Monarch Springs Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in University City, Missouri.
- Location
- 894 Leland Avenue, University City, Missouri 63130
- CMS Provider Number
- 265831
- Inspections on file
- 20
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Monarch Springs Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, depression, Wernicke’s encephalopathy, heart failure, HTN, and DM, identified as an imminent elopement risk and care planned for a wanderguard and close supervision, was able to leave the building unnoticed and was later seen across the street. On the relevant day, only one nurse and one CMT were scheduled on the second floor, and the assigned CNA last saw the resident asleep earlier in the morning. Two alarmed second-floor exit doors lacked wanderguard sensors; testing showed one alarm stopped sounding after a few seconds while the door remained open, and another alarm sounded for about 30 seconds without any staff response. Staff either did not hear the alarms or did not investigate, and the Maintenance Director was unaware of the malfunctioning alarm, while the Administrator stated staff were expected to remain on the floor and respond immediately to door alarms.
A resident with serious mental illness and a court-appointed guardian was transferred to the hospital due to behavioral changes, but the facility failed to notify the guardian of the change in condition and hospital admission. Staff interviews and record review confirmed that required notifications and documentation were not completed according to facility policy.
A resident with severe cognitive impairment fell from bed and sustained head lacerations after a CNA left them unsecured to attend to another resident. The resident's care plan required the bed to be in the lowest position with a mat on the floor, but these precautions were not in place at the time of the incident.
The facility failed to ensure cleanliness and proper labeling of food items, leading to potential foodborne illness risks for 49 residents. Observations revealed unlabeled and undated food in storage, missing temperature logs, a leaking refrigerator, and unsanitary conditions in the kitchen. Staff interviews confirmed awareness of these issues, but proper procedures were not followed.
A facility with over 120 beds failed to employ a full-time qualified social worker, as required. The current Social Service Director, who lacks a degree and is not a licensed social worker, is functioning in this role. This deficiency could affect residents' access to necessary services.
The facility failed to implement infection control measures for Legionellosis, affecting all residents. Despite having a policy to minimize Legionella risk, no comprehensive risk assessment or water testing was conducted. The Administrator and Maintenance Director were unaware of the requirements, indicating a significant gap in infection prevention.
The facility failed to provide a dignified dining experience by serving meals on disposable Styrofoam plates and cups. Observations showed that many residents in the 300-hall dining room received desserts and beverages in disposable dishware, contrary to the facility's policy. A resident expressed a preference for regular dishware, and the Dietary Manager cited a shortage of regular plates and cups as the reason for using disposables. The consultant RD confirmed this practice was a dignity issue.
The facility failed to maintain a clean and comfortable environment in its dining rooms, affecting all residents who ate there. Observations revealed unclean chairs, walls, and curtains, along with unbalanced tables. The Administrator confirmed these issues, and the Housekeeping Supervisor admitted that cleaning the dining room furniture was not part of the routine schedule.
The facility failed to remove expired medications and supplies from a treatment cart and medication room, and did not keep a treatment cart and nurse cart locked. Expired items included ipratropium bromide albuterol sulfate, test tubes, sterile swabs, and COVID-19 test kits. An LPN acknowledged the expired items were available for use, and the DON confirmed that staff should have checked for expired items and kept carts locked.
The facility failed to keep dumpster lids closed as per their sanitation policy, leading to garbage overflow and odor. Observations showed open lids with visible garbage bags and debris on the ground. The DM acknowledged the issue, but staff continued to dispose of garbage without closing the lids.
A facility failed to ensure the accuracy of an MDS assessment for a resident with schizophrenia due to a missing PASARR Level II evaluation in the EMR. The MDS Coordinator completed the assessment without knowledge of the existing evaluation, which was only available in the paper file, leading to an inaccurate reflection of the resident's mental health status.
The facility failed to follow professional standards in two cases: an LPN did not discard the first drop of blood during glucose monitoring for a diabetic resident, and another LPN placed an old dressing on a clean field during wound care for a resident with pressure ulcers. Both actions were against facility policies, as confirmed by the DON.
Three residents reported issues with food palatability and temperature, with one resident stating the food was terrible and lacked flavor. The Dietary Manager could not provide a recipe for a meal, and the Registered Dietitian indicated that recipes were not required for pre-made items, leading to deficiencies in food preparation.
The facility failed to post complete nurse staffing information, omitting Night Shift details for RNs, LPNs, CMTs, and CNAs. The receptionist, unaware of the requirement, only included Day Shift data. The Human Resource Manager and Administrator confirmed the omission, and a review of past postings showed consistent lack of Night Shift information.
A resident with a history of mood disorders and aggressive behavior was inappropriately transferred to the hospital and not allowed to return. The facility failed to document attempts to meet the resident's needs or implement recommended psychiatric services, leading to a deficiency in the transfer and discharge process.
The facility failed to revise and update a resident's care plan after multiple incidents of verbal and physical aggression. Despite several documented incidents and hospital recommendations, the care plan lacked updated interventions and did not involve the resident in creating the care plan. Staff were not fully aware of the behavior support plan and relied on shift reports for information.
The facility failed to adequately monitor and address the behavior triggers of a resident diagnosed with mental disorder and psychosocial adjustment difficulty. The resident exhibited aggressive behaviors towards other residents and staff, which were not effectively managed or documented. The care plan was not reviewed or updated when the desired outcomes were not met, and staff did not implement hospital-recommended resources for managing the resident's mood disorder and aggressive behaviors.
Failure to Supervise High-Risk Resident and Respond to Exit Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with a known history of elopement. The resident had dementia, depression, Wernicke’s encephalopathy, heart failure, hypertension, and diabetes, and used a wheelchair for mobility. An Elopement Risk Evaluation identified the resident as an imminent elopement risk, with a prior elopement and a care plan that included a wanderguard, close supervision, and regular compliance rounds. Despite this, the resident was able to leave the building unnoticed and was later observed outside across the street from the facility. On the day of the incident, staffing records showed only one nurse and one Certified Medication Technician assigned to the second floor day shift, with no other staff scheduled on that floor. The resident’s assigned CNA last saw the resident asleep in his/her room early in the morning and was aware the resident had eloped previously but did not know when. The nurse’s note documented that the resident eloped and was escorted back into the facility, but did not specify how the resident exited the building. The resident later stated he/she did not remember leaving but expressed a desire to go outside at times. Environmental observations and staff interviews revealed that the second floor had two exit doors that were alarmed but did not have wanderguard sensors, and the front door was the only door equipped with a wanderguard sensor. Testing of the second floor exit doors showed one alarm near a resident room sounded for only about three seconds before stopping while the door remained open, and another exit alarm in the dining room sounded for about 30 seconds, yet no staff responded to either alarm. Staff on the second floor, including therapy staff and housekeeping, either did not hear the alarms or heard them but did not investigate. The Maintenance Director was unaware of the malfunctioning alarm, and the Administrator stated there should always be at least one staff member on the second floor and that staff were expected to respond immediately to door alarms, but this did not occur on the day of the elopement.
Failure to Notify Guardian of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's legal guardian of a significant change in condition and subsequent transfer to a hospital. The resident, who had diagnoses of schizophrenia and major depression and was under the guardianship of a Public Administrator, experienced behavioral issues that led to a decision by facility management to send the resident to the hospital. Documentation showed the resident was admitted to the hospital and remained there for several days, but there was no record of the guardian being notified of the change in condition or the hospital transfer. The facility's policy required prompt notification of the resident's legal representative in such situations. Interviews with staff revealed that the LPN responsible for the resident's care assumed that an orientee had notified the physician and guardian and documented the incident, but this was not confirmed or recorded. The orientee, who was new and on their first day, was unsure if the guardian had been contacted. The DON and Administrator acknowledged that the required notifications and documentation were not completed as per facility protocol. The deficiency was identified through review of records and staff interviews, which confirmed the lack of timely notification to the resident's guardian.
Resident Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards when a CNA did not secure the resident in bed before leaving to attend to another resident. The incident occurred when the CNA raised the resident's bed to provide care and then left the room upon hearing another resident calling for help. Upon returning, the CNA found the resident had rolled off the bed and hit their head on the floor, resulting in two lacerations. The resident, who had severe cognitive impairment and was dependent on activities of daily living, was found on the floor with a head injury. The resident's care plan indicated they were at risk for injury due to falls, unsteady gait, and poor safety awareness, and required the bed to be in the lowest position with brakes locked. However, at the time of the incident, the bed was not in the low position, and a mat was not placed on the floor. The CNA acknowledged the failure to secure the resident before leaving the room. The resident was subsequently taken to the hospital for treatment of the head injury.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling and dating of food items in the kitchen and unit nourishment room, which could potentially lead to foodborne illness and infection for 49 residents. During an observation, it was noted that several food items in dry storage, such as cereal, bread, and hamburger buns, were not labeled or dated. In cold storage, there were missing temperature logs for the walk-in freezer, a leaking walk-in refrigerator, and improperly dated food items like maraschino cherries and sweet relish. Additionally, thawed Ready Shakes lacked expiration dates. Cleaning supplies were improperly stored with cooking utensils, and a sanitizer bucket was found to be ineffective. Further observations revealed unsanitary conditions, including a dirty can opener and damaged ceiling tiles in the kitchen. The nourishment refrigerator on the third floor lacked a thermometer, and temperatures were not documented. Sandwiches were stored without a cooling mechanism, and the refrigerator's interior was sticky with melted popsicles. Interviews with staff, including the Dietary Manager and Registered Dietitian, confirmed awareness of the issues, but proper procedures were not followed, leading to these deficiencies.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified social worker despite having more than 120 beds, which is a requirement. The facility's job description for a social worker outlines the role's importance in assessing residents' psychosocial needs and coordinating services to enhance their quality of life. However, during an interview, the Administrator and Director of Nursing revealed that the facility was licensed for 130 beds but did not have a full-time licensed social worker. Instead, the current Social Service Director (SSD) was functioning in this role without the necessary qualifications. The SSD confirmed during an interview that she was not a licensed social worker and did not hold a degree. She only had a certification as a social service designee in long-term care facilities, which she obtained through a 36-hour basic online course recognized by the Missouri Department of Health and Senior Services. This lack of a qualified social worker has the potential to impact the residents' ability to receive necessary services to maintain a normal lifestyle.
Failure to Implement Legionellosis Prevention Measures
Penalty
Summary
The facility failed to implement and maintain appropriate infection control measures for Legionellosis assessment and prevention, potentially affecting all 49 residents. The facility's policy, titled 'Nursing Home Legionella Water Policy,' aims to minimize the risk of Legionella contamination in the water system. However, the policy was not followed, as a comprehensive risk assessment of all water systems was not conducted, and the water had not been tested. The Administrator acknowledged the lack of a water Legionella system, absence of a water flow diagram, and failure to complete a comprehensive assessment. Interviews revealed a lack of awareness and understanding of the water Legionella program and requirements among facility staff. The Maintenance Director was unaware of the program and did not understand what a comprehensive risk assessment of the water systems entailed. This lack of knowledge and action indicates a significant gap in the facility's infection prevention and control program, specifically concerning Legionella risk management.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for its residents by serving meals using disposable Styrofoam plates and cups. Observations on multiple occasions revealed that a significant number of residents in the 300-hall dining room were served desserts and beverages in disposable dishware. Specifically, on two separate days, 18 out of 22 and 19 out of 23 residents were served desserts on disposable plates, and 15 residents on each day were served beverages in disposable cups. This practice was inconsistent with the facility's policy on Dinnerware and Dining Services, which aims to ensure meals are served in a clean and attractive setting. One resident, identified as cognitively intact with a BIMS score of 15 out of 15, expressed a preference for regular dishware over disposable options. The Dietary Manager acknowledged the lack of sufficient regular plates and cups, leading to the use of disposable items. The facility's consultant Registered Dietitian confirmed that serving food and beverages in disposable dishware was a dignity issue, indicating a failure to uphold the residents' right to a dignified dining experience.
Failure to Maintain Clean and Comfortable Dining Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in its two dining rooms, which had the potential to affect all residents who ate meals there. Observations over several days revealed that the 300 hall dining room had stained and unclean chairs with dried food spills, unclean walls with dried food, and stained window curtains. Additionally, some dining room tables were unbalanced, with one table being supported by adjacent tables due to a loose base. The Administrator confirmed these observations and stated that housekeeping and dietary staff were responsible for cleaning, while maintenance staff were responsible for ensuring furniture was in good repair. However, a maintenance request regarding a wobbly table dated several months prior was found uncompleted, and the Maintenance Director was unaware of the current issues. In the 200 hall dining room, similar issues were observed, with several chairs being stained and unclean. The Administrator confirmed these findings and indicated that it was the housekeeping department's responsibility to clean the chairs. The Housekeeping Supervisor admitted that cleaning the chairs and curtains in the dining rooms was not part of the routine cleaning schedule and was unsure when they were last cleaned. These observations and interviews highlight a lack of adherence to the facility's housekeeping policy, which specifies regular and deep cleaning schedules.
Expired Medications and Unlocked Carts Found in Facility
Penalty
Summary
The facility failed to ensure that expired medications and supplies were removed from a treatment cart and a medication room, and also failed to keep a treatment cart and a nurse cart locked. During an observation of the medication room on Hall 300, several expired items were found, including a vial of ipratropium bromide albuterol sulfate, test tubes for viruses, mycoplasma, and chlamydia, sterile testing swabs, Eswab collection kits, acetaminophen suppositories, and prochlorperazine. The Licensed Practical Nurse (LPN) verified the expiration dates and acknowledged that the expired items were still available for resident use. The Director of Nursing (DON) confirmed that each shift should have checked for expired medications and supplies. Additionally, a treatment cart on Hall 200 was found unlocked and contained expired items such as xeroform petrolatum dressings, zinc oxide cream, and COVID-19 test kits. An LPN admitted to knowing the cart should have been locked but thought it was acceptable to leave it unlocked if she was nearby. Another nurse cart on Hall 300 was also left unattended and unlocked. The DON stated that staff were expected to keep treatment and medication carts locked when not in use, even if they were sitting at the nurses' station.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster container lids were kept closed when not in use, as required by their sanitation policy. During an initial observation, one of the dumpster lids was found open, with multiple bags of garbage visible over the top of the bin and garbage on the ground around it, emitting an odor. Subsequent observations confirmed that both lids remained open, with garbage still present on the ground. The Dietary Manager acknowledged the issue, stating that the lids should be closed. Despite this, staff continued to dispose of garbage without closing the lids, indicating a persistent failure to adhere to the facility's sanitation policy.
Inaccurate MDS Assessment Due to Missing PASARR Evaluation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident reviewed for Preadmission Screening and Resident Review (PASARR). The deficiency involved a resident with a diagnosis of schizophrenia who was admitted to the facility. The resident's annual MDS assessment inaccurately reflected their PASARR status, as it did not indicate that a Level II PASARR evaluation had been completed. This error was due to the MDS Coordinator not having access to the resident's PASARR Level II evaluation in the electronic medical record (EMR), which was only available in the resident's paper file. The Social Service Director Assistant confirmed that the resident had previously been evaluated by Level II PASARR, and the evaluation was located in the resident's paper file. The MDS Coordinator admitted to completing the PASARR section of the MDS without knowledge of the existing Level II PASARR evaluation, leading to the inaccurate assessment. This oversight placed the resident at risk of having unmet care needs and services, as the MDS did not accurately reflect the resident's mental health status and needs.
Failure to Follow Professional Standards in Glucose Monitoring and Wound Care
Penalty
Summary
The facility failed to adhere to professional standards of practice in two separate instances involving residents with specific medical needs. In the first instance, a Licensed Practical Nurse (LPN) did not follow the facility's policy for obtaining a finger stick glucose level for a resident with type 2 diabetes mellitus. The LPN failed to discard the first drop of blood after cleaning the fingertip with alcohol, which is a necessary step to ensure accurate blood sugar readings. This oversight was acknowledged by the LPN during an observation and interview, and the Director of Nursing (DON) confirmed the correct procedure, which includes discarding the first drop of blood with gauze. In the second instance, another LPN did not maintain a clean field during wound care for a resident with a history of pressure ulcers. The LPN placed the old dressing on the clean field with the new supplies instead of disposing of it in a trash bag or trash can, as required by the facility's wound care policy. This action was also acknowledged by the LPN during an interview, and the DON reiterated that dirty items should not be placed on the clean field. Both instances highlight a failure to follow established procedures, potentially compromising the quality of care provided to the residents.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to serve palatable food to residents, as evidenced by observations and interviews with three residents. Resident 24, who was cognitively intact, reported that the food served was not good, and the coffee and food were cold. During a meal observation, Resident 24 stated that the lunch was terrible, with unseasoned noodles and flavorless meat, although the food was warm. Resident 12, with severely impaired cognition, also reported that the food did not always taste good and was sometimes not hot. During a meal observation, Resident 12 stated that the lunch lacked flavor, and he only consumed part of the meal. Resident 3, who was cognitively intact, mentioned that the food was sometimes good and sometimes not, and it was not always hot. The Dietary Manager (DM) was unable to produce a recipe for the chopped pepper steak served at lunch, indicating that recipes were sometimes known by heart rather than followed precisely. The Registered Dietitian (RD) stated that recipes were not required for pre-made items, and staff were expected to follow manufacturers' instructions. However, the RD could not confirm if the pepper steak was pre-made, and the DM could not provide manufacturers' instructions as there was no more pepper steak available. This lack of adherence to recipes and instructions contributed to the deficiency in food palatability.
Incomplete Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information was complete, as it did not include the total number and actual hours worked by licensed and unlicensed staff on duty for both the Day and Night Shifts. This deficiency was observed on 07/12/24, when the staffing information posted in the facility's front lobby only contained details for the Day Shift, omitting the Night Shift information for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and Certified Nurse Assistants (CNAs). The receptionist, who was responsible for filling out and posting the staffing information, was unaware of the requirement to include Night Shift details. Interviews with the Human Resource Manager and the Administrator confirmed that the facility's daily posted nurse staffing information consistently lacked Night Shift data. The review of staffing postings from 06/01/24 to 07/11/24 further corroborated this omission, as none of the postings included Night Shift information. The Administrator acknowledged the absence of a formal policy for the daily posting of nurse staffing information, although it was expected that all required information would be included.
Inappropriate Involuntary Transfer Discharge
Penalty
Summary
The facility failed to provide an appropriate involuntary transfer discharge for a resident who was transferred to the hospital and not allowed to return. The resident, who had a history of mood disorders and aggressive behavior, was sent to the hospital after an incident where they attacked a receptionist. Despite the hospital deeming the resident stable for discharge, the facility refused to readmit the resident, citing safety concerns and the resident's aggressive behavior as reasons for the discharge. The facility's policies require specific documentation and attempts to meet the resident's needs before a facility-initiated transfer or discharge. However, the facility did not document any implementation of the psychiatric or therapeutic services recommended in the resident's hospital summary. Additionally, the facility did not provide adequate documentation of the specific needs that could not be met, the attempts made to meet those needs, or the services available at the receiving facility to meet those needs. Interviews with facility staff and the hospital representative revealed that the facility was aware of the resident's right to appeal the discharge but chose not to readmit the resident, even with the appeal. The facility's actions led to the resident being effectively abandoned at the hospital, requiring new placement. The facility's failure to follow proper procedures and provide necessary documentation resulted in a deficiency in the care and handling of the resident's transfer and discharge.
Failure to Update Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to revise and update a resident's care plan after multiple incidents of verbal and physical aggression. The resident, who was cognitively intact and had diagnoses including anxiety disorders and mood disorders, exhibited aggressive behaviors on several occasions. Despite these incidents, the care plan was not updated to reflect new interventions or to document the resident's involvement in creating the care plan. The care plan also lacked identified triggers for the resident's aggressive behaviors and did not include the positive reinforcement agreement that was implemented by the Administrator to manage the resident's behavior temporarily. The resident's progress notes documented several incidents of aggression, including calling a CNA derogatory names, yelling about smoking restrictions, and having an outburst in the dining room over the TV volume. In each case, there was no documentation of intervention revision or updates in the care plan. Additionally, after the resident was sent to the hospital for evaluation following an aggressive incident, the hospital's recommendations and resources for managing the resident's mood disorder and aggressive behaviors were not reviewed, implemented, or added to the care plan by the facility staff. Interviews with facility staff revealed that they were not fully aware of the resident's behavior support plan and relied on shift reports and a care book for information. The Administrator acknowledged that the resident's behaviors were explosive and that the care plan should have been updated to reflect the resident's needs and the interventions in place. However, the care plan did not show the resident's involvement in creating the interventions, and the staff had not reviewed the hospital's suggested resources for managing the resident's behavior.
Failure to Address Resident's Aggressive Behaviors
Penalty
Summary
The facility failed to adequately monitor and address the behavior triggers of a resident diagnosed with mental disorder and psychosocial adjustment difficulty. The resident exhibited aggressive behaviors towards other residents and staff, which were not effectively managed or documented. The care plan for the resident did not include identified triggers for the resident's behavioral symptoms, and staff did not involve the resident in creating the care plan. Additionally, the care plan was not reviewed or updated when the desired outcomes were not met after each documented verbal or behavioral aggression incident. The resident's medical records showed multiple instances of aggressive behavior, including verbal outbursts and physical aggression. Despite these incidents, staff did not document action steps or interventions in the medical record. The resident's Positive Support Contract, which was intended to manage the resident's behavior through positive reinforcement, was not documented as an intervention in the care plan. Furthermore, the facility did not implement any of the hospital-recommended resources for managing the resident's mood disorder and aggressive behaviors after the resident was sent to the hospital for evaluation. Interviews with facility staff revealed that they were aware of the resident's explosive behaviors but did not have a clear plan for managing them. The Administrator admitted that the resident's behaviors were unpredictable and that the interventions should have been reviewed and updated. Staff members also indicated that they relied on shift reports and care books for information about the resident's care needs but were unsure if a behavior support plan was in place. The lack of proper documentation and updated care plans contributed to the facility's failure to manage the resident's aggressive behaviors effectively.
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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