revealed awareness of the resident's vegetarian diet preference but indicated that the facility did not offer adequate vegetarian options. The resident was often served only side dishes or given extra vegetables to replace meat options. The Director of Nursing incorrectly stated that no residents had dietary preferences, while the Administrator acknowledged that alternate choices should be offered for residents with specific dietary preferences.
Failure to Document Hospice Orders and Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to document hospice orders and develop a comprehensive written plan of care for a resident receiving hospice services. The deficiency was identified for one of three residents on hospice care, specifically Resident #9. The facility's policy mandates that hospice services be documented and integrated into the resident's overall plan of care, but this was not adhered to. The resident was admitted to hospice services, but the necessary hospice orders and wound care treatments were not documented in the electronic physician order sheet (ePOS) until several days later. Additionally, the resident's care plan did not reflect the hospice services being provided. Interviews with the Director of Nursing and the hospice manager revealed a lack of communication and coordination between the facility and the hospice provider. The facility did not have a hospice liaison, and the social worker was expected to coordinate with hospice providers. Despite the hospice Registered Nurse documenting skin care orders, these were not communicated effectively to the facility staff, and the hospice plan of care was not integrated into the facility's care plan. This lack of documentation and coordination led to the deficiency noted by the surveyors.
Failure to Resolve Grievance Regarding Resident Transfer Method
Penalty
Summary
The facility failed to adhere to its grievance policy concerning a resident's transfer method, leading to a deficiency. A family member of the resident, who had severe cognitive impairment and required substantial assistance for mobility, filed a grievance regarding the use of a stand-up lift, which caused the resident pain. The grievance suggested that the therapy department evaluate the resident to determine the appropriate transfer device, such as a Hoyer lift, which was believed to be more suitable given the resident's condition. Despite the grievance being logged and a resolution date being noted, the facility did not conduct the necessary evaluation. Interviews revealed that the Director of Therapy (DOT) did not evaluate the resident for the Hoyer lift, as initially recommended. The DOT believed the resident was too shaky for the Hoyer lift and too weak for the sit-to-stand lift, but this assessment was not documented or communicated to the family. The resident's care plan did not reflect any specific transfer method, and the resident was discharged to the hospital without the issue being resolved. The lack of follow-up and communication regarding the grievance led to confusion among staff, with the Social Worker assuming the evaluation had been completed based on the DOT's verbal feedback. The facility's failure to evaluate the resident and communicate the findings to the family member resulted in a deficiency, as the grievance process was not properly executed according to the facility's policy.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers and discharges, as required. The facility had a census of 53 residents. During an interview, the Ombudsman stated that they had not received a monthly transfer report from the facility since March 2024. The Social Services Director, who assumed the position in April 2024, acknowledged not sending the monthly transfers to the Ombudsman, citing a need to acclimate to the role and organize binders. The Administrator believed that the Social Services Director was responsible for notifying the Ombudsman and that the reports were being sent, as they had been previously sent by email.
Failure to Intervene in Resident Altercation Leads to Injury
Penalty
Summary
The facility failed to protect a resident from abuse when staff did not appropriately intervene during an altercation between two residents. Resident #1, who has a history of verbal and physical aggression and is diagnosed with Alzheimer's disease, dementia, and anxiety, engaged in an argument with Resident #3 over a walker. Despite the escalating situation, staff did not physically intervene to separate the residents, resulting in Resident #1 pushing Resident #3 to the ground, causing a fractured femur. The facility's abuse prevention policy emphasizes the importance of protecting residents from abuse and neglect, yet it lacked specific guidance on how staff should intervene in situations where abuse is likely to occur. During the incident, both a Certified Nurse Aide (CNA) and a Certified Medication Technician (CMT) were present but did not take physical action to separate the residents. The CNA attempted verbal redirection, but Resident #1's aggression escalated, leading to the physical altercation. Interviews with staff revealed that Resident #1 is known to become agitated and aggressive, particularly in the late afternoon, and requires redirection to prevent such behaviors. However, staff failed to anticipate and manage the resident's aggression effectively. The facility's training records showed that a significant number of staff, including CMT E, had not attended in-service training on managing resident behaviors, which may have contributed to the inadequate response during the incident.
Failure to Report and Address Resident Aggression
Penalty
Summary
The facility staff failed to adhere to the facility's policy of immediately notifying the Administrator of a physical altercation between two residents, which resulted in a delayed investigation and implementation of interventions. Resident #1, who has a history of moderate cognitive impairment and aggressive behavior, entered Resident #4's room and demonstrated physical aggression. Despite the incident, the staff did not report it to the Administrator, the residents' physicians, or their responsible parties, as required by the facility's Abuse Prevention policy. Resident #1, diagnosed with Alzheimer's disease, dementia, and anxiety, was known for verbal aggression and had a care plan in place to monitor and manage such behaviors. However, the staff failed to document the physical aggression incident in Resident #1's progress notes accurately, and there was no indication that the resident's physician or responsible party was notified. Similarly, Resident #4, who has severe cognitive impairment and requires substantial assistance, did not have any documentation in their medical record regarding the incident. Interviews with various staff members revealed that Resident #1's aggressive behavior was known, yet no increased monitoring or immediate protective measures were implemented following the incident. The Director of Nursing and the Administrator were not informed of the altercation until the following day, which allowed Resident #1 to re-enter Resident #4's room and exhibit further aggression. The lack of immediate reporting and intervention highlights a significant deficiency in the facility's handling of resident safety and abuse prevention protocols.
Inadequate Documentation and Psychosocial Support in LTC Facility
Penalty
Summary
The facility failed to ensure consistent documentation and detailed reporting of specific behaviors exhibited by a resident with dementia, leading to insufficient information for the interdisciplinary team (IDT) to determine effective non-pharmacological interventions. The resident, who had a history of Alzheimer's disease, dementia, and anxiety, displayed aggressive behaviors, including physical aggression towards other residents. Despite multiple incidents of aggression, the nursing staff's documentation lacked specific details about the behaviors, such as onset, frequency, and precipitating factors, which are crucial for developing appropriate interventions. Additionally, the facility did not provide adequate psychosocial follow-up for another resident who expressed fearfulness after being pushed down by the aggressive resident, resulting in a fractured femur. The social services director (SSD) was not informed of the ongoing behaviors or the incident's impact on the affected resident's mental well-being. The SSD's evaluations did not reflect the resident's fearfulness or the traumatic nature of the incident, and the care plan failed to address the resident's expressed fear and need for support. Interviews with staff revealed a lack of awareness and understanding of the aggressive resident's triggers and effective interventions. Staff reported feeling unsure of how to manage the resident's behaviors and noted that the documentation of these behaviors was inadequate. The facility's administration acknowledged the need for more descriptive behavior charting to identify triggers and develop resident-specific interventions, but this was not implemented at the time of the deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
