Ignite Medical Resort St Peters
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Peters, Missouri.
- Location
- 5101 Executive Centre Parkway, Saint Peters, Missouri 63376
- CMS Provider Number
- 265889
- Inspections on file
- 4
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Ignite Medical Resort St Peters during CMS and state inspections, most recent first.
The facility failed to follow its neuro assessment policy and provide appropriate EMS handoff for multiple residents. One resident on anticoagulation fell from bed, sustained a head laceration, and reported lying on the floor for a long time without staff present; no neuro checks were documented, no first aid such as pressure to the wound was provided, and EMS found the resident alone using clothing to control bleeding while the RN remained at the nurses’ station and did not give a report. Another resident on apixaban with complex cardiopulmonary history developed lower extremity discoloration, had Doppler-confirmed DVT, and was later emergently transferred for dyspnea; EMS and family reported that no staff were present in the room on EMS arrival, the family provided the clinical history, and the nurse who eventually appeared was unaware of the situation and minimized the resident’s respiratory distress. A third resident with stroke, dementia, severe cognitive impairment, and prior falls rolled out of bed, reported hitting the head, and had only a single neuro assessment documented, with no ongoing neuro checks recorded per facility protocol for unwitnessed falls.
A resident with osteomyelitis, peripheral vascular disease, and HTN was assessed as high risk for falls but had no fall care plan in place. The resident rolled out of a low bed while reaching for a phone charger, struck the head between the bed and a recliner, and required hospital evaluation with sutures placed. On return, documentation noted safety checks and a low bed, but record review showed no fall risk or post-fall care plan and the MDS inaccurately reflected no fall history. Observation later found the call light on the floor and out of reach, and the resident reported being unable to summon help and lying on the floor for a long time. Staff interviews revealed the fall was not correctly entered into the EMR, so required post-fall assessments and documentation were not triggered, and no individualized fall interventions were developed despite facility policy.
A resident with CHF, ESRD, and other comorbidities was admitted with documented superficial skin loss on the buttocks and a care plan for skin risk that included barrier cream and turning/positioning, but no Braden Scale was completed at admission and no weekly skin assessments or skin sheets were documented. The resident spent most of the time and slept in a recliner without a pressure-relieving cushion, reported a sore bottom, and stated that staff applied some cream but that no nurse had inspected the area. The pressure injury was only discovered when a CNA assisted with toileting and observed an open, draining area on the buttock, which an LPN then described as appearing to be a Stage 3 pressure ulcer, with no prior nursing documentation or notification of the wound.
Surveyors found that the facility failed to administer ordered admission medications and to use available emergency medications for two residents with pneumonia, respiratory conditions, and chronic cardiac issues. One resident did not receive newly ordered antibiotics for pneumonia on the day they were prescribed, despite those drugs being listed in the emergency supply and no documentation of physician or pharmacy notification. Another newly admitted resident did not receive ordered anticoagulant, cardiac, antifungal, and nebulized bronchodilator doses on the evening of admission, even though some of these medications were present in the e-kit and the resident later reported not getting bedtime medications because they were unavailable. LPN interviews showed uncertainty about which drugs were in the e-kit, lack of access or use of the kit, and failure to obtain needed respiratory equipment from central supply, and the facility lacked a policy outlining how to obtain new medications or what to do when they were not available.
Surveyors found that medications were repeatedly left unsecured and unattended on a nurse’s station desk, on top of a treatment cart, and in unlocked medication and treatment carts, while residents and visitors passed nearby and no staff were in line of sight. Staff, including an LPN, RN, DON, and the Administrator, acknowledged that facility policy requires all medications and carts to be locked when unattended and that medications received from the pharmacy must be secured. In a separate finding, a resident recently admitted with influenza A pneumonia, bacterial pneumonia, COPD, and acute respiratory failure had four prescription inhalers from home lying on the bed without corresponding physician orders for all inhalers or an order to self-administer, and nursing leadership reported they were unaware of these bedside medications and stated that medications should be kept in a secure location.
A resident with multiple comorbidities, severe cognitive impairment, dependence for ADLs, and an unstageable pressure ulcer experienced a significant weight loss of nearly 14% over two months. Facility policy required investigation and intervention for significant weight changes, but weights were not consistently documented, and no specific weight-loss interventions were added to the care plan. The RD identified increased nutrient needs, recommended supplements (Pro Heal, Juven) and later recommended adding Magic Cup BID, but this recommendation was not communicated to the physician, not entered as a diet order, and not provided with meals, as confirmed by observations and interviews with the resident, family, LPN, RD, and Dietary Manager. Leadership staff stated they expected RD recommendations to be reviewed and communicated, but this did not occur, resulting in failure to implement and evaluate appropriate nutritional interventions for the resident’s weight loss.
A resident admitted in the early evening with fracture pelvis, respiratory failure, and protein-calorie malnutrition, and ordered a regular mechanical soft diet, did not receive an evening meal from the facility. The family member reported that no staff offered food, a nurse stated the kitchen was closed, and the family had to purchase food from a local restaurant. The Dietary Manager stated that admission memos had prompted preparation of several trays, including one left in the kitchen window for this resident, but nursing never retrieved or delivered it. The tray remained in the window until the next morning, and the resident later reported being hungry and receiving little to eat for supper.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy for two residents with wounds and indwelling devices, including a urinary catheter, dialysis CVC, AV fistula, and multiple documented pressure and other wounds. Required EBP signage and PPE carts were absent from room entrances, and staff performed high-contact care activities such as transfers, toileting, linen changes, perineal care, catheter manipulation, and wound care wearing only gloves and no gowns, despite care plans and physician orders specifying EBP. Interviews with CNAs, an LPN, a nurse manager, the DON, the Administrator, and the Medical Director revealed uncertainty and lack of knowledge about which residents were on EBP and inconsistent implementation of the policy.
Failure to Perform Neuro Checks and Communicate with EMS After Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its own neurological assessment policy and professional standards of practice after resident falls and changes in condition, and failure to provide pertinent information to EMS. For one resident with osteomyelitis, PVD, hypertension, and an active order for Eliquis, nursing notes documented that the resident rolled out of bed while reaching for a phone charger, was found on the floor with a gash to the right temple, swelling, and a reported headache, and that 911 was contacted. Vital signs were abnormal, and the dressing to the resident’s left foot was no longer intact. There was no documentation of a neurological assessment despite the head injury and the facility’s policy requiring neuro checks for unwitnessed falls and head injuries. The resident later returned from the hospital with a negative CT scan and sutures to the forehead, but no neuro checks were documented in the record. The same resident reported lying on the floor for a long time after the fall, yelling for help and being unable to find the call light. The resident stated that when staff arrived, they said they could not get the resident off the floor because of the head injury and that they had to call 911, then left the room. The resident reported that no one applied anything to the head to stop the bleeding, and that the resident used a pair of pants to apply pressure. EMS personnel later confirmed finding the resident alone on the floor with pants on the forehead to control bleeding and no staff present in the room. EMS staff reported having to leave the room to locate a nurse, finding the RN at the nurses’ station, and that the RN came to the room only after EMS had the resident on the gurney, handed over paperwork, stated they were going to get an ice pack, and left without giving a report or providing care. The RN later acknowledged not starting neuro checks because the resident was going to the emergency room, not applying pressure to the laceration, not recalling if the resident was on blood thinners, and knowing that neuro checks should be done for unwitnessed falls. Another resident with a history including fractured pelvis, toxic encephalopathy, acute respiratory failure, interstitial pulmonary disease, atrial fibrillation, anemia, and an order for apixaban had a care plan addressing anticoagulant therapy and monitoring for adverse reactions. A nurse practitioner documented bluish discoloration on the dorsum of both feet and ordered stat arterial and venous Doppler studies. The Doppler results showed acute DVT involving multiple veins in the left lower extremity, and the physician was notified. The medical record contained no further documentation of the resident’s condition, no additional physician orders related to the Doppler findings, and no documentation of transfer to the hospital, despite ambulance records indicating an emergent transfer for dyspnea. EMS documentation and family interviews indicated that when EMS arrived, no staff were in the room, the family provided the history including Doppler results and physician conversation, and staff only appeared about 20 minutes later as EMS was exiting with the resident. The nurse who entered the room did not know what was going on with the resident and told EMS that the resident’s shortness of breath was normal, and the corporate DON later stated that the nurse on duty should have documented and given report to EMS. A third resident with stroke, dementia, severe cognitive impairment (BIMS of 4), dependence on staff for ADLs and mobility, and a history of multiple falls had a documented fall in which the resident rolled out of bed from the side opposite the fall mat and stated they hit their head. Nursing notes recorded that ROM and a neuro assessment were within normal limits for the resident and that vital signs were taken, with the resident transferred back to bed and the physician and responsible party notified. However, there was no documentation that neurological checks were completed per the facility’s neurological flow sheet protocol after this unwitnessed fall with reported head impact. The ADON confirmed that neurological flow sheets should be completed for every unwitnessed fall, that these are to be uploaded into the EMR, and that no such documentation existed for this resident. The ADON also confirmed that the fall for the first resident was not entered correctly into the EMR, so no post-fall assessment, neurological assessment, or care plan interventions were generated.
Failure to Care Plan and Implement Interventions for High Fall-Risk Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess and care plan for a resident identified as high risk for falls, and to implement post-fall interventions after an actual fall. The resident was admitted with osteomyelitis of the left ankle and foot, peripheral vascular disease, and hypertension, and was assessed on 02/16/26 as being at high risk for falls. On 03/01/26 at 4:30 p.m., nursing notes documented that the resident rolled out of bed while reaching for a phone charger, landing on the right side of the body between the bed and a recliner, and sustaining a gash to the right temple with swelling and headache, requiring transfer to the emergency room. Later that evening, notes indicated the resident returned from the hospital with sutures to the forehead, a negative CT scan, and that safety checks were in place with the bed in a low position and instructions given to report dizziness or lightheadedness. Despite the high fall risk assessment and the documented fall with head injury, review of the medical record from 03/01/26 through 03/10/26 showed no care plan addressing the resident’s fall risk or the actual fall. The comprehensive MDS dated 03/03/26 documented the resident as cognitively intact, able to make self-understood, and at risk for falls with no history of falls, even though a fall had occurred on 03/01/26. Observation on 03/10/26 found the resident in a low bed with the call light on the floor and not within reach, and the resident reported having been unable to find the call light at the time of the fall and lying on the floor for a long time before help arrived. Interviews with the ADON, MDS coordinator, interim DON, and Administrator confirmed that the fall was not correctly entered into the EMR, which prevented triggering of post-fall assessments and documentation, and that no fall care plan or interventions had been developed for this resident despite facility policy requiring assessment and care planning for residents at risk for falls and after every fall.
Failure to Prevent and Timely Identify Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services, including individualized interventions, to prevent the development and identification of a Stage 3 pressure ulcer on a resident’s buttock. The facility’s skin policy required a full-body skin assessment within 6 hours of admission, weekly skin assessments, quarterly Braden Scale risk assessments, and use of skin sheets by direct care staff to report abnormalities. For this resident, admitted with diagnoses including CHF, ESRD, heart failure, anemia, and depression, there was no Braden Scale completed upon admission and no documented weekly skin assessments after the initial admission assessment. The admission note documented normal skin color and temperature with no open areas but did note superficial skin loss on the buttocks, and the care plan identified risk for alteration in skin with interventions such as barrier cream and turning/positioning every two to three hours, yet there was no documentation that barrier cream was applied. In the days following admission, the resident was repeatedly observed sitting and sleeping in a recliner without a pressure-relieving cushion. The resident reported sitting in the recliner all the time, sleeping there because of fear of rolling out of bed, and primarily lying on his/her back. The resident stated that his/her bottom was sore and that staff had applied “some type of cream,” but also reported that no nurse had looked at the area. Observations on consecutive evenings and early mornings showed the resident in the recliner on his/her back, still without a pressure-relief cushion, despite the facility policy that staff should encourage bed use and provide a cushion for the recliner as needed. The pressure ulcer was identified only when a CNA responded to the resident’s call light for toileting and the resident complained of pain in the bottom while sitting on the toilet. The CNA observed an open area on the inner left buttock about the size of a quarter with bloody drainage and white tissue in the center surrounded by red to pink tissue, and reported not having seen it before. An LPN then assessed the area and described the larger open area as deep with white tissue and some drainage, with the appearance of a Stage 3 pressure ulcer, and also noted a superficial open area on the left buttock. The LPN stated he/she had not been notified of these open areas prior to that day. Review of the medical record showed no completed skin assessments after admission and no skin sheets per facility policy, and interviews with leadership confirmed expectations that Braden assessments, weekly skin checks, and prompt identification and reporting of skin issues should have occurred but did not in this case.
Failure to Administer Admission Medications and Use Emergency Supply for New Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered on admission and to follow procedures when medications were not available. For one resident with diagnoses including type 2 diabetes mellitus, pneumonia, and COVID, a stat chest x-ray on 1/13/26 showed pneumonia, and the physician ordered doxycycline 100 mg BID for five days and Augmentin 500/125 mg daily for five days. These orders were entered on the POS and MAR on 1/13/26 at 4:30 P.M., but there was no documentation that staff administered either antibiotic that day. The facility’s emergency medication supply list showed Augmentin 500/125 mg and doxycycline 100 mg were available, yet there was no documentation that staff notified the physician or pharmacy when the medications were not given or if they were not obtained from the emergency supply. For another resident admitted from the hospital with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, acute respiratory failure with hypoxia and hypercapnia, and chronic atrial fibrillation, hospital discharge orders included atorvastatin 80 mg at bedtime, Eliquis 5 mg BID, metoprolol 12.5 mg BID, nystatin suspension QID, and DuoNeb every six hours, with next doses due the evening and bedtime of the admission date. The POS reflected these orders, but the MAR showed staff did not administer the bedtime doses of atorvastatin, Eliquis, or metoprolol, nor the scheduled nystatin doses at 4:00 P.M. and 8:00 P.M., nor the DuoNeb dose at 8:00 P.M. The resident reported not receiving bedtime medications because the facility did not have them. The emergency medication supply list showed Eliquis 5 mg and metoprolol 25 mg were available, but they were not used. Staff interviews revealed confusion and inaction regarding medication availability and use of the emergency kit. One LPN stated the pharmacy delivered the resident’s medications the following morning, claimed no doses were due the prior night, and said he/she did not have access to the emergency kit, later acknowledging that Eliquis was in the kit and could have been administered. Another LPN stated there was an e-kit for after-hours or new admission medications but was unsure which medications it contained, confirmed the resident did not receive medications because the pharmacy had not yet delivered them, and reported the resident still had not received DuoNeb due to waiting on a nebulizer, despite central supply maintaining medical equipment such as nebulizers. The facility did not provide a policy related to obtaining newly ordered medications from the pharmacy or procedures to follow when medications were not available.
Unsecured Medications and Unauthorized Bedside Inhalers
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in locked locations and to prevent medications from being left unattended, contrary to facility policy and professional standards. Surveyors observed multiple instances where medication cards and medication bottles delivered by the pharmacy were left on the nurse’s station desk and on top of a treatment cart for an extended period without any staff present or in line of sight, while residents and visitors walked past the area. The treatment cart was not in use and was positioned in front of the nurse’s station counter, making the unsecured medications easily accessible. Staff later confirmed that medications were not to be left unlocked or unattended and acknowledged that the medications had been left out since delivery because staff had not yet put them away. Additional observations showed that both the treatment cart and the medication cart, which contained medications, were left unlocked and unattended at the nurse’s station on another occasion, again with no staff in the area or in line of sight. Nursing staff, including an LPN and an RN, stated that medication and treatment carts should always be locked when unattended and that medications should never be left unattended at the nurse’s station or on carts. The DON and the Administrator both stated that staff were expected to lock medication and treatment carts when unattended and to secure medications with a lock upon receipt from the pharmacy, consistent with facility policies on medication labeling, storage, and administration. The facility also failed to secure medications for one resident by allowing prescription inhalers to remain at the bedside without appropriate orders or assessment for self-administration. A resident recently admitted with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, and acute respiratory failure reported having inhalers at the bedside that they self-administered and had brought from home. Observation revealed four prescription inhalers lying on top of the bed covers at the foot of the resident’s bed. Review of physician orders showed an order for a fluticasone furoate inhaler but no orders for tiotropium or albuterol inhalers and no order permitting bedside self-administration. Nursing leadership stated they were unaware of the inhalers at the bedside, confirmed that residents must be assessed and have an order to self-administer medications, and stated that even with such an order, medications should be kept in a secure location rather than on the bed. The Medical Director stated that all medications should be secured behind at least one locked door or drawer.
Failure to Implement and Communicate RD-Recommended Nutritional Interventions After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement, evaluate, and modify nutritional interventions to prevent significant weight loss for one resident. The facility’s own policy required a weight change investigation for significant weight changes of 5% or more in one month, 7.5% or more in three months, and/or 10% or more in six months, with subsequent contact of the dietician and physician, updating of interventions, and ongoing monthly investigation until weight stabilized. The resident’s care plan for nutrition and hydration, initiated in early December, identified potential for alterations in nutrition and hydration and directed staff to evaluate weight changes, determine percentage change, follow facility protocol for weight change, and monitor for signs and symptoms of malnutrition. The comprehensive MDS documented severe cognitive impairment, dependence for ADLs, an unstageable pressure ulcer, and increased nutritional needs, but no difficulty swallowing and no nutritional approaches at that time. The resident was admitted with multiple significant diagnoses including acute respiratory failure, pulmonary edema, CHF, diabetes, protein-calorie malnutrition, osteoporosis, and osteomyelitis of the left ankle and foot. Weights recorded in the EMR showed 192 lbs on 12/06, 185 lbs on 12/11, and 185.2 lbs on 12/13. On 12/16, the RD evaluated the resident, noted a weight of 185.2 lbs and increased nutrient needs related to a large chronic unstageable pressure ulcer to the left heel, and recommended discontinuing certain diet restrictions, changing to a regular no added salt diet with sugar-free beverages and diet condiments, and adding Pro Heal 30 ml BID and Juven BID. The January POS reflected the NAS diet, Juven BID, and ProHealth 30 ml BID, but there were no documented weights from 12/14 through 01/21, and a weight of 159.8 lbs was then recorded on 01/22, representing a 25.4 lb loss since 12/13. The RD’s 01/29 note identified this as a significant weight loss, noted the resident reported not being interested in food, and recommended adding Magic Cup BID at lunch and dinner, to be included as dietary fluids. Despite this recommendation, the January POS contained no order for Magic Cup, and no weights were documented from 01/22 through 02/22, with the next weight of 163.8 lbs recorded on 02/23. The February POS also showed no order for Magic Cup, and the resident’s nutrition/hydration care plan contained no interventions specifically addressing weight loss. Multiple meal observations on 02/23 and 02/24 showed the resident receiving meals without Magic Cup, and both the resident and a family member reported that Magic Cups had not been provided. The RD stated that recommendations were emailed to the Administrator, DON, DM, and Care Plan Coordinator, that she had noted significant weight loss and recommended Magic Cup BID, and that she did not know why these recommendations were not communicated to the physician. The DM acknowledged receiving RD emails and changing diet cards based on recommendations, but stated the resident did not have Magic Cup in the diet order and that he must have missed that RD recommendation. The Interim DON, Administrator, and Medical Director each stated they would expect RD recommendations to be reviewed and communicated to the physician for residents with weight loss, but this did not occur, and the facility failed to implement and integrate the RD’s recommended intervention for Magic Cup or to update the care plan with weight-loss interventions while the resident experienced a 13.98% weight loss in two months. Additionally, the facility did not consistently obtain and document weights per its policy and the resident’s care plan. There were gaps in weight documentation between mid-December and late January, and again from late January to late February, despite the resident’s known risk factors, existing pressure ulcer, and documented significant weight loss. The RD reported having noted weight discrepancies that had not been addressed. The MDS also showed that dental status was not assessed. Collectively, these inactions—failure to consistently monitor weights, failure to initiate and document weight change investigations as required by policy, failure to communicate and obtain physician orders for RD-recommended interventions, and failure to update the care plan with specific weight-loss interventions—led to the resident’s unaddressed significant weight loss. The facility’s own staff interviews confirmed that the process for handling RD recommendations was not effectively carried out. The LPN reported not seeing any Magic Cup recommendations in the resident’s record. The RD described a practice of emailing recommendations but not participating in IDT meetings, and acknowledged that her recommendation for Magic Cup BID was not communicated to the physician. The DM confirmed that he relies on RD emails to change diet cards and admitted that he must have missed the Magic Cup recommendation, resulting in no diet order for Magic Cup. Leadership staff, including the Interim DON, Administrator, and Medical Director, each stated expectations that RD recommendations be reviewed and communicated to the physician for residents with weight loss, but these expectations were not met in this case, contributing to the failure to implement appropriate nutritional interventions for the resident experiencing significant weight loss.
Failure to Provide Evening Meal to Newly Admitted Resident
Penalty
Summary
The facility failed to provide an evening meal to a newly admitted resident whose diagnoses included fracture of the pelvis, respiratory failure, and protein-calorie malnutrition. The resident was admitted to the facility in the early evening with a physician’s order for a regular diet with mechanical soft foods. According to the resident’s family member, they arrived at approximately 5:55 P.M., and no staff offered or brought any food to the resident. The family member reported seeing only one nurse, who stated the kitchen was closed for the day, leading the family member to go to a local restaurant to obtain food for the resident. The resident later stated that they were hungry, did not get much to eat for supper, and that their daughter had to bring food because the facility did not provide a meal tray. The Dietary Manager reported that they are notified of expected admissions via memo and that on the day in question they had prepared three or four meal trays for anticipated admissions, including a tray intended for this resident. The Dietary Manager explained that they must wait for nursing to enter the resident’s information into the EMR before entering diet information into the dietary system, and that if a resident is admitted before 7:00 P.M., nursing is expected to inform dietary of the admission and ask the resident what they would like for the meal. On this occasion, dietary staff were not informed that the resident had arrived, so they left a tray in the kitchen window for nursing to take when the resident came in. The next morning, the tray was still in the kitchen window and had not been passed to the resident. The Dietary Manager stated this was not the first time such an occurrence had happened. The DON, Administrator, and Medical Director each indicated in interviews that they would expect new or late-returning residents to receive some type of nourishment, such as a meal tray or sandwich.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds and Indwelling Devices
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy for residents with wounds and indwelling medical devices, resulting in staff not using required gowns and gloves during high-contact care activities. The facility’s March 2024 EBP policy required EBP for all residents with wounds or indwelling medical devices, regardless of MDRO status, and specified that gowns and gloves must be used for high-contact care such as dressing, bathing, transferring, toileting, changing linens and briefs, and device and wound care. The policy also required clear EBP signage on or near the resident’s door, availability of PPE near or outside the room, and staff education and competency regarding EBP. For one resident with an indwelling urinary catheter, the comprehensive MDS documented the catheter, and the care plan directed staff to provide EBP and use gowns and gloves during high-contact care. However, observations showed there was no EBP sign on the door and no gowns available inside or outside the room. A CNA entered the room without a gown or gloves, applied a gait belt, transferred the resident from a recliner to a wheelchair, handled the urinary catheter collection bag, and pushed the resident into the bathroom. In the bathroom, the CNA donned gloves but no gown, assisted the resident to stand, pulled down pants, removed an unsoiled incontinence brief, manipulated the catheter tubing, and attached it to the handrail. After the resident complained of a sore on the bottom, the CNA removed gloves and exited the room without handwashing. Subsequently, an LPN and the same CNA entered the bathroom wearing gloves but no gowns; the CNA assisted the resident to stand while the LPN wiped the resident’s bottom, noted blood on the tissue, and left after removing gloves. Another LPN then entered with gloves but no gown, cleansed and dressed an open wound on the buttock, and left after removing gloves and using hand sanitizer. The CNA then completed perineal care, catheter manipulation, clothing adjustment, transfers, and linen changes wearing only gloves and no gown. Interviews showed the LPN believed EBP should be used when applying creams, and the CNA was unsure what EBP was used for and stated he/she only wore gloves when caring for residents. For another resident with end stage renal disease, dependence on dialysis, multiple documented wounds (coccyx, left buttock, right arm, right heel), and a dialysis CVC and AV fistula, the care plan and physician orders specified EBP for wounds and dialysis CVC, with daily wound cleansing and dressing changes. Despite this, repeated observations showed no EBP sign on the door and no PPE cart or PPE door hanger outside the room. Staff, including an LPN and CNA, entered the room and performed high-contact care such as changing linens while the resident was in bed, and other care activities, wearing only gloves and no gowns. A guest and the resident’s spouse both reported that staff only wore gloves when providing care and wound care. In interviews, a CNA stated they relied on door signage to know when to wear a gown, an LPN stated uncertainty about whether the resident was on EBP and confirmed only glove use, and a nurse manager acknowledged that residents with dialysis access and/or wounds should be on EBP, that every such resident should have PPE outside the room, and that the EBP sign likely was never placed on the door. The DON stated that EBP was required for residents with MDRO history, draining wounds, or indwelling devices including catheters, IV lines, dialysis access, and central lines, and that nurse managers were responsible for setting up EBP, while the Administrator and Medical Director both stated they expected staff to know which residents should be on EBP and to use all required PPE.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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