Life Care Center Of St Louis
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 3520 Chouteau Ave, Saint Louis, Missouri 63103
- CMS Provider Number
- 265610
- Inspections on file
- 18
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Life Care Center Of St Louis during CMS and state inspections, most recent first.
A resident with renal insufficiency, ESRD, obstructive uropathy, an indwelling catheter, and a left nephrostomy tube was admitted with hospital orders directing that the nephrostomy tube remain clamped and the dressing be changed every 24–48 hours and when soiled. Although these instructions appeared on transfer paperwork and in an early provider progress note, they were not timely transcribed onto the physician order sheet; only an order for nephrostomy output every shift was entered initially, and an order to keep the tube clamped was not added until weeks later, with no dressing-change order in place. During this time, documentation showed the nephrostomy tube draining to gravity with output recorded on multiple shifts, contrary to the clamping instructions. Interviews with nursing staff, the nurse manager, NP, and DON confirmed that the facility relied on the after-visit summary for orders, that nurses were responsible for entering and confirming provider orders, and that the clamping and dressing-change orders should have been placed at admission, but were not, resulting in services that did not meet professional standards of quality.
A resident with mild cognitive impairment, muscle weakness, cancer, and painful hidradenitis suppurativa required partial/moderate assistance with bathing and supervision for personal hygiene per MDS and care plan, which called for at least twice-weekly assisted bathing and personal hygiene support. Over several weeks, only a few showers or bed baths were documented, and repeated observations found the resident lying in bed with matted, unkempt hair and a persistent fecal odor in the room. The resident reported not receiving showers or bed baths since admission and not having hair washed, despite being unable to adequately clean themselves or wash their own hair. CNAs and an RN confirmed the resident needed assistance and that facility practice was to provide two showers weekly with hair care included, but one CNA relied strictly on the shower schedule and made a dismissive comment about the resident’s afro. Facility leadership acknowledged the resident should have been receiving at least two showers per week, including hair washing when requested, demonstrating a failure to follow the resident’s ADL care plan and hygiene needs.
A resident with a history of diabetes and heart failure fell from their bed and was ordered a stat x-ray for multiple areas. The x-ray was not completed for nine days, during which the resident experienced significant pain and refused care. Staff interviews revealed a lack of communication and follow-up regarding the x-ray orders, and the resident's physician was not informed of the delay. The mobile x-ray company attempted to contact the facility but received no response. The resident was eventually diagnosed with a possible fracture.
The facility failed to submit monthly transfer notifications to the Ombudsman since November 2022. The new Social Service Director and Administrator confirmed the lapse, with the last submission date unclear. A submission for April 2024 was made, and future submissions will be done monthly.
The facility failed to encode and transmit resident assessment data within 7 days after completing the assessments for 12 out of 19 residents investigated. The MDS Coordinator acknowledged being behind on assessments due to staffing shortages, leading to delays in completing and transmitting the MDS assessments as required by the RAI User's Manual.
The facility failed to complete quarterly resident assessments for nine residents, with the MDS Coordinator acknowledging delays due to staffing shortages. The assessments were either still in progress or needed to be signed off, affecting a significant portion of the resident population.
The facility failed to ensure that eight out of ten randomly selected CNAs received the required annual 12-hour resident care training. The absence of a Staff Development Coordinator led to a significant gap in tracking and completing the mandatory training hours, impacting the competency of the CNAs.
The facility failed to post the required daily nurse staffing information in a prominent place, with observations showing outdated or incomplete documentation of staffing details. The Administrator acknowledged the lapse, attributing it to the DON's absence.
The facility failed to follow infection control standards when an LPN did not change gloves or wash hands while administering G-tube medications, and a CNA left suction equipment uncovered. Additionally, the facility did not adhere to its TB testing policy for new hires, with incomplete documentation for eight employees.
The facility failed to complete a comprehensive resident assessment for a resident. The MDS Coordinator, who has been in the role for 5 years, acknowledged being behind on MDS assessments due to the facility being without a social worker for about a year and a half. As a result, the business office manager, director of rehab, and the MDS Coordinator herself have been filling the role, contributing to the delay in completing the assessments.
The facility failed to ensure that residents had complete, accurate, and individualized care plans. One resident's care plan lacked details on necrotizing fasciitis, discharge planning, and mental health concerns. Another resident's care plan missed focus on dietary status, difficulty swallowing, and PEG tube. A third resident's care plan was incomplete regarding dietary status, [NAME] tube, radiation treatments, and discharge planning.
The facility failed to ensure a safe discharge for a resident by not sending referrals to local contact agencies and orders for medical equipment in a timely manner. The resident, who had undergone significant surgical procedures, was discharged without the necessary support and equipment, leading to a potentially unsafe situation at home. Interviews revealed a lack of proper communication and documentation regarding the change in the discharge date.
The facility failed to provide necessary communication devices and ensure staff were knowledgeable about a deaf resident's communication needs. The resident's care plan included specific interventions, but these were not transferred to the Kardex, and staff lacked access to this information, leading to unmet needs.
A facility failed to provide timely wound care for a resident readmitted with chronic wounds. The resident's wounds were not fully assessed until several days after readmission, and treatment orders were delayed, contrary to the facility's policies. This resulted in inadequate care for the resident's wounds.
A resident missed a follow-up eye appointment due to the facility's failure to arrange transportation and reschedule the appointment. Staff interviews revealed a lack of communication and coordination regarding the resident's transportation needs.
A resident with diabetes did not receive their ordered routine insulin because an LPN decided to hold the medication without notifying the physician, contrary to the facility's medication administration policy. The ADON confirmed that the routine insulin should not have been held without physician notification.
The facility failed to ensure proper storage and labeling of medications and biologicals. Insulin pens in a medication cart were not labeled with the date they were removed from refrigeration, and ointments for two residents in a treatment cart were found with the caps off. Staff interviews confirmed non-compliance with storage policies.
The facility failed to ensure residents received care consistent with professional standards. One resident with vascular leg ulcers did not have treatments completed as per physician orders, and another resident with a blister on the right breast did not receive the prescribed treatment. Observations and interviews confirmed that treatments were not consistently documented or administered, and a systemic issue prevented weekly skin assessments from being completed.
The facility failed to ensure that two residents with pressure wounds received necessary treatments to promote healing. One resident's wound care was inconsistently documented, delaying their discharge, while another resident's existing skin issues were not properly managed, leading to worsening conditions. Interviews revealed systemic issues in documentation and execution of wound care.
Failure to Transcribe and Implement Nephrostomy Tube Orders per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards when a physician’s orders for a resident with complex renal conditions were not timely or accurately transcribed and implemented. The resident had moderately impaired cognition, an indwelling catheter, a left nephrostomy tube, and diagnoses including renal insufficiency, ESRD, and obstructive uropathy. Hospital transfer/after-visit orders specified that the left nephrostomy tube was to remain clamped and that the dressing was to be changed every 24–48 hours and when soiled, with instructions to contact the genitourinary provider if flank or back pain increased. These instructions were present on the transfer orders and reiterated in a physician progress note shortly after admission, which stated that the left nephrostomy tube should remain in place, be kept clamped, and have the dressing changed every 24–48 hours and when soiled. Despite these clear instructions, the physician order summary in use at the time of survey showed only an order for nephrostomy tube output every shift starting two days after admission, and did not include an order for dressing changes or for the tube to be clamped until several weeks later. Progress notes during the initial admission period documented that all orders were verified with the physician on the day of admission and that the nephrostomy tube was to remain in place until follow-up with urology, but there was no corresponding active order for clamping or dressing changes on the physician order sheet. Medication and treatment administration records showed that staff were documenting nephrostomy tube output on multiple shifts, which would not be expected if the tube had been clamped as ordered, and there were missed opportunities where output was not documented at all. Interviews with nursing staff and providers confirmed that the after-visit summary was the source for discharge orders and that nurses were responsible for entering and confirming orders in the electronic system. The nurse manager and NP stated that providers enter their own orders in the computer but nurses must confirm them, and that the general instructions and care of sites should be verified at admission. The NP and RNs interviewed stated that if the nephrostomy tube was properly clamped there would be no measurable output from the tube, and that the dressing should have been changed every 24–48 hours unless orders were changed during verification. Staff also reported that they did not routinely review provider notes unless told there were new orders, and that if a resident returned from an outside appointment without paperwork, the nurse would call the provider and document it. The DON stated that the resident’s orders were verified with the physician on admission, yet the clamping and dressing-change orders were not transcribed onto the physician order sheet in a timely manner, resulting in the nephrostomy tube draining to gravity instead of being clamped as ordered and the absence of a formal dressing-change order during the period reviewed.
Failure to Provide Required Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, to a resident who required help. Facility policy required that residents unable to perform ADLs receive needed assistance and that any change in ADL ability be reported to nursing, ensuring residents maintained good grooming and personal hygiene. The resident’s MDS documented mild cognitive impairment, no behaviors, and a need for partial/moderate assistance with showering/bathing and supervision or touching assistance with personal hygiene. The care plan in effect identified an ADL self-care performance deficit related to impaired balance, limited mobility, and pain, and directed staff to provide moderate assistance for bathing at least twice weekly and as necessary, along with personal assistance for hygiene. The resident’s diagnoses included hidradenitis suppurativa with painful boils on the buttocks and around the anus, muscle weakness, and cancer. The shower calendar showed only five showers or bed baths documented from admission through mid-January, despite the care plan requirement. During multiple observations over several days, the resident was repeatedly found lying in bed on their stomach with matted, unkempt hair and a persistent odor of bowel movement in the room. The resident reported significant pain from boils that leaked and caused odor and discomfort, stated they had not had a shower since admission, and consistently reported not being offered showers or bed baths, including after wound treatments when only the wound area was cleansed. Staff interviews confirmed that the resident needed assistance with showers or bed baths and that facility practice was to offer two showers per week. A CNA acknowledged the resident needed hair washed and treated and that staff were expected to offer two showers weekly. Another CNA, assigned to the resident, stated the resident was scheduled for showers on specific days and was not due for a shower on the day in question, and made a remark about the resident’s hair, saying the resident “has an afro” and questioning expectations, adding that if the resident wanted hair washed, they would wash it. An RN confirmed the resident needed assistance with showers and personal care and that hair care was part of shower or bed bath, but was unsure what was being done about the resident’s hair. Facility leadership stated the resident should have received at least two showers per week, including hair washing if requested, indicating that the resident’s documented needs and care plan interventions for ADL assistance, bathing frequency, and hair care were not consistently implemented.
Failure to Complete Ordered X-rays for Resident After Fall
Penalty
Summary
The facility failed to follow physician orders for x-rays for a resident who had fallen from their bed. The resident, who had a history of diabetes, heart failure, and peripheral vascular disease, fell on 9/6/24 and was ordered a stat x-ray for multiple areas including the left shoulder, left arm, left hip, right hip, and chest. Despite the order, the x-ray was not completed for nine days, during which the resident experienced significant pain and refused care, behaviors that were not typical for them prior to the fall. The resident's progress notes indicated multiple instances of pain and requests for medication, yet there was no documentation showing the completion of the x-rays as ordered. Staff interviews revealed a lack of communication and follow-up regarding the x-ray orders. The Assistant Director of Nurses (ADON) obtained the x-ray orders but did not ensure their completion, and the Director of Nursing (DON) was unaware of the situation until a week later. The resident's physician was also not informed of the delay in completing the x-rays. The mobile x-ray company attempted to contact the facility to recommend hospital transfer due to high radiation exposure but received no response. The resident continued to suffer from pain, requiring increased assistance for care, and was eventually diagnosed with a possible fracture. The deficiency highlights a significant lapse in the facility's process for following physician orders and ensuring timely medical interventions for residents.
Failure to Submit Monthly Transfer Notifications to Ombudsman
Penalty
Summary
The facility failed to submit facility-initiated transfer notifications to the Ombudsman on a monthly basis. The census was 92. During an interview, the Ombudsman stated that the facility had not sent their monthly transfer notifications since November 2022. Email communication between the facility's Social Service Director and the Ombudsman office showed an admission/discharge log dated April 1, 2024, through April 18, 2024. The Administrator confirmed that the social worker would be responsible for submitting hospital transfer logs monthly to the Ombudsman, but it had not been done since the new Social Service Director started two weeks ago. The last submission date was unclear, but a submission for April 2024 was made, and future submissions will be done at the end of each month.
Failure to Encode and Transmit MDS Data Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data within 7 days after completing the assessments for 12 out of 19 residents investigated. The Minimum Data Set (MDS) assessments for these residents were found to be in progress beyond the required timeframe. The MDS Coordinator, who has been in the role for 5 years, acknowledged being behind on MDS assessments due to the facility being understaffed, particularly lacking a social worker for about a year and a half. This has led to the business office manager, director of rehab, and the MDS Coordinator herself filling in the role, contributing to the delay in completing and transmitting the MDS assessments as required by the Resident Assessment Instrument (RAI) User's Manual. The residents affected by this deficiency include those with quarterly and annual MDS assessments that were not completed or signed off on time. Specific examples include residents with assessment reference dates ranging from late December to early April, all showing their MDS assessments in progress. The MDS Coordinator confirmed that these assessments either needed to be completed or signed off, indicating a significant backlog in the facility's assessment process. This failure to adhere to the mandated timelines for encoding and transmitting MDS data highlights the operational challenges faced by the facility due to staffing shortages and increased workload on the existing staff members.
Failure to Complete Quarterly Resident Assessments
Penalty
Summary
The facility failed to complete quarterly resident assessments for nine out of 19 residents investigated. The Minimum Data Set (MDS) assessments for these residents were found to be in progress and not completed within the required timeframe. The MDS Coordinator acknowledged being behind on assessments due to staffing shortages, including the absence of a social worker for about a year and a half. This has led to the business office manager, director of rehab, and the MDS Coordinator herself filling in the role, contributing to the delay in completing the assessments. The residents affected by this deficiency include Resident #54, #6, #53, #43, #2, #7, #29, #14, and #23. Each of these residents had quarterly MDS assessments that were not completed within the mandated period. The MDS Coordinator, who has been in the role for five years, confirmed that the assessments were either still in progress or needed to be signed off. The facility's census at the time was 92, indicating a significant portion of the resident population was impacted by this oversight.
Deficiency in CNA Annual Training Compliance
Penalty
Summary
The facility failed to ensure that eight out of ten randomly selected Certified Nurse Aides (CNAs) received the required annual 12-hour resident care training. The facility's census was 92. The review of the facility assessment indicated that staff training, education, and competencies were provided through various methods, including new employee orientation, in-house in-services, webinars, and other educational arrangements. However, the individual in-service records for the CNAs showed significant deficiencies in training hours. For instance, CNA L, hired in 1998, had no documentation of in-service education, and several other CNAs hired between 2002 and 2023 had either zero or insufficient hours of in-service education. This lack of training was confirmed during interviews with the Administrator, who acknowledged that the facility did not have a Staff Development Coordinator (SDC) responsible for tracking the in-service training for CNAs, leading to the deficiency in training compliance. The Administrator further explained that the Healthcare Academy would typically send a report, and the SDC would pull the report to see what training was due. However, due to the absence of an SDC, the facility failed to track and ensure the completion of the required training hours for the CNAs. This oversight resulted in a significant gap in the mandatory annual training for the CNAs, which is essential for maintaining their certification and ensuring the quality of care provided to the residents. The deficiency highlights a critical lapse in the facility's training and education system, directly impacting the competency and preparedness of the CNAs in delivering resident care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information in a prominent place, readily accessible to residents and visitors on a daily basis. Observations from 4/17/24 through 4/19/24 and 4/22/23 and 4/23/24 showed that the board behind the front desk reception contained outdated information or incomplete documentation of the total number and actual hours worked by RNs, LPNs, and CNAs per shift. The census was consistently recorded as 92, but the necessary staffing details were missing. During an interview, the Administrator acknowledged that the information should be posted daily and attributed the lapse to the Director of Nursing (DON) placing the information on a paper copy to be framed, which was not completed in the DON's absence.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control. Specifically, a Licensed Practical Nurse (LPN) did not change gloves or wash hands while administering medication via a G-tube, moving from the medication cart to the resident's room and back without proper hand hygiene. Additionally, a Certified Nursing Assistant (CNA) left suction equipment uncovered at the bedside after use, which was observed on multiple occasions. These actions were contrary to the facility's policies and professional standards of practice, as confirmed by interviews with the Registered Nurse (RN) and Assistant Director of Nursing (ADON). The facility also failed to adhere to its Tuberculosis (TB) testing policy for new hires. Eight employee files were reviewed, and none had complete documentation of the required two-step TB test. Some employees had no TB test documentation at all, while others had only completed the first step. The ADON confirmed that the facility's policy requires a two-step TB test to be completed within one to three weeks, and the lack of compliance was acknowledged during the interview. Resident #1, who required medications via a G-tube and had a care plan to remain free of complications related to tube feeding, was directly affected by the LPN's failure to follow proper hand hygiene protocols. The resident also experienced improper handling of suction equipment by the CNA, which was left uncovered, increasing the risk of infection. These deficiencies highlight significant lapses in infection control practices within the facility, as observed and documented by the surveyors.
Failure to Complete Comprehensive Resident Assessment
Penalty
Summary
The facility failed to complete a comprehensive resident assessment for one of 12 residents investigated for comprehensive assessment completion. The resident was admitted on an unspecified date, and an annual MDS assessment dated 4/1/24 with an ARD date of 2/24/24 was still in progress. The MDS Coordinator, who has been in the role for 5 years, acknowledged being behind on MDS assessments due to the facility being without a social worker for about a year and a half. As a result, the business office manager, director of rehab, and the MDS Coordinator herself have been filling the role, contributing to the delay in completing the assessments.
Incomplete and Inaccurate Care Plans
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #175, the care plan did not include focus, goals, and interventions related to the resident's diagnosis of necrotizing fasciitis of the lower left extremity, discharge planning goals, and mental health concerns. Additionally, the location of pain was not documented. Observations revealed that the resident had a bandage wrapped around the left leg with visible drainage, and the resident expressed ongoing pain and uncertainty about future care plans. The resident had not had a care plan meeting with staff. For Resident #59, the care plan lacked focus, goals, and interventions related to the resident's dietary status, difficulty swallowing, and PEG tube. The care plan also did not document the resident's rehospitalization, falls, and bowel incontinence focus, goals, and interventions. Observations showed the resident being served a puree meal and having a Jevity 1.5 bottle on the bedside table. The resident's medical record indicated multiple orders related to enteral feeding and dietary needs, but these were not reflected in the care plan. Resident #174's care plan was also incomplete, lacking focus, goals, and interventions related to the resident's dietary status, [NAME] tube, current radiation treatments, and discharge planning. The care plan did not document the resident's rehospitalization and fall goals. The resident's medical record showed multiple orders for enteral feeding and other care needs, but these were not included in the care plan. Interviews with the Administrator and MDS Coordinator confirmed that the care plans were expected to meet the residents' medical, nursing, and mental psychosocial needs but were not completed timely or comprehensively.
Failure to Ensure Safe Resident Discharge
Penalty
Summary
The facility failed to ensure a safe discharge for a resident by not sending referrals to local contact agencies and orders for medical equipment in a timely manner. This deficiency was identified for a resident who was discharged without home health setup or durable medical equipment after a change in the discharge date. The resident, who had undergone significant surgical procedures including a total laryngectomy and pharyngectomy, was discharged without the necessary support and equipment, leading to a potentially unsafe situation at home. The resident's medical record showed that the discharge plan did not include focus, goals, and interventions related to the resident's discharge planning. Despite the resident's complex medical needs, including the need for tracheostomy and PEG tube care, the facility did not update the home health referral with the new discharge date. This oversight resulted in the resident being sent home without the required medical equipment and home health services, which were crucial for the resident's post-discharge care. Interviews with facility staff revealed that there was a lack of proper communication and documentation regarding the change in the discharge date. The Social Services Director, who had only been at the facility for three weeks, stated that there was no Social Services Director at the time of the incident. The Administrator confirmed that referrals should have been resent if the discharge date was changed. This failure in the discharge planning process had the potential to affect all residents discharging from the facility, as it demonstrated a systemic issue in ensuring safe and well-coordinated discharges.
Failure to Provide Communication Assistance for Deaf Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who is deaf by not supplying necessary speech assistive devices and ensuring staff were knowledgeable about the resident's communication needs. The resident's quarterly assessment indicated severe hearing impairment and a preference for an American Sign Language (ASL) interpreter, but no hearing aids or other communication devices were provided. The care plan included specific interventions to aid communication, but these were not transferred to the Kardex, a report used by direct care staff. During observations and interviews, it was evident that the resident struggled to communicate effectively, and staff were unaware of how to access or use communication resources for the resident. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) reported that they received information about resident care during shift reports but did not have access to the computer to review the Kardex. The Assistant Director of Nursing (ADON) acknowledged that some CNAs lacked computer access and expected them to report this issue so that access could be created. The Administrator confirmed that the care plan interventions were not being transferred to the Kardex and stated that this issue would be addressed. The lack of proper communication tools and staff awareness led to the resident's needs not being fully met, as staff were unable to effectively communicate with the resident to understand their needs and preferences.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that a resident with chronic wounds received treatment and care in accordance with professional standards of practice. The resident was readmitted from the hospital with wounds on the left knee and lower extremities on 3/29/24. However, a full wound assessment was not completed until 4/3/24, and treatment orders for the left plantar foot and left knee were not obtained until 4/11/24 and 4/19/24, respectively. This delay in assessment and treatment was contrary to the facility's policies, which require immediate and comprehensive skin assessments upon admission or readmission and timely treatment orders for any identified wounds. The resident's medical history included high blood pressure, paraplegia, diabetes, and weakness. Upon readmission, the resident had open areas on the left knee and lower extremities, but no wound measurements or descriptions were documented until 4/3/24. The resident's Treatment Administration Record (TAR) showed no treatment orders for the left knee wound or the left lower extremity open areas until 4/11/24 and 4/19/24, respectively. This lack of timely documentation and treatment orders resulted in a failure to provide appropriate care for the resident's wounds. Interviews with the Wound Nurse revealed that the resident was readmitted on a weekend by an agency nurse, and the Wound Nurse had just accepted the position and was not yet fully in the role. The Wound Nurse assessed the wounds on 4/3/24 and obtained treatment orders, but the orders were missed when adding them into the computer. The facility's policies require that wounds be assessed upon arrival and that treatment orders be obtained immediately, but these procedures were not followed, leading to a delay in the resident's wound care.
Failure to Arrange Transportation for Follow-Up Eye Appointment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision by not making transportation arrangements for a follow-up appointment after eye surgery. The resident, who was cognitively intact and had diagnoses including heart disease, Parkinson's disease, and depression, missed the scheduled ophthalmology appointment due to the facility's failure to arrange transportation. Despite the resident's care plan indicating the need for assistance with activities of daily living and therapy services, the necessary transportation was not provided, and the appointment was not rescheduled after being missed. Interviews with staff revealed a lack of communication and coordination regarding the resident's transportation needs. The nurse responsible for setting up appointments and the receptionist responsible for scheduling transportation were both unaware of the missed appointment and the need to reschedule it. The optometrist's office confirmed that the resident was marked as a no-show and no follow-up appointment was made. The facility's administrator acknowledged that physician's orders should be followed and transportation provided, but could not explain why the resident missed the appointment.
Failure to Administer Ordered Insulin
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Practical Nurse (LPN) did not administer the resident's ordered routine insulin. The resident, who has diabetes, had an order for Admelog SoloStar insulin to be administered twice daily before breakfast and dinner. On the day of the incident, the LPN checked the resident's blood sugar, which was within normal limits, and decided not to administer the insulin without notifying the physician or obtaining an order to hold the medication. This action was contrary to the facility's medication administration policy, which requires medications to be administered as ordered unless a physician is notified and provides an alternative directive. The Assistant Director of Nursing (ADON) confirmed that the routine insulin should not have been held without physician notification, especially since insulin is considered a high-risk medication. The ADON also noted that the resident is a brittle diabetic, and administering insulin too far from meal times could cause blood sugar levels to drop. Despite this, the LPN did not follow the proper protocol, leading to a significant medication error. The facility's policy emphasizes the importance of adhering to the 10 rights of medication administration, which were not followed in this instance.
Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored per acceptable standards of practice for one of four medication carts and one of one treatment cart reviewed. Specifically, the medication cart contained insulin pens that were not labeled with the date they were removed from refrigeration or their expiration date after being removed from refrigeration. The treatment cart contained ointments for two residents with the caps off. The facility had a total of 10 medication/treatment carts and a census of 92 residents. During an observation, it was noted that the insulin pens in the medication cart were not currently in use and were still unopened, but the staff did not know when they were removed from the refrigerator. Manufacturer recommendations for the insulin pens indicated that they should be discarded after a certain period once removed from refrigeration, which was not adhered to in this case. Additionally, the treatment cart contained an opened tube of clotrimazole-betamethasone cream for one resident and an opened tube of gentamicin ointment for another resident, both without their lids. The facility's policy on the storage and expiration dating of medications and biologicals required that opened medications be labeled with the date opened and stored with their lids on. Interviews with the staff, including a Registered Nurse and the Assistant Director of Nursing, confirmed that the facility's practices did not align with these requirements. The Assistant Director of Nursing acknowledged that insulin pens should be dated when removed from refrigeration and that ointments and creams should be stored with their lids on.
Failure to Administer and Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards. One resident with vascular leg ulcers did not have treatments completed as per physician orders. The resident's Treatment Administration Record (TAR) showed multiple instances where the required daily treatments were not documented as administered. Observations confirmed that the dressings on the resident's lower extremities were not changed daily as required, with dressings dated several days prior still in place during the survey. The resident's care plan also did not address the vascular leg ulcers, indicating a lack of comprehensive care planning for the resident's condition. Another resident with a history of stroke, tracheostomy, and hemiplegia did not receive the prescribed treatment for a blister on the right breast. The resident's care plan included interventions such as applying Inter-dry between the breasts and arms, but observations showed that these treatments were not in place. The resident's wound observation tool indicated the presence of a blister, but no follow-up skin assessments were completed to monitor the healing process. The resident's TAR also showed that the prescribed treatments were not consistently documented as administered. Interviews with staff, including the Director of Nursing (DON), revealed that there were expectations for staff to follow physician orders and document treatments on the TAR. However, the DON acknowledged that a glitch in the system prevented weekly skin assessments from appearing for nurses to complete. This systemic issue contributed to the failure to provide consistent and documented care for the residents' wounds, leading to deficiencies in the facility's care standards.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that two residents with pressure wounds received the necessary treatments and services to promote healing. Resident #5, who was cognitively intact and had multiple diagnoses including diabetes and chronic pain syndrome, had a physician's order for wound care that was not consistently followed. The treatment administration record (TAR) showed multiple instances where the prescribed wound care was not documented as completed. Observations confirmed that the resident's dressing had not been changed for several days, and the resident expressed concern that this was delaying their discharge. The Assistant Director of Nursing (ADON) and an LPN confirmed the presence of pressure wounds that were not being properly managed according to the physician's orders. Resident #1, who had a history of diabetes, stroke, and other significant health issues, was admitted with existing skin issues including a small red open area on the sacrum. Despite being at high risk for developing pressure sores, there were no documented orders for skin or wound treatments in the resident's records. The resident's condition worsened, and they were found with non-blanching redness and an open area on the left buttocks upon discharge to the hospital. Interviews with staff revealed that CNAs did not consistently report skin issues to the nurses, and the nurses were unaware of the resident's skin condition. Interviews with the facility's nursing staff, including the DON, revealed systemic issues in the documentation and execution of wound care. Weekly skin assessments were not consistently completed, and there was a known glitch in the system that prevented skin assessments from appearing for the nurses to complete. The facility lacked a dedicated wound nurse, placing the responsibility on floor nurses who did not always follow through with the required treatments. The DON confirmed that blank boxes on the TAR indicated missed treatments, and that all skin issues should be addressed with the physician and documented properly.
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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