Lewis & Clark Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Charles, Missouri.
- Location
- 1221 Boones Lick Road, Saint Charles, Missouri 63301
- CMS Provider Number
- 265160
- Inspections on file
- 28
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lewis & Clark Gardens during CMS and state inspections, most recent first.
A cognitively intact, fully dependent resident with hemiparesis and traumatic spinal cord dysfunction reported to a CNA and the Activity Director that a staff member, identified by nickname, squeezed the resident’s cheeks and told the resident to shut up while the resident was yelling and felt like falling out of bed. The CNA and Activity Director reported this as potential abuse to the DON and Administrator, and the DON and ADON obtained a similar account from the resident and had the resident identify the suspected CNA. The Administrator then brought the CNA into the resident’s room and questioned them together, at which point the resident denied the allegation. Despite facility policy requiring immediate reporting of all abuse allegations to the state agency within two hours, the Administrator did not report the allegation or complete an investigation, basing this inaction on the resident’s later denial in the presence of the accused staff member.
The facility failed to promptly and thoroughly investigate an allegation of verbal and physical abuse involving a cognitively intact resident who was dependent on staff for ADLs and had hemiparesis, respiratory failure, and traumatic spinal cord dysfunction. The resident reported that a CNA entered the room, yelled at the resident to shut up, and forcefully squeezed the resident’s face, causing pain and fear. Although the allegation was reported by another CNA to the DON and ADON and brought to the Administrator, the Administrator interviewed the resident with the alleged CNA present, accepted the resident’s denial in that context, and did not report the allegation to the state agency or initiate the required investigation. Record review showed no interviews or statements from the alleged perpetrator, other residents, or staff, and no evidence that a comprehensive abuse investigation was conducted.
The facility did not consistently serve meals at appropriate temperatures or follow standardized recipes, resulting in residents receiving cold, unappetizing, and improperly prepared food. Multiple residents reported dissatisfaction with meal quality, and observations confirmed food was often served below required temperatures, with missing ingredients and incomplete temperature logs. Dietary staff admitted to not recording temperatures and deviating from recipes, while management was unaware of the ongoing issues.
Four dependent residents, including those on hospice and with cognitive impairment or incontinence, did not receive scheduled showers or alternative bathing assistance for several days while on the COVID isolation unit. Documentation was lacking, and interviews revealed that staff did not offer or provide bathing help despite resident requests, resulting in poor hygiene and unmet care needs.
A resident with Huntington's disease, at risk for falls, was pushed by a CNA while attempting to retrieve paper from the floor, resulting in a fall and a large bruise. The CNA did not assist the resident after the fall or call for a nurse, and the facility failed to assess the resident's injury until it was brought to their attention by a surveyor. Facility policies required protection from abuse and neglect, but these were not followed in this incident.
A resident with Huntington's disease was found living in unsanitary conditions, with food debris, dirty linens, and a cluttered room that had not been cleaned for over a week. Housekeeping staff avoided the room due to a prior incident, and the facility lacked a policy for maintaining a clean, homelike environment. The resident's needs for assistance and communication were not adequately addressed, resulting in a failure to provide a safe and sanitary living space.
A resident with Parkinson's disease reported that a staff member threatened to hit them after refusing assistance, and multiple staff became aware of the allegation. However, the incident was not promptly reported to the Administrator or state authorities as required by facility policy, resulting in a delay in addressing the abuse allegation.
A resident with Huntington's disease, traumatic subdural hemorrhage, and anxiety did not have a comprehensive, person-centered care plan addressing the specific symptoms and care needs related to Huntington's disease. Staff were not adequately informed about the disease, leading to fear, miscommunication, and misunderstanding of the resident's behaviors. Family and staff interviews confirmed that the lack of a disease-specific care plan resulted in inadequate and inappropriate care approaches.
A certified medication technician verbally abused a resident with dementia and other cognitive impairments by yelling, cussing, and using vulgar language after the resident refused care. Multiple witnesses, including another resident and a visitor, confirmed the staff member's inappropriate behavior, and the staff member admitted to verbally abusing the resident in response to the situation.
A resident with severe cognitive impairment and a history of wandering exited the facility through an alarmed door without staff knowledge due to insufficient alarm volume and missed 15-minute checks. The resident was later found outside with multiple injuries, and staff only became aware of the absence after noticing a call light and searching the premises.
A CNA took a resident's government-issued debit card without permission and used it for unauthorized ATM withdrawals and payments for food delivery, utilities, and a cell phone provider, totaling over $1,300. The resident, who was able to handle their own finances, noticed the missing funds and reported it to the BOM. The incident was confirmed through transaction records and ATM footage, and the resident denied authorizing the transactions.
The facility failed to maintain a clean kitchen environment, with issues in food storage, preparation, and service. Observations showed improper sealing and labeling of food, unclean kitchen surfaces, and a freezer not maintaining the required temperature. Staff did not follow handwashing and glove use protocols, handling food and utensils without changing gloves or washing hands. The three-compartment sink lacked sanitizer, and the sink compartments did not hold water, leading to improper dishwashing. The Dietary Manager was aware of these issues but did not address them effectively.
During a survey, hazardous materials such as chafing fuel, nail polish remover, and cleaning products were found unsecured in areas accessible to residents. Staff interviews revealed a lack of awareness about securing these items, contributing to the deficiency.
The facility failed to provide adequate respiratory care for several residents, including improper use and documentation of CPAP and BiPAP machines, unlabeled oxygen tubing, and improperly stored nebulizer masks. Observations and interviews revealed a lack of adherence to physician's orders and facility policies, resulting in inadequate care for residents with chronic respiratory conditions.
The facility failed to serve food that was palatable and at the correct temperature, as required by policy. Residents reported the food as bland and cold. Observations showed pasta salad and barbeque pork were served below the required temperatures, and potatoes were served without seasoning. The Dietary Manager confirmed that food temperatures were only checked at the start of meal service.
The facility failed to provide bedtime snacks to residents, despite having a policy and physician orders in place. Several residents reported not receiving snacks, and staff interviews revealed a lack of awareness and communication about the requirement to offer snacks to all residents. Snacks were often left at the nurse's station, leading to limited availability for residents.
The facility failed to ensure proper hand hygiene and glove use during resident care, did not implement Enhanced Barrier Precautions for a resident with a urinary catheter, and neglected to complete Tuberculin Skin Testing for three employees. Staff were observed not washing hands or changing gloves appropriately, and there was a lack of awareness regarding PPE use. Employee files showed missing documentation for TB testing, which was attributed to the departure of the responsible Staffing Coordinator.
The facility failed to administer pneumococcal vaccinations according to CDC guidelines for five residents. Despite consent from residents or their representatives, the PCV20 vaccine was not documented as administered, and no clinical decision-making or refusal was recorded. Interviews with the DON and ADON indicated awareness of the issue, but necessary follow-up actions were not completed.
A resident with shortness of breath and a pacemaker was not provided with portable oxygen or a wheelchair, despite requests and medical necessity. Staff were unaware of the resident's needs, and the care plan did not address these requirements. The resident attempted to walk to the dining room without assistance, leading to dizziness and shortness of breath. Observations confirmed the lack of necessary equipment, and the facility did not have a policy for accommodating resident needs.
The facility failed to prepare pureed food to the required smooth consistency for a resident on a pureed diet. Observations showed that pureed meals, including chicken, carrots, barbeque pork, pasta salad, and three-bean salad, contained visible chunks, contrary to the facility's policy. Interviews confirmed that pureed food should be smooth, like baby food or applesauce, but the served meals required chewing.
The facility failed to provide necessary care and services for two residents who were unable to perform their own ADLs, specifically neglecting nail care and grooming, including shaving. This deficiency was identified through observation, interview, and record review during the survey.
A facility failed to apply hand splints and palm protectors for a resident with hand contractures as directed by Occupational Therapy. This deficiency was identified through observation, interview, and record review, affecting the resident's care and potentially leading to further deformity.
Two residents with cognitive impairments engaged in sexual intercourse without their capacity to consent being determined. Despite prior observations of the residents' interactions, staff failed to report or address these appropriately. The primary care physician confirmed neither resident could consent, highlighting a significant oversight in the facility's duty to protect its residents.
Two residents in an LTC facility did not receive necessary assistance with ADLs, including regular showers and grooming. One resident, dependent due to quadriplegia, had long, dirty fingernails and was unshaven, while another resident reported infrequent bathing and dry skin. Staff interviews revealed issues with staffing and time constraints, leading to missed care opportunities.
A resident with quadriplegia and hand contractures did not receive necessary care as the facility failed to apply hand splints and palm protectors as directed by occupational therapy. Despite training, staff did not consistently apply these devices, leading to the resident experiencing pain and further contracture. Observations showed the resident's hands were in poor condition, and interviews revealed a lack of clarity among staff regarding the application of these devices.
Failure to Timely Report and Investigate Allegation of Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of physical abuse to the state survey agency within the required two-hour timeframe and to conduct an appropriate investigation. Facility policy stated that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, and no later than two hours, when abuse or serious bodily injury is alleged. Despite this, the Administrator acknowledged that an allegation that a staff member squeezed a resident’s face and told the resident to shut up was not reported to the state agency, and no investigation was completed because the resident later denied the allegation when interviewed in the presence of the accused staff member. The resident involved had a quarterly MDS dated 1/6/26 showing that the resident was cognitively intact (BIMS score of 13), able to make self-understood and understand others, and dependent on staff for ADLs, with diagnoses including hemiparesis, respiratory failure, and traumatic spinal cord dysfunction. The resident’s care plans documented behavioral issues, including becoming easily angered, yelling at staff and family, and pushing against staff while demanding unsafe repositioning methods. Interventions included redirection, involvement of family, and reminders about safe repositioning techniques. These documented behaviors formed part of the context in which the alleged abuse occurred but did not negate the requirement to treat the report as an abuse allegation. Multiple staff interviews established that on or about Friday, January 9th, the resident told a CNA and the Activity Director that a staff member the resident called “Firehead” had squeezed the resident’s cheeks and told the resident to shut up while the resident was yelling and felt like falling out of bed. The CNA and Activity Director reported this as potential abuse to the DON and Administrator. The DON and ADON then interviewed the resident, who reported that a CNA had come into the room, told the resident to be quiet, and squeezed the resident’s cheeks, and the Administrator walked the suspected CNA past the resident’s door, where the resident identified the CNA as the person involved. The Administrator then brought the CNA into the room and questioned both together; at that time, the resident denied the allegation. The Administrator later confirmed that the allegation had been reported to her on January 9th, but she did not report it to the state agency or complete an investigation because the resident denied the allegation during that joint interview.
Failure to Investigate Allegation of Verbal and Physical Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation of an allegation of verbal and physical abuse involving one resident. Facility policy required that all reports of abuse, including verbal and physical abuse, be promptly and thoroughly investigated, with the investigation begun immediately and including interviews with the involved resident, alleged perpetrator, other residents, and staff, as well as steps to protect residents. Resident #1, who was cognitively intact per a recent MDS with a BIMS score of 13 and dependent on staff for ADLs with diagnoses including hemiparesis, respiratory failure, and traumatic spinal cord dysfunction, reported that a CNA the resident referred to as “Firehead” had been rude. The Administrator stated that CNA B reported to the DON and ADON that Resident #1 said this staff member, later identified as CNA A, squeezed the resident’s face and told the resident to shut up. Resident #1 later described that the staff member entered the room, yelled at the resident to shut up, and squeezed the resident’s cheeks very hard, causing pain and fear. The Administrator initially considered the report could be abuse but interviewed the resident with CNA A present, and when the resident denied the allegation in that setting, the Administrator did not report the allegation to the state agency and did not initiate or complete an investigation. Review of facility documentation showed no interviews or statements from the alleged perpetrator, other staff, residents, or witnesses, and no evidence of a thorough investigation. The Administrator later clarified that the incident had been reported to her on January 9 but still had not been investigated at the time of the surveyor’s review.
Failure to Serve Palatable Meals at Safe Temperatures
Penalty
Summary
The facility failed to provide residents with meals that were palatable, served at appetizing temperatures and textures, and that conserved nutritive value and flavor, as required by facility policy. Observations and interviews revealed that hot foods were often served below the required temperature, with a sample tray showing a hot dog at 118°F, below the minimum standard of 120°F, and salads and desserts served at improper temperatures. The dietary temperature logs were incomplete, with missing entries for vegetables and desserts, and staff admitted to not recording temperatures due to being busy. Additionally, the preparation of menu items did not always follow standardized recipes, such as the banana pudding being served without bananas or vanilla wafers due to lack of ingredients and no substitutions being made. Multiple residents reported dissatisfaction with the food, describing it as cold, undercooked, bland, and sometimes unidentifiable. Several residents stated that their meals were cold by the time they were delivered, and that food was often served without proper covering, resulting in dried-out meals. Observations confirmed that salads were limp and at room temperature, and desserts were not properly chilled. Residents also noted that condiments and margarine were not consistently provided with meals. Interviews with dietary staff and the Dietary Manager revealed inconsistencies in following recipes and food preparation procedures. The Dietary Manager acknowledged receiving complaints about cold food and described efforts to keep food hot, such as using plate warmers and domes, but was unable to explain delays in meal delivery. The staff also deviated from recipes, such as using more salad dressing than required, and failed to document food temperatures as expected. The Administrator stated that there were no instructions for the amount of salad dressing to use and was unaware of the extent of food temperature and palatability issues.
Failure to Provide Bathing Assistance to Dependent Residents During COVID Isolation
Penalty
Summary
The facility failed to provide adequate bathing assistance to four residents who were dependent on staff for activities of daily living (ADLs) during their temporary relocation to the COVID isolation unit. These residents, some of whom were receiving hospice services and had varying levels of cognitive impairment and incontinence, did not receive scheduled showers or alternative bathing assistance for extended periods, ranging from six to thirteen days. Documentation such as shower sheets and care plans lacked specific instructions on bathing frequency, and there was no record of showers or bed baths being provided during the isolation period for these residents. Interviews with residents revealed that they were not offered showers or assistance with bathing while on the COVID isolation unit, despite requesting help from staff. Some residents reported feeling dirty, not having changed clothes, or not having brushed their teeth for several days. Observations confirmed physical signs of poor hygiene, such as greasy hair and unshaven facial hair. Staff interviews indicated confusion regarding responsibilities for providing showers, especially for residents on hospice, and inconsistent documentation of care provided. Facility leadership, including the DON, ADON, and Administrator, acknowledged that residents were supposed to receive showers at least twice a week, including those on the COVID isolation unit and those receiving hospice care. However, there was a lack of clear documentation and follow-through, particularly when the designated shower aide was absent or when the shower facility was temporarily out of service. Staff reported that bed baths were to be provided when the shower was unavailable, but these were not documented. The deficiency was identified through observation, interview, and record review, highlighting a failure to ensure basic hygiene care for dependent residents during a critical period.
Failure to Protect Resident from Abuse and Neglect During Fall Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to protect a resident with Huntington's disease from abuse and neglect. The resident, who had a history of falls, impaired mobility, and behavioral symptoms related to Huntington's disease, requested assistance to retrieve paper from the floor. The CNA, while sweeping the resident's room, refused to assist and instead grabbed the resident's left hand/arm, pushing the resident back, which caused the resident to fall onto the footboard of the bed and then slide off onto the floor. The CNA did not attempt to prevent the fall or assist the resident after the incident, nor did the CNA call for a nurse to assess the resident. The resident sustained a large bruise to the right buttock area and reported pain, but the facility did not assess the resident after the fall until ten days later, when the surveyor brought the resident's complaint of pain to the facility's attention. Video footage confirmed the CNA's actions and lack of intervention, and interviews with the resident and family corroborated the events. The resident expressed frustration with the CNA's behavior and stated that the CNA was not nice and did not want the CNA in the room again. Facility policies reviewed indicated a clear expectation that residents be free from abuse, neglect, and exploitation, and that staff are to provide necessary assistance and report any allegations or suspicions of abuse immediately. Despite these policies, the CNA's actions and the facility's failure to promptly assess the resident after the fall constituted neglect and a violation of the resident's right to be free from abuse and neglect.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to provide housekeeping services to maintain a clean, sanitary, and orderly environment for one resident diagnosed with Huntington's disease, who required assistance with activities of daily living and had a history of falls. Video footage and direct observation revealed the resident's room was cluttered with numerous disposable plates, cups, utensils, and food debris on the floor, a full trash can, and dark stains on the bed linens. The over-bed table was covered with dried food and spilled drinks, attracting gnats, and the bathroom was unsanitary with a dirty toilet, empty paper towel dispenser, and no trash can. Dirty and clean clothing were scattered on the floor, and the bed frame was broken. Interviews indicated that housekeeping staff had not entered the resident's room for over a week due to a prior incident involving aggression, as directed by a former administrator. The current administrator was unaware of this directive and the lack of cleaning, as well as a request for a larger trash can to accommodate the resident's needs. The resident's family member reported that the resident often refused cleaning due to staff not communicating or discarding items without asking, and that staff did not understand the resident's condition. The facility did not provide a policy for housekeeping services or maintaining a clean and comfortable environment.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner after a resident with Parkinson's disease reported that a staff member threatened to hit them with a closed fist following an incident where the resident, unable to use their hands due to their condition, threw a urinal at the aide who refused to assist. The resident expressed fear of retaliation. The facility's policy requires all staff to report any allegations of abuse, neglect, or mistreatment to the Administrator or designee, and mandates reporting to the State Survey agency within specified timeframes depending on the severity of the event. Multiple staff members, including a therapy aide and the Social Services Director (SSD), became aware of the incident through direct reports from the resident and discussions among staff. The SSD reported the incident to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), but the ADON did not relay the information to the Administrator until much later. The DON was not aware of the incident until interviewed by surveyors. The delay in reporting the allegation to the appropriate authorities constituted a failure to follow the facility's abuse reporting policy.
Failure to Develop Disease-Specific Care Plan for Resident with Huntington's Disease
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident diagnosed with Huntington's disease, traumatic subdural hemorrhage, and anxiety. The care plans in place addressed some behavioral symptoms, activities of daily living (ADLs), and communication challenges, but none were specific to the unique symptoms and care needs associated with Huntington's disease. The care plans lacked detailed interventions to address the resident's neurodegenerative condition, including the progressive cognitive decline, mood disturbances, and involuntary movements characteristic of Huntington's disease. Observations, interviews, and record reviews revealed that staff were not adequately informed or trained about Huntington's disease and its impact on the resident. Multiple staff members, including a Certified Medication Technician and housekeeping staff, expressed fear of the resident and admitted to not knowing what Huntington's disease was or how to approach or communicate with the resident. The resident reported that staff did not listen or understand that certain behaviors, such as spilling things, were due to the disease and not intentional actions. Family members and staff interviews further indicated that the lack of disease-specific care planning led to misunderstandings and inadequate care. Family observed that staff did not communicate effectively with the resident, often entering the room without explanation or knocking, and misinterpreted the resident's behaviors as intentional aggression rather than symptoms of the disease. The Registered Nurse responsible for care planning acknowledged the absence of a care plan specific to Huntington's disease, and the Administrator confirmed the expectation that such plans should be in place to guide staff and ensure appropriate care.
Verbal Abuse of Resident by Certified Medication Technician
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) verbally abused a resident by yelling, cussing, and using vulgar language, including telling the resident to "shut the F up" and calling the resident derogatory names. The incident took place when the resident, who had a history of dementia with behavioral disturbances, generalized anxiety disorder, Alzheimer's disease, and cerebral infarction, refused care. The resident was described as having moderately impaired cognitive skills, frequent care refusals, and requiring significant assistance with activities of daily living. Multiple sources, including the resident, another resident, a visitor, and a licensed practical nurse (LPN), confirmed that the CMT yelled and used inappropriate language toward the resident. The resident reported feeling shocked and scared by the CMT's behavior. Witnesses described the CMT as becoming frustrated and using the F word while providing care, and a visitor observed the CMT screaming and cussing at the resident in the hallway. The CMT admitted during an interview to verbally abusing the resident after being yelled at and having care refused. The CMT acknowledged that this was the first time encountering such behavior from a resident and admitted to responding inappropriately. The facility's abuse policy explicitly prohibits any form of abuse, including verbal or mental, and requires that residents be protected from such treatment.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A resident with a history of schizophrenia, bipolar disorder, Alzheimer's disease, and vascular dementia, who was assessed as being at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. The resident was ambulatory with a wheelchair, had a severely impaired cognition, and had recently exhibited aggressive behavior, resulting in an order for 15-minute checks. However, staff failed to complete and document the required 15-minute checks during the relevant time period. The door alarm intended to alert staff to unauthorized exits was not loud enough to be heard until staff were already partway down the hall, as confirmed by multiple staff and resident interviews. Neither the resident's roommate nor another resident on the same hall heard the alarm, and staff only became aware of the resident's absence when a call light was noticed and the resident was found missing from their room. The resident's wheelchair was found by the exit door, and the alarm was only heard after staff began searching for the resident. The resident was later found outside the facility by a local citizen, having sustained multiple serious injuries including facial fractures and a subdural hemorrhage. The timeline and interviews indicate that the lack of timely supervision, failure to perform required checks, and insufficient alarm volume contributed to the resident's unsupervised exit and subsequent injury.
Removal Plan
- Conduct an investigation and notify appropriate parties including the police.
- Provide in-service education for all facility staff including elopement policies, check policies and door monitoring policies.
- Complete elopement risk assessments for all residents.
- Update the elopement risk and code white procedure books with current risk assessments and code white procedures.
- Adjust alarmed, fire, exit door alarms to increase the volume of the alarm for staff to recognize the alarm promptly.
- Perform alarmed door audits and check audits and continue ongoing audits.
Misappropriation of Resident Funds by CNA
Penalty
Summary
A certified nurse aide (CNA) took a resident's government-issued debit card without the resident's knowledge or permission and used it to make unauthorized withdrawals and purchases. The resident, who was newly admitted, able to make themselves understood, had some difficulty making decisions, and was independent with activities of daily living, noticed discrepancies in their account balance. The resident reported the missing funds to the business office manager (BOM), who, with the resident's permission, set up an online account to review the transactions. The review revealed multiple unauthorized ATM withdrawals and payments for food delivery, utilities, and a cell phone provider, totaling $1,369.69 over several days. The resident denied giving anyone permission to use the debit card for these transactions, except for a previous instance where the CNA was allowed to purchase cigarettes and returned the card. Law enforcement was notified, and the resident identified the CNA as the individual using the card in ATM footage provided by the police. The CNA claimed to have received permission to use the card for some purchases, but the resident denied this. The incident was reported to the facility administrator, who confirmed the resident's ability to handle their own finances and that the resident had not authorized the transactions in question. The facility's policy required that residents be free from abuse, including misappropriation of property, and outlined procedures for investigating such incidents. The investigation included interviews with the resident, staff, and review of transaction records. The facility also confirmed that the CNA was suspended pending investigation, and the incident was reported to the appropriate authorities as required by policy.
Deficiencies in Kitchen Sanitation and Food Safety Protocols
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, leading to multiple deficiencies in food storage, preparation, and service. Observations revealed that open food items were not properly sealed, labeled, or dated, and various kitchen surfaces, including the stove, microwave, and cooler/freezer, were not clean. The kitchen floor, walls, and equipment such as the plate warmer and steam table were heavily soiled with food debris and grease. Additionally, the facility did not ensure that the temperature in one freezer was maintained at 0 degrees Fahrenheit or below, with temperatures observed as high as 28 degrees Fahrenheit, causing ice to melt and pool inside the freezer. Staff failed to adhere to proper handwashing and glove use protocols during meal preparation and service. Dietary staff were observed handling food with gloved hands, then touching various surfaces and utensils without changing gloves or washing hands. This included handling ready-to-eat food, opening refrigerator doors, and touching meal cards and utensils, all while wearing the same pair of gloves. The facility's policies on handwashing and glove use were not followed, as staff did not wash hands between tasks or after disposing of trash and handling dirty dishes. The facility's three-compartment sink was not properly set up for dishwashing, as the sanitizer solution was unavailable, and the sink compartments did not hold water. Staff washed dishes in dirty water without rinsing or sanitizing them, and the floor drain overflowed with dirty water and food debris. The Dietary Manager was aware of these issues but had not effectively addressed them, and the Administrator was not informed about the sink drainage problem. The facility's failure to maintain a clean kitchen and adhere to food safety protocols resulted in significant deficiencies in food service operations.
Unsecured Hazardous Materials Found in Facility
Penalty
Summary
The facility failed to ensure that hazardous materials were secured and inaccessible to residents, as observed during a life safety code tour. Several hazardous items were found in unlocked cabinets throughout the facility, including six containers of chafing fuel, a bottle of nail polish remover labeled as extremely flammable, a commercial surface disinfectant, and two unlabeled spray bottles containing cleaning products. These items were located in areas accessible to residents, such as dining rooms and sitting areas, posing potential safety risks. Interviews with facility staff revealed a lack of awareness and oversight regarding the secure storage of these hazardous materials. The Maintenance Supervisor was unaware of the unsecured items and expected them to be properly secured and labeled. The Activities Director, who had only recently started working at the facility, was also unaware of the need to secure these items from resident access. This lack of awareness and failure to secure hazardous materials contributed to the deficiency identified during the survey.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as evidenced by multiple observations and interviews. Resident #135 did not receive oxygen therapy per physician's orders and lacked proper documentation for the use of a CPAP machine upon admission. The resident expressed frustration over the lack of assistance in setting up the CPAP machine, which was necessary for managing obstructive sleep apnea. Observations showed the resident using oxygen without a physician's order and the oxygen tubing was not labeled as required. Resident #136 also experienced inadequate respiratory care, as the BiPAP machine was not applied at night as ordered by the physician. The resident reported feeling more tired due to not using the BiPAP, which had been a part of their routine for years. Observations confirmed that the BiPAP machine was not in use, and interviews with staff revealed a lack of awareness and responsibility for ensuring the machine was applied correctly. Additionally, the facility failed to properly store and label respiratory equipment for other residents. Residents #3, #22, #43, and #42 had issues with unlabeled oxygen tubing and humidification bottles, as well as improperly stored nebulizer masks. Observations showed nebulizer equipment left uncovered and on the floor, contrary to the facility's policy. Interviews with the Director of Nursing and the Administrator highlighted expectations for staff to label and store equipment correctly, but these practices were not consistently followed.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at an appetizing temperature, as observed during a survey. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, and cold items to be placed over an ice bath. However, multiple residents reported dissatisfaction with the food, describing it as bland and cold. Observations revealed that the pasta salad was not prepared according to the recipe, as it was served at 85 degrees Fahrenheit without being placed over an ice bath. Additionally, the barbeque pork was served at 100 degrees Fahrenheit, below the required temperature, due to the steam table heating unit being turned off. Further observations showed that potatoes were served instead of the planned cornbread stuffing, without any seasoning, resulting in a bland taste. The potatoes were served at 110 degrees Fahrenheit, below the required temperature. Interviews with residents confirmed the lack of flavor in the potatoes. The Dietary Manager admitted that staff only took food temperatures at the beginning of the meal service, indicating a lack of ongoing monitoring to ensure food was served at the correct temperature throughout the meal service.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to ensure that staff offered nourishing evening snacks to residents who wished to have them, affecting nine residents out of a sample of 18, and potentially impacting the entire facility census of 82. The facility's policy required that bedtime snacks be offered to all residents, but interviews and record reviews revealed that this was not being consistently implemented. Several residents, including those with intact cognition and those with moderate cognitive impairment, expressed that they were not provided with bedtime snacks despite having physician orders for them. Some residents reported that snacks were only available at the nurse's station and were limited in quantity, leading to situations where not all residents could receive a snack. Interviews with staff, including a CNA, the Dietary Manager, the Director of Nursing, and the Administrator, highlighted a lack of awareness and communication regarding the policy to offer snacks to all residents. The CNA was unaware of the requirement to provide bedtime snacks, and the Dietary Manager described a process where snacks were prepared and taken to the nurse's station, but not directly offered to residents. The Director of Nursing and the Administrator both acknowledged that snacks should be offered to all residents, but were not aware that this was not happening. This deficiency indicates a breakdown in the implementation of the facility's policy on providing snacks, resulting in residents not receiving the nourishment they desired and were entitled to.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use among nursing staff during the provision of care for several residents. Observations revealed that staff members did not wash their hands or change gloves appropriately when moving from dirty to clean tasks. For instance, a CNA was observed providing incontinence care to a resident without washing hands or changing gloves before touching clean items and assisting the resident with a drink. Similar lapses were noted with other residents, where staff did not change gloves or wash hands between tasks, leading to potential cross-contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. The resident's care plan did not identify the need for EBP, and staff were observed not wearing gowns when providing care, despite the presence of PPE on the resident's room door. Interviews with staff indicated a lack of awareness regarding the purpose of the PPE and the requirements for EBP, leading to non-compliance with infection control guidelines. The facility also failed to complete Tuberculin Skin Testing (TST) for three employees as part of their pre-employment procedures. Employee files showed missing documentation for the second-step TST, and in one case, no documentation of the first-step TST. The Director of Nursing acknowledged the oversight, attributing it to the departure of the Staffing Coordinator responsible for employee TB testing. This lapse in protocol could potentially compromise the health and safety of both staff and residents.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to provide pneumococcal vaccinations according to CDC guidelines for five residents out of a sample of 18. The facility's policy required physician consultation and orders for vaccinations, as well as informed consent from residents or their responsible parties. However, the facility did not document the administration of the PCV20 vaccine for several residents who had consented to receive it, nor did they document any clinical decision-making or refusal by the residents or their representatives. Resident #23 had received previous pneumococcal vaccinations but had not been administered the PCV20 vaccine despite consenting to it. The resident's POA confirmed that the updated pneumonia vaccine was not offered. Similarly, Resident #78 had received the PPSV23 vaccine but was not offered the PCV15 or PCV20 vaccine, and the resident's POA expressed a desire for the updated vaccine. Resident #3, who had intact cognition, believed their vaccines were up to date, but there was no evidence of receiving any pneumococcal vaccines after admission. Residents #19 and #45 had both consented to receive the pneumococcal vaccination, but their medical records showed no documentation of the vaccine being administered. Interviews with the DON and ADON revealed that the facility was aware of the issue and that the ADON was responsible for ensuring vaccinations were up to date. However, the necessary follow-up actions to administer the vaccines were not completed, leading to the deficiency.
Failure to Accommodate Resident's Needs for Oxygen and Mobility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident #135, who required portable oxygen and a wheelchair for mobility due to shortness of breath and a history of falls. Despite the resident's requests and medical conditions, staff did not provide the necessary equipment, leading to the resident feeling confined to their room. The resident attempted to walk to the dining room without assistance or oxygen, resulting in dizziness and shortness of breath. The resident's care plan and assessments did not adequately address their need for a wheelchair, portable oxygen, or the use of a cardiac monitor for their pacemaker. Staff, including a Certified Medication Technician, a Certified Nursing Assistant, and an agency Licensed Practical Nurse, were unaware of the resident's needs for these accommodations. The Director of Therapy Services was informed about the need for a wheelchair but did not evaluate the resident, and the Director of Nursing was unfamiliar with the resident's needs due to being off during the admission. Observations confirmed the absence of a portable oxygen tank and wheelchair in the resident's room, and the resident was seen without supplemental oxygen or mobility aids in the dining room. The facility lacked a policy for accommodating resident needs, contributing to the oversight in providing necessary equipment and support for Resident #135.
Failure to Prepare Pureed Food to Required Consistency
Penalty
Summary
The facility failed to prepare pureed food items according to the required smooth consistency for a resident on a pureed diet. Observations revealed that the pureed chicken and carrots served to the resident contained visible chunks, indicating that the food was not processed to the appropriate consistency. Additionally, the pureed barbeque pork was stringy with visible pieces of pulled pork, and the pureed pasta salad and three-bean salad contained chunks of pasta and beans, respectively. These observations were inconsistent with the facility's policy and recipes, which specified that pureed foods should be processed until smooth. Interviews with the Dietary Manager and the Speech Therapist confirmed that pureed food should be the consistency of baby food or applesauce, without any chunks or the need for chewing. However, the pureed roast turkey served during a test tray observation was thick and required chewing, resembling ground turkey rather than a smooth puree. The facility's failure to adhere to the pureed food preparation guidelines resulted in the resident receiving meals that did not meet their dietary needs.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that staff provided necessary care and services to maintain good personal hygiene for two residents who were unable to complete their own activities of daily living (ADL). Specifically, staff did not assist with nail care and grooming, including shaving, for these residents. This deficiency was identified through observation, interview, and record review during the survey, which included a sample of nine residents out of a facility census of 82.
Failure to Apply Hand Splints and Palm Protectors
Penalty
Summary
The facility failed to provide appropriate care for a resident with hand contractures by not applying hand splints and palm protectors as directed by Occupational Therapy. This deficiency was identified through observation, interview, and record review. The resident, who was part of a sample of nine residents, required these devices to support and protect injured tissues and to prevent further deformity. The facility's census at the time was 82.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to prevent sexual abuse between two residents whose capacity to consent to sexual activity had not been determined. Resident #1, who was severely cognitively impaired with diagnoses including Alzheimer's disease, dementia, herpes viral infection, and HIV, was found engaging in sexual intercourse with Resident #2, who had vascular dementia and depression. The incident occurred despite Resident #2 expressing fear and unwillingness to be around Resident #1 after the event. The facility's abuse prohibition protocol and policy on resident sexual expression were not effectively implemented, as there was no documentation of interventions regarding the residents' capacity to consent to a sexual relationship. Prior to the incident, staff observed interactions between the two residents, such as holding hands and being in each other's rooms, but these observations were not adequately reported or addressed. Certified Nurse Aide C and the Maintenance Director both witnessed the residents together in situations that should have prompted further investigation and intervention. However, these observations were not communicated to the Director of Nursing or the Administrator, and no measures were taken to assess the residents' capacity to consent or to prevent inappropriate contact. The facility's failure to monitor and report the interactions between the residents led to the incident of sexual abuse. The primary care physician confirmed that neither resident had the cognitive ability to consent to sexual activity, highlighting a significant oversight in the facility's responsibility to protect its residents. The lack of communication and appropriate action by the staff contributed to the deficiency, as the facility did not ensure a safe environment for the residents involved.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for two residents who were unable to complete these tasks independently. Resident #1, who was cognitively intact but dependent on staff for all ADLs due to quadriplegia and severely impaired vision, did not receive regular grooming and hygiene care. The resident's shower records indicated infrequent showers, with significant gaps between them, and observations showed long, dirty fingernails with debris, dry skin, and a foul odor. The resident expressed dissatisfaction with the lack of care, stating that the long nails caused pain and the lack of shaving led to discomfort. Resident #5, also cognitively intact and dependent on staff for personal hygiene, experienced similar neglect. The resident's care plan indicated a preference for weekly showers, but records showed only one shower in June 2024. Observations noted a strong body odor and flaky, dry skin. The resident reported going without a bath for up to two weeks and expressed a desire for more frequent bathing, stating that staff did not return to assist after initial refusals due to feeling unwell. Interviews with facility staff, including CNAs and the Director of Nursing, revealed systemic issues contributing to the deficiencies. Staff acknowledged difficulties in trimming nails and shaving due to time constraints and the absence of a full-time shower aide on the residents' hall. The Director of Nursing and the Administrator both stated expectations for regular showers and grooming, but acknowledged that staffing changes and inadequate follow-up on refusals may have led to missed care opportunities.
Failure to Apply Hand Splints and Palm Protectors
Penalty
Summary
The facility failed to provide appropriate care for a resident with hand contractures by not applying hand splints and palm protectors as directed by occupational therapy. The resident, who had diagnoses including quadriplegia and contractures of both hands, was dependent on staff for all activities of daily living. Despite therapy instructions and training provided to staff, there was no documentation in the medical record indicating that the splints were applied, nor was there any record of the resident refusing them. Observations over two days showed that the resident did not have palm protectors or splints in place, and their hands were in poor condition, with long, uneven fingernails and patches of dry skin. Interviews with the resident and their family member revealed that the resident experienced pain due to the lack of splints and palm protectors, and the family member confirmed that the resident never had these devices in place during visits. Staff interviews indicated a lack of clarity and consistency in applying the splints and palm protectors, with some staff unsure of the procedures or the location of the devices. The Rehab Director and Director of Nursing acknowledged the issue, noting that staff were not following through with the application of splints and palm protectors as instructed. The Rehab Director suggested that the CNAs were too rushed and did not take the time to properly stretch the resident's hands, leading to pain. The Director of Nursing admitted that new staff might not have been adequately educated on the use of special devices, resulting in the oversight. The Administrator expected that the restorative aide would ensure the application of these devices, but this was not happening consistently.
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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