Lansdowne Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4624 Lansdowne Avenue, Saint Louis, Missouri 63116
- CMS Provider Number
- 265351
- Inspections on file
- 23
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lansdowne Village during CMS and state inspections, most recent first.
Staff did not follow posted menus or recipes, resulting in residents not receiving the meals or textures specified, including the omission of breakfast sandwiches and improper preparation of puree diets. Residents' documented meal preferences, such as requests for fresh fruit, were not consistently honored, despite availability. These failures were confirmed by staff and had the potential to impact all residents.
The facility did not maintain an effective pest control program in the kitchen, resulting in repeated observations of live and dead roaches, food debris, and trash in food prep and storage areas. Despite regular pest control visits, documentation was lacking, and cleaning duties were not consistently performed, contributing to ongoing pest activity.
Surveyors found that food was prepared and served in ways that did not ensure palatability, flavor, or proper texture, including pureed eggs that were bland and gritty, watery and undercooked oatmeal, and inconsistently cooked bacon. Trays were sent without basic condiments such as salt, sugar, creamer, or other flavor enhancers. Several cognitively intact residents reported that meals often tasted terrible or were inedible, with items like fried eggs, carrots, and scalloped potatoes described as hard or poorly prepared, and that their documented dislikes were not honored. Residents also reported difficulty obtaining coffee, sugar, creamer, and condiments, especially on one floor, despite repeated complaints in resident council meetings.
Surveyors found that kitchen staff repeatedly failed to follow basic hand hygiene and food safety practices, including not washing hands with hot water, changing gloves without handwashing, handling food after touching masks, phones, and other unclean surfaces, and beginning meal prep without prior handwashing. The designated handwashing sink did not produce hot water during multiple checks. The kitchen environment was repeatedly observed with dirty floors, dried and sticky spills, caked‑on food debris in the 3‑vat sink and dishwashing area, improperly stored dry goods and seasonings left uncovered, and food storage bins kept on the floor with soiled exteriors. Evidence of roach activity and significant debris and moisture damage behind the ice machine were also documented. Review of sanitation policies and daily, weekly, and monthly cleaning checklists showed many required cleaning tasks were either incomplete or undocumented, while meals continued to be prepared and served from this environment to all residents.
Surveyors found that the facility did not notify Medicaid residents or their representatives when resident trust fund balances came within $200 of the Medicaid resource limit or exceeded that limit, despite facility policy and administrative expectations. Several Medicaid residents had account balances well above the allowable threshold with no documented fund balance notifications. In addition, for two residents who died with money remaining in their accounts, the facility did not complete and send required third party liability (TPL) forms within 30 days of death, even though the BOM acknowledged that TPL letters were expected within that timeframe.
Surveyors found that two residents receiving continuous tube feedings did not receive care consistent with physician orders and safe practices. One resident with dysphagia had Jevity 1.5 ordered at a continuous rate, but repeated observations showed that large amounts of formula remained in the bottle when significant volumes should have infused, pumps alarmed "inactive" or with cassette errors while no feeding was delivered, and the same formula bottles were left hanging for more than 24 hours. Another resident with a history of pneumonia and hemiplegia received personal care from a CNA on two occasions while the tube feeding continued to infuse and the head of bed was lowered, with a wound nurse present during one episode who did not intervene. Staff later acknowledged that tube feeding formula should not hang longer than 24 hours and that continuous feedings should be paused and the nurse notified when care requiring lowering the head of bed is provided.
The facility failed to ensure that the interval between the evening meal and breakfast did not exceed 14 hours and did not consistently provide substantial bedtime snacks when that interval was longer. Scheduled meal times and observed service patterns resulted in up to 15–16 hours between dinner and breakfast, while snacks were typically left at the nurse’s station and not routinely passed. Multiple cognitively intact residents reported not receiving evening snacks, not being informed they could request substantial items such as sandwiches, and sometimes going long periods without food, with staff at times refusing sandwich requests because residents had already eaten dinner. Available snacks were generally limited to cookies, chips, and snack cakes, and an inspection of the designated resident refrigerator revealed no sandwiches despite claims they were stored there. Resident council minutes and staff interviews corroborated ongoing complaints about lack of snacks and late breakfasts, and the dietitian confirmed that a substantial snack would be expected when more than 14 hours elapsed between meals.
Staff failed to follow the facility’s hand hygiene, incontinence care, and Enhanced Barrier Precautions (EBP) policies during care for multiple residents who were incontinent and/or had wounds. In several observations, CNAs performed peri-care without cleansing the genital and anal areas, reused the same side of washcloths or wipes for multiple strokes, and did not change gloves or perform hand hygiene between dirty and clean tasks while continuing to handle linens, clothing, and resident items. For residents on EBP due to wounds, CNAs, a wound nurse, and a Wound Practitioner provided high-contact care and wound treatments using gloves only, without required gowns, and door magnets did not specify PPE or high-contact activities. Interviews with CNAs, CMTs, nursing staff, and leadership showed inconsistent understanding of EBP indications, the meaning of red door magnets, and when gowns and gloves were required, despite written policies and stated expectations for proper infection control practices.
Three residents who were dependent on staff for incontinence care were left wet or soiled for extended periods, with staff failing to respond promptly to call lights or check on them as required. Observations showed incomplete cleansing during care, and staff interviews confirmed that inadequate staffing contributed to delays and lapses in following facility policy.
An LPN failed to treat a cognitively intact resident with respect and dignity during medication administration. The facility’s Resident Rights policy required staff to treat residents with kindness, respect, and dignity. During an observed interaction, the resident, who had depression and a psychotic disorder, took ordered medication and began to set the medication cup down, stating they could take care of it themselves when the LPN attempted to take the cup. The LPN’s facial expression became irritated, the LPN turned away from the resident, and in a clearly audible, rude tone stated, “see the type of attitude we have to deal with, you don’t talk to us that way,” before leaving the room and closing the door. The resident reported that staff can be rude and treat them as if they have dementia, despite their ability to care for themselves. Facility leadership later stated that staff are expected to speak respectfully to residents, face them when speaking, and not criticize them.
A cognitively intact resident with COPD had a physician’s order allowing an albuterol inhaler to be kept at bedside, but the facility did not complete or document an assessment of the resident’s ability to safely self-administer medications, nor include self-administration in the care plan as required by policy. The resident reported wanting and needing the rescue inhaler at bedside and initially did not receive it despite the order; later, staff provided the inhaler for bedside use without any documented self-administration assessment. A CMT described usual practices for residents who self-administer, and the DON acknowledged uncertainty about whether this resident had been reassessed after readmission, despite the requirement to assess residents who keep medications at bedside.
Two residents with diabetes were incorrectly coded on their MDS assessments as having received insulin, even though their active medication orders showed only GLP-1 receptor agonists (Ozempic and Mounjaro) administered weekly and no current insulin orders. The MDS Coordinator acknowledged that these medications are not insulin and should not be coded as such, and the Administrator stated an expectation that insulin use be coded accurately, confirming that the assessments did not reflect the residents’ actual treatment during the assessment period.
Surveyors found that the facility failed to prepare and serve fortified "super cereal" and health shakes as ordered for multiple residents requiring fortified diets, and instead served thin, undercooked oatmeal without fortification to both regular and fortified diet trays. A resident with dementia, Parkinson’s disease, significant recent weight loss, and documented need for double portions, fortified foods, house shakes, a divided plate, and 1:1 feeding assistance was observed alone, unable to eat independently, without a shake, and with a nearly full meal tray. On another day, this resident did not receive a breakfast tray at all by late morning despite staff acknowledging the omission, while documentation inaccurately reflected that a house shake was given and that the resident consumed a high percentage of meals.
Surveyors found multiple instances of improper medication and biological storage and labeling, including an undated opened Lispro insulin pen in a nurse cart, an uncapped tube of triamcinolone cream on a treatment cart, and an opened Breo Ellipta inhaler left on a medication room countertop without a resident label. In two separate carts, Nitroglycerin 0.4 mg bottles were present with no identifying resident information, and the LPN and CMT using those carts did not know to whom the medications belonged. One cart also contained several Ensure Plus cartons, including one that had been opened by a CMT and was not kept on ice or refrigerated as required by the manufacturer.
Staff did not schedule required urology follow-up appointments for a resident with recurrent UTIs and severe urethra erosion from prolonged indwelling catheter use, despite multiple physician and hospital orders. The care plan inaccurately documented a suprapubic catheter, and necessary follow-up was not arranged until identified during surveyor review. Nursing and administrative staff were unaware of the missed appointments and the resident's ongoing condition.
A resident with a full code status was found unresponsive with signs of rigor mortis, and CPR was not initiated as per facility policy. Staff interviews revealed uncertainty about when CPR should not be performed, indicating a lack of understanding of the policy. The facility acknowledged the need for improved staff competency in CPR procedures.
Failure to Follow Menus, Recipes, and Resident Preferences in Meal Service
Penalty
Summary
The facility failed to ensure that menus and recipes were followed as written, resulting in residents not receiving meals that met their documented nutritional needs and preferences. During breakfast meal observations, staff did not serve the breakfast sandwiches listed on the menu, instead providing items such as eggs, bacon, and oatmeal. Residents reported through interviews and resident council meetings that the meals served often did not match the posted menus, and this concern had been ongoing without resolution. The Dietary Manager confirmed that breakfast sandwiches should have been served, but staff chose not to prepare them, citing resident limitations and preferences without documented justification or menu changes. Further deficiencies were observed in the preparation of special diets, specifically puree diets. Staff did not follow the facility's puree egg recipe, instead blending scrambled and hardboiled eggs with unmeasured amounts of hot water, resulting in a product that was thick, chunky, bland, and gritty. The recipe book was not consulted during preparation, and the staff member was unsure of the quantities used. Similarly, oatmeal was prepared with unmeasured ingredients and insufficient cooking time, resulting in a thin, watery, and undercooked product. The oatmeal was not pureed for residents on puree diets as required by the recipe, and the staff member admitted to being pressed for time. Additionally, the facility failed to accommodate resident meal preferences as documented on meal tickets. One resident, who was supposed to receive fresh fruit with each meal, consistently did not receive it despite it being listed on the meal ticket and fresh fruit being available in the kitchen. The resident reported receiving the same breakfast daily without the requested fruit, and staff acknowledged that preferences should be followed when possible. These failures had the potential to affect all residents in the facility.
Failure to Maintain Effective Pest Control and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by repeated observations of live and dead roaches, food debris, and trash in various areas of the kitchen. Despite having a pest control policy and regular visits from a pest control company, documentation of these visits lacked details on areas treated, recommendations, or findings. Observations during meal preparation revealed multiple instances of roaches crawling on food prep areas, under sinks, behind ovens, and inside storage bins containing serving utensils. Food debris, trash, and dirty dishes were found under and around kitchen equipment, with visible buildup of dirt and debris in floor grout and drains. Staff interviews indicated that cleaning duties were expected to be completed daily, with food debris not to be left overnight. However, observations contradicted these expectations, as food debris and trash were present during early morning meal prep and on subsequent days. The Dietary Manager stated that she had not seen any roaches and reiterated that staff should clean before leaving, but was shown evidence of dead roaches and debris by the surveyor. The Administrator reported that pest control recommendations, if any, were not communicated to her but possibly to the maintenance supervisor. The lack of thorough cleaning and failure to address food debris and trash contributed to the presence of roaches in the kitchen. The pest control program was not effectively implemented, as evidenced by ongoing pest activity and insufficient documentation or follow-up on pest control visits. The facility census at the time was 121.
Unpalatable Food Preparation and Lack of Condiments Affecting Meal Quality
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food that is palatable, flavorful, and properly prepared, as well as the failure to provide condiments and seasonings with meals. Surveyors observed a cook preparing pureed eggs by blending scrambled and hardboiled eggs with hot water, resulting in a thick, slightly chunky puree that tasted bland, watered down, and gritty. Oatmeal was prepared with quick rolled oats in hot water, with a small, unmeasured amount of melted butter added; it appeared watery, the oats were not fully cooked, and it had no flavor, only a greasy feel on the lips. A test tray showed oatmeal with no flavor and bacon that was inconsistently cooked, with one piece properly cooked and another flimsy and rubbery with unrendered fat. Breakfast trays were sent out without salt, sugar, or other condiments. Multiple cognitively intact residents reported ongoing concerns about the taste and palatability of the food. Members of the resident council stated the food was terrible, sometimes inedible, with specific complaints about hard fried eggs and poor-quality oatmeal, and that listed dislikes on meal tickets were not honored. One resident reported that the food did not taste right and was inconsistent, with hot dogs offered as an alternative if the main meal was disliked. Another resident stated that food tasted bad, some items such as carrots and scalloped potatoes were too hard to eat, and that residents had difficulty obtaining coffee, sugar, creamer, and condiments, particularly on the second floor. Additional residents described the food as nasty, gross, and horrible, and reported that even offered alternatives were not good. The Dietary Manager and Dietician acknowledged that oatmeal designated as “super cereal” should receive butter and brown sugar, while regular oatmeal did not get additions unless requested, and that bacon should be cooked through with fat rendered, which contrasted with the surveyors’ observations and resident reports.
Widespread Kitchen Sanitation and Hand Hygiene Failures During Food Preparation and Service
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, and serve food in accordance with professional standards and its own policies over multiple days of observation. Surveyors observed that the designated kitchen handwashing sink did not produce hot water despite being allowed to run for approximately two minutes on several occasions. Staff, including dietary personnel, were unaware of whether the water ever became hot. Handwashing signage posted at the sink specified that hands should be washed with hot running water and outlined proper handwashing steps, but staff did not consistently follow these procedures. The facility’s Administrator and Dietary Manager (DM) later stated that they had not been informed of the hot water issue until the survey, and the Maintenance Supervisor reported he was only told about the problem on the day of the survey. During breakfast meal preparation, surveyors observed multiple instances of staff failing to wash their hands at appropriate times and handling food after contact with potentially contaminated surfaces. One dietary staff member began meal preparation after only donning gloves, without first washing hands. This staff member handled a dirty blender in the 3‑vat sink, then, without washing hands, entered the walk‑in cooler, retrieved a box of individual butter servings, and placed butter on resident trays. After picking up a butter container that had fallen on the floor, the staff member discarded it but again did not wash hands before resuming food handling, instead only changing gloves. The same staff member repeatedly changed gloves without handwashing between tasks, including after washing equipment in the sink and before preparing pureed foods and handling other meal components. Another dietary aide arrived carrying a personal cell phone and wearing a face mask, placed the phone on a serving cart, and later moved it to a food preparation station. After answering the kitchen phone, pulling the face mask down, and handling trays and condiments, this aide did not wash hands or don gloves before continuing to handle resident trays and food items. Although the aide did wash hands at one point, the water at the handwashing sink was noted to be cold. The aide was also observed adjusting a face mask and then continuing to handle syrup containers and cups, and later placing gloves on without washing hands. The DM later stated that staff were expected to wash their hands when they first arrive, when changing gloves, and after touching masks or phones, and that phones should not be placed on food preparation stations. The facility also failed to maintain a clean and sanitary kitchen environment as required by its Nutritional Services Sanitation and Ware Washing policies and its daily, weekly, and monthly kitchen checklists. On multiple days, surveyors observed kitchen floors with dirt and debris, dried and sticky spills, and food items such as a juice cup and tater tot left on floors and carts. In the dry storage room, a single‑serve juice cup lay on the floor surrounded by dried liquid, and oily and sticky spills remained under and near storage racks and the doorway over several days. Dirty dishes with caked‑on food debris from the prior day were left in the dishwashing area. Under the 3‑vat sink, the floor was sticky, with wet cardboard, an opened butter container, and food debris present. The 3‑vat sink’s sanitize basin contained dried, caked‑on meat and food debris, and a baby roach was seen crawling across the shelf above the sink. Additional unsanitary conditions included flour and sugar bins stored on the floor, with exteriors covered in drips and greasy smears and dried puree‑like drips on the sugar bin lid. A two‑tier stainless‑steel table in the back serving area had rusty spots where the finish was missing and dried food drips and greasy spills on the bottom tier, where clean muffin pans and a cutting board were stored. Behind the ice machine, surveyors observed a large amount of debris and trash, a build‑up of a black, thick substance, a leak causing a puddle, and a swollen, wet wall with a hole and dark, fuzzy material. Under the dishwashing sink, an opened single‑serve peanut butter container and crumpled plastic wrap were on the floor. The dishwashing sink contained dried food debris including pickles, onions, strawberries, greens, and other items, and a floor drain near the 3‑vat sink had food debris caked around the edges, with a roach seen crawling out of the drain. Evidence of pest activity was repeatedly documented. Surveyors observed a baby roach near the 3‑vat sink, a large roach crawling from under the stove to under the steam table, and dead roaches on the steam table shelf next to clean dishes and on the floor in front of the steam table. A greasy paper towel was stuck to the bottom shelf of the steam table, and there was a build‑up of debris under the serving station/steam table. The DM acknowledged seeing roaches and stated there was a daily cleaning list that staff were supposed to sign when tasks were completed. Dry goods and seasonings were not properly covered or stored. On multiple observations in the back preparation station, containers of fajita seasoning, ground thyme leaves, rotisserie seasoning, black pepper, and salt were left open on shelves or counters, and a large tub of parsley flakes had no lid. The sugar bin on the floor had its lid propped open. The DM later stated she was unsure where the parsley lid was and acknowledged that seasoning containers and the sugar and salt bin lids should be closed when not in use. Review of the facility’s daily, weekly, and monthly kitchen checklists showed numerous items either left blank or not documented as completed, including cleaning of dishes, sinks, work counters, steam tables, floors, storage areas, ovens, stainless‑steel surfaces, deep fryer, and deep cleaning under prep stations and cook’s areas. These observations and records showed that the facility did not consistently follow its own sanitation and ware washing policies or complete required cleaning tasks, affecting the kitchen environment from which food was prepared and served to all residents.
Failure to Notify Medicaid Residents of Excess Trust Fund Balances and Complete TPL Forms After Death
Penalty
Summary
Surveyors identified that the facility failed to notify Medicaid residents or their representatives when resident trust fund balances approached or exceeded the Medicaid resource limit, as required by facility policy. Review of the business office Resident Statement Landscapes showed that three Medicaid residents had trust fund balances significantly above the Medicaid limit ($12,161.13, $8,496.39, and $7,460.29), with no Resident Fund Balance Notifications documented in their medical records. During interview, the Business Office Manager acknowledged that she had not sent any Resident Fund Balance Notifications when residents reached the $200 threshold below the Medicaid limit and stated she was only now aware that such letters should have been sent. The Administrator stated she expected Medicaid resource letters to be sent when resident balances were within $200 of the resource limit. Surveyors also found that the facility failed to complete and send third party liability (TPL) forms within 30 days for deceased residents who had remaining funds in their accounts. Record review showed that two residents who had expired still had balances of $837.25 and $4,239.70, respectively, with no TPL letters sent. In interview, the Business Office Manager stated that TPL letters should be sent within 30 days of a resident’s death and acknowledged that these letters had not been sent for the deceased residents reviewed. The Administrator stated she expected TPL letters to be sent within 30 days of a resident’s death.
Failure to Provide Ordered Tube Feedings and Safe Positioning During Enteral Nutrition
Penalty
Summary
Surveyors identified that the facility failed to ensure residents receiving tube feeding were provided nutrition as ordered and that tube feeding formula and equipment were properly maintained. One resident with dysphagia oropharyngeal phase had a continuous order for Jevity 1.5 at 65 ml/hr. Multiple observations over several days showed that factory-sealed 1500 ml bottles of Jevity 1.5, labeled with hang times, were not infusing at the ordered rate despite the pump being set correctly. Large volumes of formula remained in the bottles when significant amounts should have infused based on the documented start times and ordered rate, and on at least two occasions the same bottle remained hanging for over 24 hours. The pump was observed alarming “inactive” or “cassette error” with no formula infusing, yet the same bottles continued to hang, and staff did not replace the formula or tubing within the 24-hour timeframe. The observations for this resident showed repeated instances where the amount of formula remaining in the bottle did not match what should have been delivered according to the physician’s order and elapsed time. For example, a bottle hung the previous evening still had nearly the full volume present the next morning, and later in the day the same bottle continued to show minimal infusion despite the pump being set at 65 ml/hr. On another day, a bottle hung early in the morning still had almost the entire volume remaining several hours later while the pump alarmed with an error and no feeding was infusing. On subsequent observation, the same bottle remained in use more than 24 hours after it was hung, with substantial formula still present when, by calculation, the entire bottle plus additional formula should have infused. Staff interviews confirmed that tube feeding bottles and tubing were supposed to be changed at least every 24 hours and that formula should not hang longer than that. Surveyors also found that another resident with a history of pneumonia, stroke, and hemiplegia/hemiparesis, who had an order for continuous Jevity 1.5 at 60 ml/hr via pump with allowance for disconnection for care, received personal care while the tube feeding continued to infuse and the head of bed was lowered. On two separate observations, a CNA entered the room, donned gloves, and lowered the resident’s head of bed to provide personal care while the tube feeding continued without being paused. After care, the CNA then repositioned the resident and elevated the head of bed. During one of these episodes, a Wound Nurse was present for a skin assessment and did not pause the feeding or instruct the CNA to avoid lowering the head of bed while the feeding was running. In interviews, nursing staff, including an LPN and the DON, stated that CNAs should notify the nurse so the pump can be turned off during care and that allowing tube feeding to infuse with the head of bed low increases the risk of aspiration.
Failure to Provide Substantial Bedtime Snacks When Meal Intervals Exceeded 14 Hours
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals and snacks were provided in a manner that limited the interval between the evening meal and breakfast to 14 hours or less and to provide a substantial bedtime snack when that interval exceeded 14 hours. The facility’s written Meals and Snacks policy required meals to be provided on a regularly scheduled basis and specified that mealtimes be scheduled to ensure a maximum of 14 hours from dinner to breakfast, but the policy did not address the requirement for a substantial bedtime snack when more than 14 hours elapsed between meals. The posted mealtime schedule for several halls showed breakfast from 8:00 A.M. to 9:30 A.M., lunch from 12:00 P.M. to 1:30 P.M., and dinner from 5:00 P.M. to 6:30 P.M., resulting in up to 15 hours between dinner and breakfast. Observations on multiple days confirmed that meals were served during these timeframes, including dinner service as late as 6:30 P.M. and breakfast trays still leaving the kitchen as late as 9:22 A.M. Resident council minutes documented repeated complaints that snacks were not being given out, that residents were not receiving what they ordered, and that beverages were missing from trays. Residents reported that bedtime snacks were left at the nurse’s station and that staff did not routinely pass them unless residents specifically asked, with one resident stating they did not know snacks were available. An activity aide reported that residents frequently complained that breakfast was served late and that they were not receiving evening snacks, and that snacks were not being offered or provided when requested. Interviews with cognitively intact residents revealed that they typically did not receive evening or bedtime snacks, that available snacks were limited to cookies, chips, or snack cakes, and that they were not informed they could receive more substantial items such as sandwiches. Several residents described long intervals without food and difficulty obtaining substantial snacks at night. One resident stated dinner was usually served around 5:00 P.M. but sometimes later, and that they had not been offered snacks in the evening for months except on one recent occasion; they had never been offered a sandwich and would be interested in one, especially when dinner was early or intake was low. Another resident reported that breakfast sometimes arrived as late as 9:30 or 10:00 A.M., that no snacks were offered at night, and that when they requested a sandwich at bedtime, staff refused, stating the resident had already eaten dinner. A different resident reported sometimes going up to 16 hours without food and only being offered insubstantial snacks like chips. Another resident stated that staff sometimes received snacks from the kitchen but did not always pass them out, and that snacks consisted of cookies and snack cakes, not substantial or healthy items; when this resident requested a sandwich at night, staff responded that no sandwiches had been sent and that they were “lucky” to get snacks at all. The dietary manager reported that sandwiches were placed in a resident refrigerator on the first floor, but observation of that refrigerator showed it was largely filled with personal items and contained no sandwiches. The dietitian stated that if more than 14 hours elapsed between dinner and breakfast, a substantial bedtime snack such as a sandwich, fruit cup, yogurt, and cookies would be expected, but also reported being told by the dietary manager that there were not more than 14 hours between meals and that residents were provided mainly snack items like peanut butter bars and chips, without mention of sandwiches.
Failure to Follow Hand Hygiene, Incontinence Care Technique, and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene, incontinence care technique, and use of Enhanced Barrier Precautions (EBP). Review of facility policies showed that staff were required to perform hand hygiene at key points during care, use clean surfaces of wipes for each stroke, cleanse the perineal area from front to back including the genital and anal areas, and change gloves with hand hygiene between dirty and clean tasks. The EBP policy required gown and glove use for high-contact resident care activities such as dressing, transferring, providing hygiene, changing briefs/toileting, and wound care for residents with wounds or indwelling devices, with appropriate signage indicating required PPE and high-contact activities. Multiple observations showed staff did not follow these policies during incontinence care. One resident who was always incontinent of bowel and bladder and dependent on staff for personal hygiene had peri-care performed by a CNA who double-gloved, removed only one pair of gloves after cleaning stool, did not perform hand hygiene, then applied barrier cream and a clean brief and adjusted the resident’s pillow while wearing the same soiled gloves. Another resident with severe cognitive impairment, frequent incontinence, and limited mobility was found sitting with feet in a puddle of urine and reported being wet all night; during care, the CNA wore the same gloves throughout, wiped only the buttocks with disposable wipes, did not cleanse the front genital or anal areas, and then dressed and transferred the resident without changing gloves or performing hand hygiene. A third resident, cognitively intact but fully dependent for toileting, reported being left soiled; the CNA providing care did not wear a gown, used the same side of a wet washcloth for multiple wipes to the groin without cleansing the genital or anal areas, then applied a clean brief, handled linens, and adjusted the bed while wearing the same gloves, and left the room without performing hand hygiene. Surveyors also observed failures to implement EBP requirements for residents with wounds. One resident with dementia, a stage 3 heel pressure ulcer, and an EBP order had only a red magnet on the door that did not specify PPE or high-contact activities; a CNA provided incontinence care and dressing without a gown, and later the Wound Practitioner and wound nurse performed wound care on heel and foot eschar without gowns, using only gloves. Another resident with severe cognitive impairment, multiple comorbidities, incontinence, and EBP orders for wounds had a similar red magnet lacking PPE details; a CNA donned gloves in the hallway, provided full incontinence care, dressing, and mechanical lift preparation without changing gloves or performing hand hygiene, and neither the CNA nor the Activities Director wore gowns during the mechanical lift transfer. The Wound Practitioner and wound nurse later performed wound care on this resident’s buttocks wound with gloves only, no gowns. Additional EBP lapses were observed for other residents with wound-related EBP orders. One cognitively intact resident with a weeping right shin wound on EBP had wound care performed by the wound nurse using gloves only, without a gown, despite active drainage and dressing application. Another resident with severe cognitive impairment and a stage 3 pressure ulcer on EBP had wound care to a buttocks wound performed by the Wound Practitioner and wound nurse wearing gloves but no gowns. Interviews with CNAs, CMTs, nursing staff, the wound nurse, ADON, DON, and the Administrator revealed inconsistent understanding of EBP indications, the meaning of the red door magnets, and required PPE. Some staff believed EBP meant only glove use or associated the red magnet with oxygen use, while others stated that gowns and gloves should be used for all hands-on or high-contact care for residents with wounds. Leadership staff stated expectations that hand hygiene be performed when entering and exiting rooms and between dirty and clean tasks, that peri-care include cleaning all potentially soiled areas including genitals, and that gowns and gloves be used for EBP residents during high-contact care and wound care, which contrasted with the observed practices.
Failure to Provide Timely and Complete Incontinence Care
Penalty
Summary
The facility failed to provide timely and thorough incontinence care for three residents who were dependent on staff for personal hygiene. Observations and interviews revealed that these residents were left wet or soiled for extended periods, with staff not responding promptly to call lights or checking on residents as required. In one case, a resident's spouse reported consistently finding the resident wet in the mornings and having to assist with care due to staff inattention. Direct observation showed the resident lying in a saturated brief with urine and stool, and staff did not cleanse all necessary areas during incontinence care. Another resident was found sitting in a puddle of urine with soaked bedding and clothing, stating they had been waiting all night for assistance. The call light was not within reach, and the resident was confused about its use. Staff acknowledged that night shift coverage was insufficient, making it difficult to provide timely care. A third resident, also fully dependent on staff, reported being left wet after using the call light, particularly during evening and night shifts. Observation confirmed the resident was left in a soaked brief for an extended period before staff responded. Facility policy required incontinence care to be provided as directed in the care plan, including checking residents every two hours, performing thorough cleansing, and applying barrier cream as needed. However, staff failed to follow these procedures, resulting in residents remaining wet or soiled for prolonged periods and incomplete cleansing during care. Interviews with staff and the Director of Nursing confirmed that these lapses occurred, and that inadequate staffing contributed to the delays in care.
Failure to Treat Cognitively Intact Resident With Respect and Dignity
Penalty
Summary
The facility failed to honor a resident’s right to be treated with respect and dignity when an LPN spoke rudely to a cognitively intact resident. The facility’s Resident Rights policy dated 4/26/23 stated that residents must be treated with kindness, respect, and dignity, and that resident rights include respect and dignity. Resident #61’s quarterly MDS dated 9/4/25 showed the resident was cognitively intact and had diagnoses of depression and a psychotic disorder. During an observation and interview on 10/1/25 at 8:32 A.M., the resident was sitting up in bed drinking coffee when LPN A entered after knocking and handed the resident a medication cup. After taking the medication, the resident began to set the cup down, and when LPN A attempted to take the cup, the resident stated he/she could take care of it him/herself. LPN A’s facial expression changed to appear irritated, and the LPN turned his/her back to the resident, began walking away, and stated in a clearly audible, rude tone, “see the type of attitude we have to deal with, you don’t talk to us that way,” before exiting the room and closing the door. The resident then reported that staff can be rude, that they treat him/her as if he/she has dementia, and that he/she is able to do things independently. In a subsequent interview, the Administrator, DON, and Corporate Administrator stated that staff should speak to residents with respect, face residents when speaking, and should not criticize them. This deficiency involved one resident out of a sample of 24, with a total facility census of 121, and was based on observation, interview, and record review showing that the LPN’s rude and critical verbal response and demeanor toward a cognitively intact resident did not comply with the facility’s Resident Rights policy requiring respect and dignity.
Failure to Assess and Care Plan Resident for Self-Administration of Bedside Inhaler
Penalty
Summary
The facility failed to ensure a resident’s right to self-administer medications was protected in accordance with its own bedside medication storage policy. The policy required a prescriber’s written order, an interdisciplinary team assessment of self-administration skills, documentation of bedside storage on the MAR and care plan, resident instruction with documentation, and at least once-per-shift nursing checks for usage. For a cognitively intact resident with COPD who had an order for albuterol inhaler "may keep at bedside," the care plan did not address self-administration, and there was no documented assessment of the resident’s ability to safely self-administer medications. The resident reported wanting to keep the rescue inhaler at bedside and stated that the physician had ordered this, but staff initially did not provide the inhaler, telling the resident they needed to speak with the physician. On subsequent observation, the resident produced the albuterol inhaler from the bedside drawer and stated staff had given it to be kept at bedside. Review of the medical record at that time still showed no assessment for self-administration. A CMT reported that if a resident is able to self-administer, the order would indicate the medication may be left at bedside and that residents are educated on proper technique, but also stated there were currently no residents self-administering medications. The DON stated the resident had been assessed in the past but was unsure if reassessment occurred after the last admission, and confirmed that residents requesting to self-administer should be assessed for safety when medications are kept at bedside.
Inaccurate MDS Coding of GLP-1 Therapy as Insulin
Penalty
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) for two residents with diabetes, where their assessments were incorrectly coded to show they received insulin. For one resident, the quarterly MDS indicated that insulin injections were received on one day during the 7-day look-back period. However, the resident’s order summary showed a standing order for Ozempic, a GLP-1 receptor agonist, administered subcutaneously once weekly for type 2 diabetes, with no indication of insulin use during that period. Ozempic is not classified as insulin and therefore should not have been coded as insulin on the MDS. For the second resident, the quarterly MDS also documented that insulin injections were received on one day during the 7-day look-back period. Record review showed that this resident had previously been on insulin, which was discontinued months earlier, and was subsequently placed on Ozempic and then Mounjaro, both GLP-1 receptor agonists administered subcutaneously. The current order summary reflected a weekly Mounjaro injection, with no active insulin order. During interviews, the MDS Coordinator confirmed that Ozempic and Mounjaro are not insulin and should not be coded as such, and the Administrator stated an expectation that insulin be coded accurately on the MDS, confirming that the assessments did not accurately reflect the residents’ actual medication regimens at the time of assessment.
Failure to Provide Ordered Fortified Foods and One-on-One Feeding Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fortified foods and adequate nutritional support, including one-on-one feeding assistance, to residents identified as needing enhanced nutrition. The facility’s own policy on weight variances required RD assessment and interventions such as fortification and supplements for residents with significant or unplanned weight loss. During a breakfast meal preparation observation, dietary staff prepared oatmeal using two 42-ounce tubs of quick oats in a 40-quart pot with steaming water, adding an unmeasured amount of melted butter. The oatmeal was described as thin, watery, undercooked, lacking flavor, and greasy, and the cook stated it was not cooked longer due to time pressure. Despite a facility recipe specifying 2½ gallons of water and 3 pounds of instant oatmeal with a defined cooking process, the oatmeal did not meet the described consistency, and super cereal, the facility’s fortified oatmeal product, was not prepared at all that morning. The facility had identified 33 residents who were to receive fortified foods, and its fortified list and RD guidance required that fortified foods, including super cereal, be prepared and served daily to residents with orders. However, during the observed breakfast service, the same oatmeal was served to residents on both regular and fortified diets, and no health (house) shakes were placed on the trays, despite expectations that dietary staff would ensure shakes were included. A CNA later reported not being familiar with fortified foods or super cereal and could not confirm whether residents received them with breakfast. The Dietary Manager and RD both stated that super cereal should be made daily, separate from regular oatmeal, and that house shakes should be provided on trays with meals for residents with orders, but on the observed day these fortified items were not provided as required. The deficiency also involved a specific resident with documented nutritional needs and significant weight loss who did not receive ordered fortified foods, health shakes, or one-on-one feeding assistance. This resident had impaired cognition, dementia, anxiety, and Parkinson’s disease, required substantial/maximal assistance with eating per the MDS, and had experienced unplanned weight loss from 167.8 lbs in April 2025 to 138.4 lbs by early September, and then to 131.0 lbs by the end of September. The care plan and physician’s orders called for a regular diet with double portions, fortified foods with all meals, a divided plate, house shakes with meals, and one-on-one feeding assistance. Observations showed the resident alone in the room at lunch with a regular plate (not divided), attempting but unable to eat spaghetti independently, stating they were done eating despite a nearly full plate, and reporting not receiving a shake. The lunch ticket listed double portions, fortified foods, a 4 oz house shake, and feeding assistance, yet no shake was present and no assistance was provided. On a subsequent morning, the resident did not receive a breakfast tray at all by mid-morning, despite call lights being activated and turned off, and staff acknowledging the resident had not been given a tray. Documentation in the MAR and nutrition intake records indicated a house shake was given and high meal consumption percentages, which conflicted with direct observations that the resident did not receive the ordered shake, fortified foods, or required one-on-one feeding assistance.
Improper Labeling and Storage of Medications and Nutritional Supplements
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications and biologicals during review of multiple medication and treatment carts and medication rooms. The facility’s own Storage of Medication policy required medications and biologicals to be stored safely, securely, and properly per manufacturer or supplier recommendations, to be kept in pharmacy-labeled containers, and for opened multi-dose preparations to be dated when first used. Despite this, an opened, undated Lispro insulin pen was found in the top drawer of a nurse medication cart, and the nurse present stated it should have been dated once opened but did not know who had opened or administered it. On the same hall’s treatment cart, an open tube of triamcinolone 0.1% cream was found without a cap, and the nurse acknowledged the medication should have had a cap but reported the cap was lost. Additional observations showed an opened Breo Ellipta 200 mcg/25 mcg inhaler sitting on a medication room countertop without any label identifying the resident to whom it belonged. In one treatment cart, a bottle of Nitroglycerin 0.4 mg was present without a label indicating the resident’s name or expiration date, and the LPN using the cart stated they did not know who the medication belonged to. Another medication cart contained a second bottle of Nitroglycerin 0.4 mg with no identifying name, as well as several cartons of Ensure Plus, one of which was open and not stored on ice or refrigerated, contrary to manufacturer instructions that opened Ensure should be refrigerated. The CMT using that cart stated they did not know who the Nitroglycerin belonged to and confirmed they had opened the Ensure that day.
Failure to Schedule Urology Follow-Up for Resident with Indwelling Catheter
Penalty
Summary
Facility staff failed to ensure that a resident with recurrent urinary tract infections and severe urethra erosion from prolonged use of an indwelling urinary catheter received care consistent with professional standards. Despite multiple physician and hospital orders for regular urology follow-up and catheter exchanges, staff did not schedule the required follow-up appointments with the urologist. The resident's care plan inaccurately documented the presence of a suprapubic catheter, which was not supported by the medical record, and there was no evidence that the necessary urology appointments were made after hospital discharges or as directed by the physician. Record reviews showed that the resident had a history of obstructive and reflux uropathy, bladder-neck obstruction, cognitive impairment, and required maximum assistance for all activities of daily living. Orders included regular catheter care and exchanges, and hospital discharge summaries repeatedly indicated the need for urology follow-up. However, documentation of these follow-up appointments was missing, and interviews with staff and administration revealed a lack of awareness regarding the missed appointments and the resident's ongoing urethra erosion. Interviews with nursing and administrative staff confirmed that the responsibility for scheduling follow-up appointments and transcribing orders fell to the charge nurse upon the resident's return from hospital or physician visits. Despite these expectations, the required follow-up appointments were not made until prompted by the surveyor's investigation, and the oversight was not identified by supervisory staff. The resident experienced ongoing issues with catheter clogging, leakage, and skin breakdown, further highlighting the lack of adherence to professional standards of care.
Lack of Staff Competency in CPR Policy Leads to Deficiency
Penalty
Summary
The facility failed to ensure that their licensed staff was competent in their knowledge of the facility policy regarding when to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. This deficiency was identified when staff members were unsure of the circumstances under which CPR should not be initiated, such as in the presence of clinical signs of irreversible death. The incident involved a resident who was found unresponsive with signs of rigor mortis, and CPR was not initiated as per the facility's policy. The resident in question was cognitively intact but required substantial assistance with daily activities and had a history of cancer, stroke, and other medical conditions. On the day of the incident, the resident had undergone chemotherapy and was reported to be feeling unwell. The resident was last seen alive by staff at 4:30 A.M., and was found unresponsive at 5:55 A.M. with signs of rigor mortis. Despite the resident's full code status, CPR was not performed due to the presence of these signs, which was in accordance with the facility's policy. Interviews with staff revealed a lack of clarity and understanding of the CPR policy, with some staff members unsure of when CPR should not be performed. The facility's investigation confirmed that the resident's condition was related to a gradual decline due to their medical diagnoses. The Director of Nursing and Administrator acknowledged the need for staff to be competent in understanding code status and the facility's CPR policy, highlighting a gap in staff training and knowledge.
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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