Magnolia Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 3421 Gasconade, Saint Louis, Missouri 63118
- CMS Provider Number
- 265672
- Inspections on file
- 27
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Magnolia Wellness Center during CMS and state inspections, most recent first.
A resident with a history of opioid dependence and behavioral issues repeatedly violated facility policies by bringing in contraband, hosting unauthorized guests, and leaving the facility without proper notification. Staff reported being unable to effectively intervene due to the resident's aggressive behavior and lack of clear guidance from administration. The care plan lacked specific interventions for these behaviors, and documentation of incidents and follow-up actions was inconsistent, resulting in a failure to provide necessary behavioral health care and services.
The facility did not consistently ensure that two nurses verified and signed the controlled substance inventory tracker sheets at shift changes, resulting in incomplete and inaccurate documentation for one floor. Despite policies requiring dual signatures and thorough recordkeeping, multiple instances were found where only one nurse signed or signatures were missing entirely, and some medication additions lacked proper documentation. This failure prevented accurate reconciliation of controlled substances as required by regulations.
A resident with severe cognitive impairment and total dependence for transfers was being moved using a Hoyer lift by two CNAs, who used an incorrect pad instead of the required large Hoyer sling. The straps broke during the transfer, causing the resident to fall and sustain a head laceration that required hospital treatment. Investigation confirmed that the wrong type of pad was used, and staff did not follow the care plan or facility policy.
Two separate incidents occurred in which a staff member verbally threatened and used profanity towards a resident, requiring intervention by other staff, and in another case, two residents were involved in a physical altercation after one, under the influence of alcohol, pushed and attempted to strike their roommate. Both incidents were witnessed by staff, confirmed through interviews, and resulted in a failure to protect residents from abuse and neglect as required by facility policy.
A dietary aide failed to provide requested condiments to a resident during meal service and engaged in an argument, including taunting and making derogatory remarks about the resident's appearance. Multiple staff witnessed the aide's unprofessional and disrespectful behavior, which violated the resident's right to dignity and respectful treatment.
A medication error rate exceeding 25% was observed when a single CMT was responsible for administering medications to about 40 residents, resulting in significant delays. Multiple residents reported receiving their medications late, and staff interviews revealed confusion about medication pass schedules. The facility failed to ensure medications were administered within the required time frame, leading to numerous errors and resident complaints.
The facility did not ensure Enhanced Barrier Precautions were implemented for residents with indwelling devices or wounds, as required. Staff provided care to multiple residents with feeding tubes and pressure ulcers without using gowns or posting EBP signage, and PPE supplies were not readily accessible. Interviews revealed staff were not adequately trained or informed about EBP requirements, and leadership confirmed that signage and supplies had not been put in place despite having them available.
Staff did not consistently notify physicians when two residents' blood glucose levels exceeded ordered parameters, as required by facility policy. Despite multiple high readings in residents with diabetes, there was no documentation of physician notification or follow-up in the medical records. Interviews with LPNs and the DON confirmed that staff are expected to report and document such events, but this was not done in these cases.
A resident with diabetes and cognitive impairment developed blisters on both feet that were documented by CNAs and co-signed by the ADON, but staff failed to notify the physician or initiate wound monitoring as required. The care plan did not address the actual wounds, and there were lapses in documentation and treatment administration, including missing initials on the TAR and undated dressings. The resident was also observed without prescribed pressure-relieving boots, and interviews revealed a lack of communication and follow-through among nursing staff regarding wound care protocols.
Two residents with significant cognitive and physical impairments did not receive recommended restorative nursing services after discharge from skilled therapy, as required by facility policy. Care plans lacked restorative interventions, physician notification was not documented, and staff interviews revealed the restorative program was inactive due to staffing and communication issues.
Two residents were involved in a physical altercation after one, who was already agitated and verbally aggressive, was allowed to go outside unsupervised with another resident. Despite staff awareness of the agitation and existing care plans for behavioral issues, preventive interventions were not implemented, resulting in one resident being choked and sustaining visible bruising and a sore throat before staff intervened.
Staff failed to intervene appropriately during episodes of resident agitation and aggression, resulting in one resident kicking another and a separate incident where a resident was choked by a peer, causing visible bruising and a sore throat. Despite care plans outlining the need for early intervention and de-escalation, staff did not consistently implement these strategies, and some were unaware of the required interventions, leading to preventable resident-to-resident altercations.
A resident with severe cognitive impairment and a history of wandering and aggression placed their hands around another resident's neck in a hallway altercation. Staff intervened immediately, but the incident highlights a lapse in monitoring and intervention, as the aggressive resident's care plan included measures to prevent such behavior.
The facility failed to monitor and intervene for a resident in respiratory distress, leading to delayed treatment and the resident's subsequent death. The resident was found unresponsive and not connected to a working oxygen source. EMS found the resident in critical condition, and the facility's policies did not adequately address emergency situations.
Failure to Provide Necessary Behavioral Health Services and Address Repeated Policy Violations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for multiple residents, specifically by not addressing ongoing behavioral issues such as repeated violations of drug and alcohol, out on pass, visiting, and contraband policies, as well as physical and verbal aggression toward other residents and staff. One resident with a history of opioid dependence and other psychoactive substance abuse was frequently observed leaving and returning to the facility at all hours, often without signing in or out, and sometimes refusing or missing prescribed medication doses. The resident also repeatedly brought unauthorized guests into the facility, including overnight stays, and was found with contraband items such as box cutters, utility blades, and lighters in their room. Staff interviews revealed that the resident would become hostile or threatening when confronted about these behaviors, leading staff to avoid entering the resident's room or addressing the issues directly. Despite the facility's policies requiring timely assessment, documentation, and intervention for adverse behavioral symptoms, there was a lack of consistent documentation and follow-up regarding the resident's behaviors and the presence of contraband. The care plan did not include interventions for the resident's repeated policy violations, such as bringing guests into the facility at inappropriate times, leaving the facility without proper notification, or bringing in potentially dangerous items. Staff reported uncertainty about their roles in monitoring for contraband and managing the resident's behaviors, with some believing that only housekeeping should check rooms, and others stating they were told not to confront the resident due to his aggressive demeanor. Interviews with staff, including LPNs, CNAs, and the Social Worker, indicated that administration was aware of the ongoing issues but did not provide clear guidance or effective interventions to address the resident's non-compliance and behavioral health needs. The Social Worker noted that the resident was not on a behavior contract and was often not present when psychiatric services were available. The DON and Administrator had removed contraband items from the resident's room on several occasions, but the resident continued to bring in more. Staff expressed concerns for their safety and the safety of other residents, as there were no clear instructions on how to manage the resident's aggressive or non-compliant behavior, especially when administration was not present.
Failure to Maintain Accurate Controlled Substance Inventory Records
Penalty
Summary
The facility failed to maintain accurate and thorough records of receipt and disposition of controlled substances, as required by both federal and state regulations. Review of the facility's policies indicated that controlled substances must be documented with the date, time, and signatures of the receiving personnel, and that shift change inventory counts must be verified and signed by two nurses. However, examination of the controlled substance inventory sheets for one of the two facility floors revealed multiple instances where only one nurse signature was present, or where there was no documentation of signatures at all for both morning and evening shift changes. There were also occasions where the total number of medication cards was inconsistent or not documented, and instances where medications were added without corresponding documentation of the resident or medication details. Interviews with staff confirmed that the expected practice was for two nurses to count and sign off on the narcotic inventory tracker at each shift change and whenever the narcotic box was accessed. One LPN stated that he/she always counted narcotics with another nurse and suggested that missing signatures were likely due to the other staff member forgetting to sign. The DON and Administrator both confirmed their expectation that two staff members sign off on every entry, both at shift changes and when the narcotic box was accessed for any reason. Despite these expectations, the documented records showed repeated failures to comply with the facility's own policy and regulatory requirements for controlled substance accountability. The lack of consistent dual signatures and incomplete documentation prevented accurate reconciliation of controlled substances, as required to ensure proper pharmaceutical services for residents. No specific residents were identified as being directly affected in the report, and the census at the time was 80.
Resident Fall Due to Incorrect Sling Use During Hoyer Lift Transfer
Penalty
Summary
Staff failed to provide adequate assistance to prevent accidents when two CNAs used a Hoyer lift to transfer a resident but did not use the correct size or type of sling. During the transfer, the sling straps broke while the resident was suspended in mid-air, resulting in the resident falling to the ground and sustaining a laceration to the back of the head. The resident required hospital evaluation and sutures for the injury. The resident involved had severe cognitive impairment, was dependent on staff for all transfers, and had diagnoses including stroke with right-sided hemiplegia, seizures, non-Alzheimer's dementia, and malnutrition. The care plan specified the need for two staff members to assist with Hoyer lift transfers and the use of a large sling, as ordered by the physician. Despite these requirements, staff used a pad that was not the correct Hoyer sling, and it was later determined that a slide transfer pad, which resembled a Hoyer pad but was not designed for use with the lift, was used instead. This led to the failure of the straps and the resident's fall. Interviews and record reviews revealed inconsistencies in staff accounts regarding who was present during the incident, but it was confirmed that the wrong pad was used and that the staff did not follow the resident's care plan or the facility's policy for mechanical lift transfers. The incident occurred at the end of a shift, and the resident was found on the floor with a head laceration. The facility's investigation concluded that the use of the incorrect pad directly contributed to the accident.
Failure to Prevent Abuse and Neglect Among Residents and Staff
Penalty
Summary
The facility failed to protect residents from abuse and neglect in two separate incidents. In the first incident, a staff member engaged in a verbal altercation with a resident, during which both parties exchanged insults and profanity. The staff member escalated the situation by making a threatening statement towards the resident and using inappropriate language, including insults about the resident's mother. Multiple staff and resident interviews confirmed that the staff member had to be physically held back by other staff to prevent further escalation. The resident involved was cognitively intact and had a history of verbal aggression, but at the time of the incident, there was no physical contact or injury reported. In the second incident, two residents were involved in a physical altercation. One resident, who had a diagnosis of alcohol abuse and was under the influence at the time, became angry with their roommate for making noise early in the morning. The aggressive resident pushed the other resident to the floor and attempted to strike them, but missed. Staff intervened and separated the residents. The resident who was pushed had severe cognitive impairment but did not sustain any injuries and reported feeling safe after the incident. The aggressive resident admitted to consuming alcohol and had previously signed a behavior agreement to refrain from alcohol use and aggressive behavior. Both incidents were witnessed by staff and corroborated through interviews and documentation. The facility's policies required staff to prevent, identify, and report abuse, but in these cases, the staff member's actions and the resident-to-resident altercation were not prevented, resulting in violations of residents' rights to be free from abuse and neglect. The events were reported to the appropriate facility leadership and law enforcement, and the facility's failure to prevent these incidents constituted a deficiency.
Failure to Honor Resident Dignity and Respect During Meal Service
Penalty
Summary
A deficiency occurred when a dietary aide (DA) failed to accommodate a resident's request for condiments during meal service and engaged in an argument with the resident. The resident, who was cognitively intact and had diagnoses including depression and an unspecified mood disorder, requested salt and pepper during breakfast. The DA informed the resident that there were no condiments available and did not attempt to fulfill the request. The resident then went to another floor to obtain the condiments independently. Upon returning, the DA taunted and insulted the resident, making derogatory remarks about the resident's appearance and age. Multiple staff members witnessed the exchange, reporting that the DA laughed at the resident, called the resident names such as 'skinny' and 'bald-headed,' and used inappropriate language. The situation escalated as the DA continued to argue with the resident, despite being instructed by a nurse to stop. The argument included cursing and threats, with both the DA and the resident exchanging hostile words. The DA admitted to being irritated by the resident and acknowledged making inappropriate comments during the altercation. The facility's policies and job descriptions require staff to treat residents with dignity and respect, to provide prompt and polite service, and to deescalate situations when residents become agitated. In this incident, the DA did not follow these protocols, failed to meet the resident's needs, and engaged in unprofessional and disrespectful behavior, resulting in a violation of the resident's right to dignity and respectful treatment during meal service.
High Medication Error Rate Due to Delayed Administration and Policy Noncompliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. Out of 34 observed medication administration opportunities, nine errors were identified, resulting in a 26.47% error rate. These errors were primarily due to medications being administered outside the required time window, with several residents receiving their scheduled morning medications significantly later than ordered. Observations showed that a single Certified Medication Technician (CMT) was responsible for passing medications to approximately 40 residents on one hall, leading to delays. The CMT reported starting the medication pass at 7:30 A.M. and not finishing until after 11:00 A.M., with some residents receiving their 8:00 A.M. medications as late as 10:36 A.M. or later. Multiple residents, including those attending a Resident Council meeting, voiced concerns about consistently receiving medications late. Interviews with staff revealed confusion regarding whether the facility was operating under a traditional or liberalized medication pass schedule, with both the Director of Nursing and the Administrator unaware that specific times were still being used. The facility's policy required medications to be administered within one hour before or after the scheduled time, and administration outside this window was considered a medication error. The combination of insufficient staffing, lack of clarity on medication pass schedules, and failure to adhere to policy led directly to the high medication error rate and resident complaints.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents at risk of multidrug-resistant organism (MDRO) transmission. Observations, interviews, and record reviews revealed that residents who required EBP did not have the required signage on their doors or walls instructing staff to use EBPs during personal care. Additionally, personal protective equipment (PPE) such as gowns, masks, and goggles/face shields were not readily accessible for staff use in the care of these residents, with only gloves being available in or near the rooms. Multiple residents with significant medical needs, including those with feeding tubes, pressure ulcers, and other indwelling devices, were identified as requiring EBP. For example, one resident had a gastrostomy tube and both Stage 3 and Stage 4 pressure ulcers, while another had a feeding tube and was at risk for pressure ulcers. Despite these conditions, there was no documentation in the care plans or medical records indicating that staff were using EBP during care. Direct observations showed that staff, including LPNs and CNAs, provided care to these residents using only gloves and not gowns, even when performing high-contact activities such as wound care and handling feeding tubes. Interviews with staff members revealed a lack of awareness and training regarding EBP requirements. Several CNAs and LPNs stated they were either unaware of which residents required EBP or did not know that gowns should be worn in addition to gloves. Some staff indicated they would have used gowns if they were available, but supplies were not accessible. Leadership acknowledged that EBP signs and supplies were not in place, citing delays in receiving containers for PPE, but confirmed that the necessary supplies were on hand. A list provided by the DON identified 18 residents who should have had EBP signage and supplies available, but these measures were not implemented at the time of the survey.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that staff consistently notified physicians when residents' blood glucose levels exceeded the parameters ordered by the physician. According to the facility's policy, staff are required to inform the physician of significant changes in a resident's condition, including when blood glucose levels fall outside of specified ranges, and to document these notifications. However, review of medical records and interviews revealed that this protocol was not followed for two residents with diabetes who had orders for routine blood glucose monitoring. One resident with a history of diabetes, hypertension, and dementia had multiple blood glucose readings above the ordered threshold of 250, including values of 301, 272, 274, 285, and 401. There was no documentation in the Medication Administration Record or progress notes that the physician was notified of these elevated readings. Similarly, another resident with diabetes, dementia, and malnutrition had a blood glucose reading of 540, which exceeded the physician's ordered parameter of 400, but there was no evidence that the physician was contacted or that this was documented in the resident's records. Interviews with nursing staff and the Director of Nursing confirmed that staff are expected to notify the physician and document any blood glucose readings outside of the ordered parameters, but in these cases, there was no documentation of such notifications. The lack of communication and documentation regarding these significant changes in residents' conditions constituted a failure to meet professional standards of quality for monitoring and reporting in diabetic care.
Failure to Notify Physician and Monitor Wounds Following Discovery of Foot Blisters
Penalty
Summary
Facility staff failed to ensure that a resident with diabetes, dementia, and malnutrition received appropriate wound care and physician notification after blisters were observed on both feet. Despite documentation of blisters on shower review forms by CNAs and co-signature by the ADON, there was no evidence that the physician was notified or that wound monitoring was initiated as required by facility policy. The ADON assumed the wound nurse was aware and did not document her assessment or communicate with the wound nurse, and the wound nurse confirmed she was not notified until much later. The resident's care plan included general interventions for diabetes, such as daily foot inspections, but did not address the actual wounds present on the feet. Multiple skin assessments and shower review forms documented the presence of blisters and open areas, but there were no corresponding physician orders or progress notes regarding these wounds for over two weeks. When wound care orders were finally obtained, there were lapses in documentation, including missing initials on the Treatment Administration Record (TAR) and undated dressings on the resident's feet. Observations revealed that the resident was not consistently wearing prescribed pressure-relieving boots, with the boots found on a second bed rather than on the resident. Interviews with nursing staff confirmed a lack of communication and follow-through regarding wound care protocols, including failure to notify the physician, incomplete documentation, and lack of coordination between staff members. These failures resulted in delayed treatment and incomplete monitoring of the resident's wounds.
Failure to Provide Restorative Nursing Services After Discharge from Skilled Therapy
Penalty
Summary
The facility failed to provide services and/or treatment to maintain or improve range of motion (ROM) for residents who required restorative nursing interventions after discharge from skilled therapy. Specifically, the facility did not maintain a measurable, goal-oriented restorative nursing or exercise program as outlined in its own policy. Of 11 residents discharged from skilled therapy, two were identified as not receiving the recommended restorative therapy. The facility's Restorative Nursing Program Guidelines require interdisciplinary team (IDT) review, physician notification, individualized care planning, and regular documentation, none of which were consistently followed for these residents. One resident with severe cognitive impairment, hemiparesis, and a history of stroke required partial to moderate assistance with activities of daily living (ADLs) and used a wheelchair for mobility. The occupational therapy (OT) discharge summary recommended a restorative program, including a dining/swallowing program and ROM exercises. However, there was no documentation that the physician was notified of these recommendations, and the resident's care plan did not include ROM or restorative therapy interventions. Forms related to ROM and eating lacked documentation of frequency, and the resident reported not receiving restorative therapy or knowing when they were last evaluated. Another resident with moderate cognitive impairment, anemia, congestive heart failure, and high blood pressure was also discharged from OT with recommendations for a restorative dining/swallowing program and adaptive equipment. The care plan did not reflect these OT recommendations or restorative therapy interventions, and the relevant forms were incomplete. Staff interviews revealed that the restorative aide had not performed restorative exercises for any residents due to other commitments, and there was confusion among staff regarding oversight and implementation of the restorative program. The program was not active, and communication between therapy, nursing, and administration was unclear, resulting in residents not receiving the restorative care recommended by therapy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when two residents were involved in a physical altercation that resulted in one resident being choked, causing visible bruising and a sore throat. Prior to the incident, the resident who was later choked had been agitated and verbally aggressive, with staff noting the resident was yelling at others about food issues. Despite this agitation, the resident was allowed to go outside to the patio, where the altercation with another resident occurred. Staff were present and aware of the resident's heightened agitation but did not intervene to prevent the two residents from being together in an unsupervised setting. The resident who committed the choking had a diagnosis of Alzheimer's Disease but was assessed as cognitively intact and had no prior history of physical behavioral symptoms directed toward others. The resident who was choked was also cognitively intact and had a history of depression and poor impulse control, with care plans in place addressing potential for physical and verbal aggression. Staff and social services were aware of the resident's agitation earlier in the day, and the care plan included interventions for de-escalation, but these were not effectively implemented prior to the altercation. Multiple staff interviews confirmed that the altercation escalated from a verbal argument to physical violence, with staff intervening only after the choking had begun. The facility's abuse prevention policy required proactive intervention and monitoring of residents with known behavioral issues, but staff actions were reactive rather than preventive. The failure to intervene before the situation escalated resulted in physical harm to a resident, in violation of the facility's abuse prevention and prohibition program.
Failure to Provide Necessary Behavioral Health Interventions Leads to Resident-to-Resident Altercations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services when staff did not intervene appropriately during incidents involving agitated and aggressive resident behavior. One resident, who was cognitively intact and had a history of depression and poor impulse control, became agitated and verbally aggressive, escalating to physically kicking another resident who was severely cognitively impaired and had a history of daily physical behavioral symptoms. Staff did not intervene before the situation escalated, despite care plan interventions that required early intervention and de-escalation strategies when the resident became agitated. Additionally, the same resident was involved in a verbal altercation with another cognitively intact resident, which escalated to physical aggression when the second resident wrapped their hands around the first resident's neck, resulting in visible bruising and a sore throat. Staff interviews and documentation revealed that while some attempts at verbal redirection and separation were made, staff were not consistently aware of or did not implement all required interventions outlined in the residents' care plans. Several staff members admitted to not knowing the specific interventions for the residents involved, and there was a lack of proactive measures to prevent escalation, as required by facility policy. The facility's behavior management policy emphasized the need for individualized, proactive interventions and ongoing assessment to prevent behaviors that could harm residents or others. However, the report documents that staff failed to intervene before agitation escalated in both incidents, and did not consistently monitor or implement care plan strategies designed to de-escalate situations and protect residents from harm. The lack of timely and effective intervention contributed to physical altercations between residents, resulting in injury and distress.
Resident-to-Resident Altercation Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse when two residents were involved in a physical altercation. One resident, who had severe cognitive impairment and a history of wandering and aggressive behavior, placed their hands around another resident's neck. The incident occurred in the hallway outside the second resident's room, and staff intervened immediately to separate the residents. The resident who was attacked did not report any pain or injury, although there was redness on their neck, which they attributed to wiping drool off with a cloth. The resident who initiated the altercation had a care plan that identified them as having severe cognitive impairment, wandering behavior, and a history of physical aggression related to dementia. Despite these known issues, the resident was able to approach and physically engage with another resident, indicating a lapse in monitoring or intervention. The care plan included interventions such as administering medications, monitoring for signs of aggression, and redirecting the resident from wandering, but these measures were not sufficient to prevent the incident. The facility's investigation revealed that the incident was discovered immediately by staff, who heard screaming and found the resident with their hands on the other resident's neck. The staff acted quickly to separate the residents and assess the situation. However, the fact that the incident occurred suggests that the existing interventions and monitoring were inadequate to prevent the resident's aggressive behavior from escalating to physical contact with another resident.
Failure to Monitor and Intervene for Resident in Respiratory Distress
Penalty
Summary
The facility failed to provide acceptable nursing services by not directly and continuously monitoring and intervening for a resident who was in respiratory distress. Two therapy staff found the resident difficult to wake, breathing heavily, and not connected to the oxygen concentrator, which was broken. The emergency oxygen tank on the resident's wheelchair was also found empty, further delaying treatment. When staff finally applied the nasal cannula with oxygen at 4 liters from a full e-tank, the resident's oxygen saturation level was critically low at 68%. The resident had an order for a BiPap, which was not applied when the resident was noted to be in distress. When Emergency Medical Services (EMS) arrived, the resident was unattended, prone on a flat bed, with audible rales, thick white sputum, peripheral cyanosis, and an oxygen saturation level of 57%. EMS placed the resident on a nonrebreather mask at 15 liters, but the resident's condition continued to deteriorate. The resident was transferred to the hospital, where they expired a short time later. The facility's policies on abuse and neglect, pulse oximetry, oxygen administration, and acute condition changes did not adequately address emergency situations such as respiratory distress. Interviews with staff revealed that the resident was known to wear oxygen and did not refuse care. However, there was a lack of consistent monitoring and documentation of the resident's oxygen use and condition. Staff members reported the resident's change in condition to the nurse, but appropriate and timely interventions were not taken. The facility's failure to monitor and intervene promptly and effectively contributed to the resident's critical condition and subsequent death.
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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