Life Care Center Of Bridgeton
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeton, Missouri.
- Location
- 12145 Bridgeton Square Dr, Bridgeton, Missouri 63044
- CMS Provider Number
- 265345
- Inspections on file
- 26
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Life Care Center Of Bridgeton during CMS and state inspections, most recent first.
A resident, who was cognitively intact and able to communicate, informed a CNA that another CNA had been physically abusive by twisting the resident's arm. The CNA did not observe any bruising and, doubting the claim, failed to report the allegation to supervisory staff as required by facility policy. This resulted in a delay in the facility's response and allowed the accused CNA to continue working until the administration was eventually notified.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, as required by their care plan.
Two residents at risk for falls did not consistently have fall mats in place or their beds maintained in the lowest position when unattended, despite documented fall risk and facility policy. One resident's care plan did not initially include these interventions, and observations showed repeated lapses in implementing fall prevention measures. Staff interviews confirmed these interventions were expected but not always followed.
The facility did not designate a qualified director for food and nutrition services when a full-time consultant RD was not employed. The Dietary Director had the necessary qualifications but lacked documentation, and their certifications had expired, as confirmed by the Executive Director.
Facility staff failed to treat residents with dignity and respect, as evidenced by incidents where personal items were removed without permission, unprofessional communication occurred, and a CNA used a cell phone during meal assistance. These actions affected residents with varying cognitive and physical impairments, leading to distress and unmet care needs.
The facility failed to follow general accounting principles by not investigating outstanding checks during monthly resident trust fund reconciliations. The policy lacked guidance for follow-up on such checks, and staff were unaware of the need for routine follow-up. Outstanding checks dating back to 2020 were identified, with amounts ranging from $10.00 to $1,500.18.
A resident with quadriplegia and multiple sclerosis was not provided with an accessible call light adapted to their needs, as the push button call light was found on the floor and inaccessible. The resident's care plan did not document the need for a specialized call light, and staff were unaware of the resident's existing breath-activated call light, which was not in use. The facility's leadership acknowledged the oversight and emphasized the importance of ensuring all residents have access to a usable call light.
A resident with a complex medical history developed an elevated temperature, but the LPN on duty failed to document the temperature or notify the physician, contrary to facility policy. The resident was later diagnosed with sepsis and pneumonia after being sent to the hospital the next day. The DON confirmed the LPN should have documented and communicated the change in condition.
A resident in an LTC facility did not receive adequate ADL care, including hair washing, shaving, and foot care. The resident reported infrequent bed baths and unaddressed foot issues, with observations confirming poor hygiene and foot conditions. Staff interviews revealed a lack of communication and documentation, leading to unmet care needs.
A facility failed to obtain necessary labs and document a resident's change in condition, leading to inadequate care and communication between shifts. Another resident, dependent on feeding assistance, was not positioned correctly during meals, and staff used straws against physician orders, increasing aspiration risk.
A facility failed to provide proper pressure ulcer care and prevention for a resident with dermatitis on the coccyx/sacrum area. The resident had an open area that was not identified by staff, and no treatment order was obtained. The family applied Desitin and A&D ointment without a physician's order, and the facility did not ensure ongoing assessments or treatment orders. The open area was later identified as a stage 2 pressure ulcer.
A resident with anxiety and other medical conditions did not receive necessary behavioral health care in a LTC facility. The resident frequently expressed anxiety and dissatisfaction with care, including concerns about personal belongings being removed without permission and prolonged wait times for assistance. Despite recommendations for counseling services, these were delayed, and the resident's spiritual needs were not addressed. Staff responses to the resident's requests were inconsistent, contributing to the deficiency in care.
Facility staff failed to manage medications properly, leading to expired and improperly stored medications in two medication carts. Observations revealed expired Rena Vite tablets, undated bacitracin/polyophthalmic eye ointment, and improperly stored insulin pens. The LPN Coordinator confirmed the need for proper dating and storage, while the Administrator and DON expected adherence to policies.
The facility failed to maintain proper hand hygiene and food safety standards during meal service, affecting three residents. Staff were observed not sanitizing hands between tasks and using unsanitary methods to handle and serve food. Interviews confirmed these practices were against the facility's policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds, gastrostomy tubes, or tracheostomies. EBP signs were not consistently posted, and PPE was not always used by staff or family members during care. Interviews confirmed that EBP signs should be posted, and PPE should be used for residents meeting EBP criteria, but staff did not consistently follow procedures.
A resident with severe cognitive impairment eloped from a facility through an unsecured kitchen door, which was not locked or armed. The resident, who required substantial assistance for mobility, was found outside on the premises. Staff interviews revealed the door alarm may have been disabled from a previous delivery, and the dietary aide did not respond to the door click, assuming it was another employee.
A facility failed to uphold a resident's right to receive visitors by restricting a relative due to alleged erratic behavior without providing alternative visitation methods. The resident, who was cognitively intact but physically impaired, expressed a desire to see the relative. The facility did not document the restriction process or communicate it to the resident, despite acknowledging the need for such actions.
The facility failed to prevent abuse and neglect by continuing to employ a CNA listed on the Employee Disqualification List (EDL) for over three years. The CNA was hired before being added to the EDL and remained employed until the facility discovered the disqualification. The Administrator and AP/Payroll Coordinator were unaware of the need for routine post-hire background checks, leading to non-compliance with the facility's zero-tolerance policy on abuse and neglect.
Failure to Report Resident's Abuse Allegation as Required by Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the facility's abuse and neglect policy after a resident reported an allegation of physical abuse by another CNA. The resident, who was cognitively intact and able to communicate clearly, informed CNA K that CNA P had been mean and twisted the resident's right arm tightly, allegedly leaving a bruise. CNA K did not observe any visible bruising and, based on personal judgment and prior experience with CNA P, chose not to report the allegation to the charge nurse or any supervisory staff. The facility's policies require immediate reporting and investigation of any abuse allegations, regardless of the staff member's belief in the validity of the claim. However, CNA K disregarded this protocol, resulting in a delay in the facility's awareness and response to the alleged incident. During this period, CNA P continued to work and had access to residents, as the administration was not notified until later, at which point CNA P was suspended pending investigation. Interviews with other staff, including the LPN and the Administrator, confirmed that they were not made aware of the resident's allegation at the time it was reported to CNA K. The resident's care plan noted a history of being resistive to care and making false assumptions, but the facility's policy still required all allegations to be reported and investigated. The failure to report the allegation as required by policy constituted the deficiency identified by surveyors.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident’s preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as specified, but the report does not provide further details about the resident’s medical history, condition, or the specific nature of the care that was omitted or incorrectly provided.
Failure to Maintain Fall Prevention Interventions for Residents at Risk
Penalty
Summary
The facility failed to ensure that two residents at risk for falls had appropriate fall prevention interventions in place, specifically the use of fall mats and maintaining beds in the lowest possible position when residents were in bed and unattended. For one resident with a history of falls, moderate cognitive impairment, and significant physical assistance needs, observations revealed that fall mats were not consistently placed on the floor as required, and the bed was not always kept in the lowest position. The resident confirmed experiencing two falls since admission, one from the bed, and noted that the fall mats were only sometimes in place. Staff interviews corroborated that the mats should have been on the floor and the bed in the lowest position whenever the resident was unattended, but this was not consistently done. Additionally, the care plan for this resident did not initially include specific interventions such as the use of fall mats and keeping the bed in the lowest position, despite the resident's documented fall risk and previous falls. Progress notes indicated that after the resident's fall, staff documented the use of fall mats and bed positioning, but these interventions were not reflected in the care plan until after the deficiency was identified. Observations on multiple occasions showed the fall mats leaning against the wall and the bed elevated above the lowest setting while the resident was unattended. A second resident, also at risk for falls due to severe cognitive impairment and requiring substantial assistance, was observed with fall mats in place but with the bed not consistently maintained in the lowest position when unattended. Staff interviews confirmed the expectation that the bed should be kept in the lowest position for residents with fall mats, but this was not always followed. The care plan for this resident did include the use of fall mats and low bed positioning, but observations showed lapses in maintaining the bed at the lowest height. These failures were contrary to the facility's fall management policy and federal regulations requiring the environment to be free from accident hazards and for residents to receive adequate supervision and assistive devices to prevent accidents.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, as required when a consultant Registered Dietician (RD) was not employed full-time. The facility's dietary manager job description mandates completion of an approved Certified Dietary Manager course and maintenance of active certification. During an interview, the Dietary Director confirmed having the necessary qualifications but lacked a physical copy of the documentation. Further, the Executive Director acknowledged that the Dietary Director's required certifications had expired, indicating a lapse in maintaining the necessary credentials for the role.
Dignity and Respect Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to treat residents with dignity and respect, as evidenced by several incidents involving multiple residents. One resident, who is cognitively intact and dependent on staff for showers, reported that personal items were removed from their room without permission while they were receiving a shower. This resident expressed anxiety and distress over the repeated removal of items, which had occurred multiple times over the past six months. Staff admitted to removing soiled linens and clothing without the resident's consent, citing the resident's hoarding behavior as a reason for discreetly removing items. In another incident, staff spoke to residents in an unprofessional manner. A resident who is cognitively intact and dependent on staff for toileting hygiene was told by a CNA that they should be happy to be alive, which was deemed inappropriate by other staff members. Additionally, a resident with moderate cognitive impairment and requiring maximum assistance for toilet hygiene was referred to as wearing a 'diaper' by a CNA, a term considered demeaning and inappropriate for adult residents. Furthermore, a resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease, was left unattended during meal time while a CNA used their personal cell phone. The CNA was observed texting on their phone instead of assisting the resident with their meal, which went untouched. This behavior was against the facility's cell phone policy, which prohibits cell phone use in resident care areas to ensure resident privacy and quality care.
Failure to Follow Up on Outstanding Resident Trust Fund Checks
Penalty
Summary
The facility failed to adhere to general accounting principles by not following up on outstanding checks during monthly resident trust fund (RTF) reconciliations. The facility managed funds for 35 residents, with a total census of 89. The facility's Resident Trust Policy and Procedures, last reviewed on June 15, 2022, did not include guidance for follow-up on outstanding checks. A review of the facility's monthly RTF reconciliations from February 2024 through January 2025 revealed several outstanding checks dating back to September 2020, with amounts ranging from $10.00 to $1,500.18. Interviews with facility staff revealed a lack of awareness regarding the need to investigate outstanding checks. The Assistant Business Office Manager stated that she reconciles the RTF monthly and submits the reconciliations to the corporate office but was unaware of the need to follow up on outstanding checks. Similarly, the Regional Business Office Manager was not aware of the requirement for routine follow-up on these checks. The Executive Director expressed an expectation that general accounting principles should be followed by both the facility and the corporate business office.
Failure to Provide Accessible Call Light for Resident with Mobility Impairments
Penalty
Summary
The facility failed to accommodate the needs of a resident with significant mobility impairments, including quadriplegia and multiple sclerosis, by not providing an accessible call light adapted to the resident's needs. The resident was observed multiple times in bed with a push button call light on the floor behind the head of the bed, which was inaccessible due to the resident's inability to move his or her arms or legs. Interviews with the resident confirmed the lack of a usable call light, and staff were unaware of the resident's need for a specialized call light, such as a touchpad or breath-activated call light. The resident's care plan did not document the need for a specialized call light, and staff, including the Therapy Director and CNAs, were not aware of the resident's existing breath-activated call light, which was found coated with dust and not in use. The resident's family had previously opted against the breath-activated call light, and this decision was not documented in the medical record. The Director of Nurses and Executive Director acknowledged the oversight, emphasizing the expectation that all residents should have access to a call light they can use, and that such needs should be documented in the care plan.
Failure to Notify Physician of Elevated Temperature
Penalty
Summary
The facility failed to notify a resident's physician after the resident developed an elevated temperature during the evening shift. The resident, who had a complex medical history including a tracheostomy, was later diagnosed with sepsis and pneumonia after being sent to the hospital the following morning. The facility's policy required immediate notification of the physician in such cases, but this was not adhered to. The Licensed Practical Nurse (LPN) on duty during the evening shift assessed the resident and noted an elevated temperature of 101°F. Despite this, the LPN did not document the temperature or the administration of Tylenol, nor did they notify the physician. The LPN was unsure of the exact temperature threshold for notifying the physician and was waiting for lab results, which contributed to the delay in communication. The Director of Nursing (DON) confirmed that the LPN should have documented the temperature and the administration of Tylenol, as well as contacted the physician. The resident's physician stated that had they been informed of the elevated temperature, they would have likely sent the resident to the hospital immediately, given the resident's complex condition. The lack of timely communication and documentation led to a delay in appropriate medical intervention for the resident.
Failure to Provide Adequate ADL and Foot Care
Penalty
Summary
The facility failed to meet the Activities of Daily Living (ADL) care needs for a resident, identified as Resident #29, who was observed to have unclean hair, unshaved facial hair, and a body that was not clean and free from odors. The resident reported receiving only two bed baths a week, with staff not consistently washing their hair. The resident also mentioned spilling their urinal on themselves, contributing to a musky odor. Observations confirmed the resident's hair was oily and stringy, and there was a dark amber film on their skin, indicating inadequate hygiene care. Additionally, the facility did not provide necessary foot care for the resident, who had large chunks of dry skin, cracked skin, and thick, jagged toenails. The resident's feet were discolored, and they had not seen a podiatrist since arriving at the facility, despite expressing a desire for toenail care and dry skin treatment. The facility's foot care policy requires consistent care and documentation of any abnormal findings, which was not adhered to in this case. Interviews with facility staff, including CNAs, the Infection Preventionist, and the Director of Nursing, revealed expectations for regular hygiene care, including hair washing, shaving, and foot care, which were not met. The Social Services Director, responsible for scheduling podiatrist visits, was unaware of the resident's need for such care. The lack of communication and documentation contributed to the deficiency in providing adequate ADL and foot care for the resident.
Failure to Obtain Labs and Provide Proper Feeding Assistance
Penalty
Summary
The facility failed to obtain necessary laboratory tests and document a thorough assessment following a change in condition for a resident with a history of congestive heart failure and chronic respiratory failure. The resident was supposed to have a basic metabolic panel (BMP) drawn on a specific date, but the lab company missed the draw, and the test was not rescheduled before the resident's condition deteriorated. Additionally, there was a lack of documentation regarding the resident's change in condition, including vital signs and assessments, and inadequate communication between shifts about the resident's status. The resident experienced a significant change in condition, including shaking, rapid breathing, and low oxygen saturation levels. Despite these symptoms, there was no documentation of a discussion with the physician regarding a STAT chest x-ray ordered, and the resident's condition was not communicated effectively to the next shift. The resident's oxygen levels fluctuated, and the staff failed to monitor and adjust the oxygen as needed, leading to the resident's eventual expiration without appropriate intervention. Another resident, who was dependent on assistance for eating and had a history of dysphagia, was not provided feeding assistance in accordance with physician orders. The resident was observed being fed while not positioned at the recommended 90-degree angle, and staff used straws despite orders against it due to aspiration risk. The facility's staff did not follow the prescribed feeding precautions, and there was a lack of communication and understanding among staff regarding the resident's specific needs and orders.
Failure to Provide Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident with a history of dermatitis on the coccyx/sacrum area. The resident was observed to have an open area on the morning of February 24, 2025, which was not identified by staff, and the physician was not notified until the following day. The facility's policy required weekly skin assessments by a licensed nurse and immediate reporting of any changes or open areas to the nurse, which did not occur in this case. The resident's care plan indicated a risk of pressure ulcers, but there was no treatment order for the dermatitis or the open area on the resident's buttocks/sacrum/coccyx. The resident's family was applying Desitin and A&D ointment without a physician's order, and the facility staff failed to obtain a treatment order for these applications. The resident's TAR for February showed no treatment orders for the affected area, and the facility's computer system did not prompt nurses to apply treatment without an order. Interviews with facility staff revealed that the area on the resident's coccyx had been red and excoriated for an extended period, and the family had requested the use of Desitin. However, the facility did not contact the physician to obtain an order for Desitin. The DON confirmed that there should have been ongoing assessments and a treatment order on the TAR. The open area was later identified as a stage 2 pressure ulcer, and the facility's failure to follow its policies and procedures contributed to the deficiency.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with anxiety, cognitive communication deficit, and other medical conditions. The resident frequently expressed anxiety and dissatisfaction with the care provided, including concerns about personal belongings being removed without permission, prolonged wait times for care, and lack of communication about daily care routines. Despite the resident's expressed need for counseling services, these were not arranged, and the facility's grievance log showed no grievances filed by the resident, indicating a lack of formal documentation of the resident's concerns. Observations and interviews revealed that the resident often used the call light for assistance, but staff responses were inconsistent, with some staff members ignoring the resident's requests or responding inappropriately. The resident reported feeling anxious and neglected, particularly when staff removed items from the room without consent or failed to inform the resident about care schedules. The resident's spiritual needs were also not adequately addressed, as no chaplain services were offered despite the resident's expressed Christian values. Interviews with staff, including CNAs, LPNs, and the SSD, highlighted a lack of coordinated behavioral management and communication regarding the resident's care needs. The Psychiatry NP had recommended counseling services for the resident, but these were delayed due to corporate processes. The facility's administration acknowledged the resident's frequent calls and anxiety but did not consistently document or address the resident's behavioral health needs, contributing to the deficiency in care.
Medication Management Deficiencies in Facility
Penalty
Summary
Facility staff failed to properly manage and store medications, leading to several deficiencies in medication handling. During an observation of the South 1 medication cart, it was found that an opened stock bottle of Rena Vite tablets had expired, and a tube of bacitracin/polyophthalmic eye ointment lacked an opening date, making it impossible to determine when it should be discarded. Additionally, a bottle of liquid docusate sodium had no expiration date, and a bottle of folic acid was expired. An unopened glargine insulin pen was improperly stored in the medication cart instead of the refrigerator. Similarly, the South 2 medication cart contained an opened bottle of prednisolone AC 1% ophthalmic eye drops without an opening date, and an unopened aspart insulin pen was not stored in the refrigerator. A stock bottle of boric acid vaginal suppositories also lacked an expiration date. The LPN Coordinator confirmed that medications without expiration dates or those that were expired should be removed from the cart. The facility's Administrator and Director of Nurses expected adherence to policies regarding medication storage and expiration management.
Failure in Hand Hygiene and Food Safety Standards
Penalty
Summary
The facility failed to ensure proper hand hygiene and food safety standards during meal service, affecting three residents. Observations revealed that a Restorative Aide (RA) and a Certified Nurses Aide (CNA) did not perform hand hygiene before and after resident contact or after touching objects and surfaces in the dining room. The RA was observed handling a resident's wheelchair and feeding utensils without sanitizing hands, while the CNA was seen using a mobile phone, touching personal items, and then handling residents' food and utensils without washing hands. The report highlights specific instances where the CNA engaged in unsanitary practices, such as texting on a phone, wiping their forehead, and then handling residents' food and drinks without sanitizing hands. The CNA also blew on residents' food to cool it down and used ungloved hands to pick up food and feed residents, which is against professional food safety standards. These actions were observed during lunch service in the main dining room, affecting residents with severe cognitive impairments and other medical conditions such as dementia, diabetes, and muscle weakness. Interviews with staff, including another CNA, the Dietary Director, and the Executive Director, confirmed that the observed practices were inappropriate and not in line with the facility's hand hygiene policy. The staff acknowledged that hand hygiene should be performed before entering the dining room, after touching residents or objects, and between assisting different residents. They also confirmed that it is not appropriate to blow on food or use hands to handle food directly, as these actions pose a risk of contamination.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS for three residents with wounds, gastrostomy tubes, or tracheostomies. The facility's EBP policy mandates the use of gowns and gloves during high-contact resident care activities for residents with MDROs, wounds, or indwelling medical devices. However, observations revealed that EBP signs were not consistently posted on residents' doors, and personal protective equipment (PPE) was not always used by staff or family members during care. Resident #26, who has a tracheostomy tube and a g-tube, was observed without an EBP sign on the door, and the family member providing care did not wear a gown. The family member was not educated about the EBP policy, and the waste can for PPE disposal was not placed near the exit as required. Similarly, Resident #29, with leg wounds, did not have an EBP sign on the door, and staff entered the room and provided care without wearing gowns. Resident #45, who has a g-tube, had an EBP sign posted, but staff did not wear gowns during care, exposing the resident's abdomen and g-tube. Interviews with the facility's Infection Preventionist, Administrator, and Director of Nursing confirmed that EBP signs should be posted, and PPE should be used for residents meeting EBP criteria. However, there was a lack of documentation showing that family members were educated on the EBP policy, and staff did not consistently follow the facility's EBP procedures, leading to the deficiency.
Resident Elopement Due to Unsecured Kitchen Door
Penalty
Summary
The facility failed to ensure that a kitchen exit door was locked and armed, leading to the elopement of a resident. The incident occurred during the early morning hours when a resident, who was not initially assessed as an elopement risk, left the facility through the kitchen door. The resident was found approximately 30 feet from the exit door on the facility's premises. The kitchen door was not locked and armed, which allowed the resident to exit the building unnoticed by staff. The resident involved in the incident had severe cognitive impairment and required substantial assistance for mobility, using a walker and wheelchair. Despite these needs, the resident managed to leave the facility without supervision. The resident's care plan had been updated to reflect a risk for elopement due to disorientation and impaired safety awareness, but the elopement assessment conducted upon admission did not identify the resident as an elopement risk. Interviews with staff revealed that the kitchen door alarm may have been disabled from a previous delivery, and staff did not hear or respond to the door alarm when the resident exited. The dietary aide working at the time heard the door click but did not investigate further, assuming it was another employee. The facility's investigation determined that the resident had walked down the hall and exited through the kitchen door, which was not secured, leading to the resident being found outside in cold weather conditions.
Facility Fails to Uphold Resident's Visitation Rights
Penalty
Summary
The facility failed to uphold a resident's right to receive visitors of their choosing, as outlined in their policy and federal regulations. The deficiency occurred when the facility restricted a resident's relative from visiting due to allegations of unruly and erratic behavior. Despite the facility's policy requiring immediate access for family members and the provision of alternative visitation methods, such as video teleconferencing, no such accommodations were documented or offered to the resident. The resident in question was cognitively intact but had significant physical impairments, including total dependence on staff for mobility and personal care, and suffered from conditions such as expressive aphasia, stroke, and depression. The facility's records did not document any incidents of aggression by the relative towards staff, nor did they provide any court orders justifying the restriction. The resident expressed a desire to see the relative, indicating sadness over the lack of visits. Interviews with facility staff revealed that the relative was barred due to a history of stalking behavior and an incident where they were found under another resident's bed. However, the facility did not document the process of barring the relative or communicate this to the resident. The facility's leadership acknowledged the need for proper documentation and communication regarding such restrictions, but these actions were not taken in this case.
Failure to Implement Routine Background Checks
Penalty
Summary
The facility failed to develop and implement policies and procedures to prevent abuse, neglect, and misappropriation of resident property by continuing to employ a Certified Nurse Aide (CNA) who was listed on the Employee Disqualification List (EDL). The CNA was hired on 12/17/14 and was added to the EDL on 8/13/20, indicating ineligibility to work in a certified long-term care facility. Despite this, the CNA remained employed until 1/12/24, when the facility discovered the CNA's disqualification and terminated their employment. The facility's failure to conduct routine post-hire background checks allowed the CNA to work for over three years while being ineligible, compromising resident safety and welfare. The Administrator and AP/Payroll Coordinator were unaware of the requirement to perform routine background checks post-hire. The Administrator was notified of the deficiency on 1/12/24 and subsequently removed the CNA from the schedule. An audit of all current employees' background checks was completed, revealing the oversight. The facility's policy, reviewed on 11/27/23, emphasized a zero-tolerance approach to abuse and neglect, yet the lack of routine screenings led to non-compliance with these standards. The deficiency was identified during an interview and record review conducted on 2/20/24.
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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