Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monarch Springs Wellness & Rehabilitation during CMS and state inspections, most recent first.
Kitchen sanitation and dishwasher temperature failures: Surveyors observed caked-on stains and dirty grease on the stove, oven, and deep fryer, along with a kitchen floor that was dirty with crumbs, dirt, and debris. Cleaning logs showed the equipment and floor were marked as cleaned across multiple weeks, but no responsible party was listed. The dishwasher wash cycle was observed at 88 degrees and the rinse cycle at 104 degrees, and logs showed the wash cycle did not reach 120 degrees in any recorded opportunities, while the DM and another staff member stated they run the machine multiple times to get it up to temperature.
A facility failed to offer or document influenza and/or pneumococcal vaccinations for four sampled residents. EMR review showed no evidence that three residents were offered either vaccine and one resident had no documentation that pneumococcal vaccine was offered. Staff stated the admitting nurse was expected to verify immunization records, offer vaccines on admission and seasonally, and document the results in the EMR.
Failure to Follow Discharge Procedures After Immediate Discharge: A resident with repeated PCP use, AMS episodes, and multiple hospital transfers was issued an immediate/emergent discharge after violating the facility’s drug and alcohol policy and behavioral contract. After the resident left the facility with DPOA permission and was later sent to the hospital again for suspected intoxication, the hospital social worker said the resident would return despite the facility’s discharge paperwork, and staff documented that the resident was not to be accepted back.
A resident with DVT, HF, arthritis, malnutrition, and significant mobility impairment was assessed by therapy as needing bilateral 1/4 bed rails to support bed mobility, but the resident remained in bed without side rails. The resident said a side rail was wanted for repositioning and reported therapy had requested and ordered it, while staff gave conflicting accounts about whether side rails were used in the facility and noted there was no physician order and the rail had not been installed.
The facility failed to follow physician orders for three residents. One resident with severe cognitive impairment and multiple diagnoses received medications despite blood pressure readings outside ordered parameters, including midodrine when the BP was 131/83 and other meds when the BP was 89/54. Another resident with ESRD, aphasia, seizure disorder, and malnutrition missed ordered MedPass supplements because the orders were not transcribed correctly, and staff observed no supplement provided with meals. A third resident with severe cognitive impairment and Alzheimer’s disease was served pureed foods even though the order called for a minced and moist diet with thin liquids.
The facility failed to complete bed rail assessments and update care plans for two residents whose beds had assist rails in place. Both residents were cognitively intact, had multiple medical diagnoses, and were observed awake in bed with both assist rails up on several occasions. The records showed no physician orders for the rails, no bed rail assessments, and no documentation in the care plans for assist and/or enabler rail use. The DON stated assessments and physician orders were expected for residents with bed rails or assist rails.
A facility failed to document physician responses to pharmacist MRR recommendations for three residents. One resident was receiving PRN diazepam beyond the usual 14-day limit, another had PRN cyclobenzaprine and tizanidine recommended for discontinuation because they had not been used, and a third had a recommendation for GDR evaluation for duloxetine. The records did not show physician rationale or responses to the pharmacist findings, and the DON stated physician responses to monthly medication recommendations were expected.
Medication administration errors exceeded the allowed rate when a CMT gave an antihypertensive before checking a resident’s BP and another resident’s gabapentin was dropped on the floor and could not be replaced because no refill was available. The residents had diagnoses including HTN, CHF, stroke, hemiplegia, malnutrition, COPD, and Type I DM, and the observed error rate was 5.41%.
Expired IV meds were found in a medication storage room, including multiple bags of NS used to prepare cefepime and vancomycin. Staff said no single nurse or CMT was responsible for routinely checking and removing expired meds, and the RN, Administrator, and DON all stated staff were expected to waste or remove them when noticed.
Failure to use EBP and provide accessible PPE: Staff did not wear gowns and gloves while giving direct care to a resident with a g-tube, including transfers and bedside care. Another resident with VRE, active wounds, and EBP orders had an EBP sign on the door, but no PPE was available near the room. Staff and leadership stated gowns and gloves were expected for direct care and PPE should be available at or near the room entrance.
Failure to post Ombudsman and survey hotline information: Observations showed no readily available posting of the State LTC Ombudsman program or State Survey Agency hotline number in the entrances, dining room, or unit halls. In a group interview, 9 of 9 residents said they did not know where the information was located. The Administrator later stated the contact info was posted on a sheet of paper across from the elevator, and a white 8 x 11 inch sheet with several contact numbers was observed there.
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.
Kitchen sanitation and dishwasher temperature failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations of the kitchen, surveyors found the stove with caked-on stains along the front and top and on the burners, the oven with heavy caked-on stains and caked-on matter along the inside doors and along the bottom, top, and sides, and the deep fryer containing dirty grease and heavy caked-on stains inside. The kitchen floor was also noticeably dirty with food crumbs, dirt, and debris. Review of the kitchen daily/after each use cleaning schedules showed the floor, range/grill, and oven were initialed as cleaned Monday through Friday across multiple weeks, but no responsible party was listed for any of the days. The facility also failed to ensure the dishwasher wash and rinse cycles reached the required temperatures during the dishwashing process. Observation of the dishwasher showed the wash cycle reached 88 degrees and the rinse cycle reached 104 degrees. Review of the April 2026 and May 2026 dish machine logs showed the wash cycle temperatures were logged and initialed at 120 degrees and/or above for 0 of 90 opportunities in April and 0 of 18 opportunities in May, while the sanitizer temperatures were logged and initialed at 120 degrees and/or above for 22 of 90 opportunities in April and 6 of 18 opportunities in May. During interview, the Dietary Manager and another staff member stated they run the dishwasher a couple of times to get it up to temperature, that the wash cycle should be at 120 degrees and the rinse cycle at least 115 degrees or above, and that a booster was being installed because of electrical work affecting water temperatures.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide or offer influenza and/or pneumococcal vaccinations for four of five residents sampled for immunization status, out of a sample of 16 residents. Review of the facility’s policies showed that residents or their legal representatives were to receive education about the benefits and potential side effects of pneumococcal and influenza immunizations, have the opportunity to refuse, and have the offer, consent/refusal, and vaccination status documented in the medical record. Record review showed no documentation that Resident #2 received or was offered influenza or pneumococcal vaccines, no documentation that Resident #9 received or was offered influenza or pneumococcal vaccines, and no documentation that Resident #40 received or was offered influenza or pneumococcal vaccines. Resident #33’s record also lacked documentation that pneumococcal vaccine was offered. Staff interviews indicated the admitting nurse was expected to check immunization records on admission, offer influenza and pneumococcal vaccines upon admission and when seasonally appropriate, and document immunizations in the EMR. The DON and Administrator stated they expected residents to be offered these vaccines upon admission unless prior immunization documentation was available, and that the ADON/IP was responsible for auditing vaccination status.
Failure to Follow Discharge Procedures After Immediate Discharge
Penalty
Summary
The facility failed to follow appropriate discharge procedures for a resident when staff did not re-admit the resident after the resident returned from the hospital following an immediate discharge. The resident had a history of substance use, including repeated positive tests for PCP and marijuana, altered mental status episodes, and multiple hospital transfers related to intoxication or suspected intoxication. The resident’s care plan and progress notes documented ongoing concerns about illicit drug use, room searches, monitoring for intoxication, and discussions with the DON, Administrator, Social Services, and the resident’s DPOA about the resident’s behavior and possible discharge if the behavior continued. The resident returned from the hospital on 4/14/26 after an episode of altered mental status and was later re-educated on the facility’s drug and alcohol policy. The record showed that on 4/22/26 the facility issued a notice of transfer or discharge stating that the resident was a danger to self and others and that an immediate and emergent discharge was necessary. The resident later left the facility with DPOA permission to get fresh air and did not return as expected. The next morning, staff noted dilated pupils and searched the resident’s belongings, finding four cigars dipped in an unknown wet substance with a pungent smell. EMS, police, the physician, the Administrator, and the DPOA were contacted, and the resident was sent to the hospital for further evaluation. After the resident was sent out, the hospital social worker contacted the facility and stated the resident would be returning despite the facility’s immediate discharge paperwork. Facility staff documented that the resident had been issued immediate discharge paperwork and that the resident was not to be accepted back. The resident remained at the hospital, and the facility later met with the DPOA and documented that the resident had been issued an emergency discharge related to violating the behavioral contract and waiving the right to appeal. Interviews with CNA, SW, DON, and the Administrator confirmed the resident’s repeated drug-related incidents, the facility’s belief that the resident was not to return, and the disagreement with the hospital regarding whether the resident could appeal and return.
Failure to Provide Ordered Bed Rails
Penalty
Summary
The facility failed to ensure staff provided one resident with the appropriate bed rails to assist with repositioning. The resident had diagnoses including deep venous thrombosis, heart failure, arthritis, and malnutrition, was cognitively intact, used a wheelchair, had impairment to both sides of the upper and lower extremities, and required substantial to maximal assistance to roll and dependent assistance for bed mobility and transfers. The resident’s care plan addressed the need for staff assistance with repositioning, and a bed rail utilization assessment completed by therapy recommended bilateral 1/4 rails as an enabler to promote bed mobility and independence. During observation, the resident was in bed without a side rail and stated a side rail was wanted to assist with repositioning. The resident later said therapy had requested and ordered the rail, but it was not on the bed. The Maintenance Director stated he had been told residents in the facility did not use side rails and that he had never installed one, while the Director of Rehab said the resident was able to receive side rails and expected them to be present after the assessment, depending on the type of rail and bed. The Administrator stated residents could have side rails after assessment and physician order, but there was no physician order for this resident and the rail had not been installed.
Physician Orders and Diet Orders Not Followed
Penalty
Summary
The facility failed to obtain and follow physician orders for three residents. For one resident with severe cognitive impairment, heart failure, hypertension, orthostatic hypotension, diabetes, bipolar disorder, asthma, and respiratory failure, the medication administration record showed hydrochlorothiazide and gabapentin were given when the documented blood pressure was 89/54, even though both orders required holding the medications if blood pressure was below 100/60. The same resident also received midodrine on multiple occasions, including when the blood pressure was 131/83, despite the order directing staff to hold the medication if systolic blood pressure was greater than or equal to 100 mmHg or diastolic blood pressure was greater than or equal to 80 mmHg. During interview, nursing staff and the DON acknowledged the blood pressure parameters should have been followed and the medication should have been held when the reading was 131/83. For another resident with ESRD, aphasia, seizure disorder, and malnutrition, the registered dietician documented that weekly weights were stable and later documented weight loss with a recommendation to increase MedPass from 60 mL three times daily to 120 mL three times daily. The physician orders showed the 60 mL order ended and later an active 120 mL order was entered, but observations on multiple meals showed no meal supplement shake was provided at breakfast or lunch. Staff interviews confirmed the resident was supposed to receive meal supplements with meals, that the supplements were kept on the medication carts, and that the resident missed doses of MedPass because the orders were not transcribed correctly. For a third resident with severe cognitive impairment, non-traumatic brain dysfunction, Alzheimer's disease, and malnutrition, the care plan and physician order called for a regular diet with minced and moist texture and thin consistency. However, during meal observations the resident was served foods in a pureed consistency, including spaghetti, vegetables, garlic bread, beef tacos, Spanish rice, and refried beans. The Administrator stated speech therapy was responsible for changing diet orders in the electronic medical record and said the diet orders should have been accurate and the care plan should have reflected a pureed diet.
Failure to Assess and Document Assist Rail Use
Penalty
Summary
The facility failed to ensure bed rail assessments were completed and care plans were updated for two residents whose beds had assist rails in place. The facility policy required an individualized assessment of bed rail use, review of alternatives, informed consent when used as an enabler, documentation in the plan of care, and quarterly review and maintenance checks. However, for both residents, the record showed no physician order for assist rails, no bed rail assessment, and no documentation in the care plan for use of assist and/or enabler rails. Resident #43 had an admission MDS dated 2/9/26 showing intact cognition and diagnoses including depression, anxiety disorder, asthma, and malnutrition, with additional diagnoses of dystonia, hallucinations, anemia, and rhabdomyolysis in the medical record. Resident #33 had a quarterly MDS dated 4/13/26 showing intact cognition and diagnoses including depression, anxiety disorder, asthma, other orthopedic conditions, and PVD, with additional diagnoses of major depressive disorder, hypothyroidism, and atrial fibrillation. Observations showed both assist rails up while each resident was awake in bed on multiple occasions. The DON stated it was her expectation that bed rail assessments should have been done for residents with assist rails or bed rails and that there should also be physician orders for the assist rails.
Missing Physician Responses to Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that physician responses were documented for pharmacist medication regimen review recommendations for three sampled residents. The report states that the consultant pharmacist performed monthly medication regimen reviews and identified irregularities, but the medical record did not show physician responses to those recommendations for Residents #43, #33, and #4. The facility’s policy required monthly review of each resident’s medication regimen and clinical record, reporting of findings and recommendations, and documentation of prescriber responses or explanations when recommendations were not followed. For Resident #43, the record showed diagnoses including depression, anxiety disorder, asthma, malnutrition, dystonia, hallucinations, anemia, and rhabdomyolysis. The resident was receiving Diazepam 5 mg every eight hours as needed for anxiety. The pharmacist’s monthly medication review dated 3/29/26 recommended evaluating the continued need for the medication and, if extended beyond the usual 14-day PRN limit, documenting the rationale and a specific duration. The record did not contain documentation of the physician’s rationale for extending the medication or any physician response to the review. For Resident #33, the record showed diagnoses including major depressive disorder, hypothyroidism, atrial fibrillation, depression, anxiety disorder, asthma, orthopedic conditions, and peripheral vascular disease. The pharmacist’s monthly medication review dated 3/29/26 recommended discontinuing PRN cyclobenzaprine 10 mg every eight hours and tizanidine 4 mg every six hours because neither muscle relaxant had been used since admission, and the pharmacist noted this would reduce CNS depression and polypharmacy. The record did not contain a physician response to that recommendation. For Resident #4, the record showed moderate impaired cognition and diagnoses including depression, dementia, stroke, psychotic disorder, anxiety disorder, coronary artery disease, Parkinson’s disease, and hyperlipidemia. The pharmacist’s monthly medication review dated 1/29/26 stated that the resident had been receiving Duloxetine 30 mg twice daily since 5/2025 and that an evaluation for gradual dose reduction should be documented. The review included checkboxes for reasons a gradual dose reduction might be contraindicated, but nothing was marked, and the record did not contain documentation of the physician’s response to the review. During interview, the DON stated she would expect the physician to document a response to pharmacist recommendations or document a rationale if not following them, and that monthly medication reviews were expected to be acted upon.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, and the medication error rate was 5.41% based on two errors observed during 37 medication administrations. One resident with diagnoses including congestive heart failure, hypertension, UTI, and Type I diabetes had an active order for losartan 25 mg daily for hypertension, but during the morning medication pass the CMT gave the resident the medication before obtaining the resident’s blood pressure. The blood pressure cuff was applied only after the resident had already taken the medication. A second resident with diagnoses including stroke, hypertension, hemiplegia, malnutrition, and COPD had an active order for gabapentin 100 mg three times daily with meals. During the morning medication pass, the resident dropped the gabapentin capsule on the floor after it had been administered, and the CMT wasted the medication because it was no longer clean. The CMT then reported that the medication was the last capsule in the card, no replacement card was available, and none had been reordered in the system. Interviews with RN D and the Administrator/DON confirmed that vital signs should be obtained before giving medications dependent on blood pressure and that medication refills were expected before the last dose was used to avoid missed doses.
Expired IV Medications Found in Medication Storage Room
Penalty
Summary
The facility failed to properly store medications and biologicals in the medication rooms. During observation of the third-floor medication storage room behind the nurse’s station, surveyors found 17 expired bags of intravenous solutions used for antibiotic preparation: six 100 mL bags of normal saline for cefepime expired on 2/7/26, six 100 mL bags of normal saline for cefepime expired on 2/24/26, and five 200 mL bags of normal saline for vancomycin expired on 3/1/26. The sample size was 16 and the census was 53. The facility’s policy stated that only authorized staff could access medications, medication rooms and supplies were to be locked when unattended, and outdated medications were to be removed from inventory and disposed of according to procedure. In interview, a CMT stated no one staff member was primarily responsible for removing or wasting expired medications, and each CMT or nurse was expected to do so if they noticed them. An RN stated nursing staff did not routinely go through the third-floor medication room and that most stock medications were kept in the second-floor central supply room. The Administrator and DON stated they would have expected staff to waste or remove the expired medications, and noted the facility pharmacy partner came twice daily to provide medication wasting and removal services.
Failure to Use EBP and Provide Accessible PPE
Penalty
Summary
The facility failed to follow infection control standards for Enhanced Barrier Precautions (EBP) when staff did not wear a gown and gloves while providing direct care to a resident with a gastrostomy tube and when PPE was not readily available near the room of another resident with EBP orders. The facility’s policy stated that EBP should be used for residents meeting specified criteria and during high-contact care activities such as dressing, bathing, transferring, hygiene, changing linens, changing briefs, toileting assistance, device care, and wound care. One resident’s quarterly MDS showed cognitive impairment and a diagnosis that included a g-tube. The resident’s care plan included EBP with instructions for direct care staff to use gowns and gloves for any direct care. During observation, CNA H and CNA I assisted the resident with meals, transferred the resident from a Broda chair to bed, and covered the resident with bed sheets, but neither CNA donned PPE before providing direct care on two separate occasions. The resident’s ePOS showed no active EBP order related to the g-tube. Another resident’s quarterly MDS showed cognitive intactness and diagnoses including depression, anxiety disorder, asthma, orthopedic conditions, and PVD. The resident had orders for contact isolation precautions due to VRE, EBP related to wounds, and multiple wound treatment orders for a venous insufficiency ulcer and a surgical dehiscence wound. Observations on three occasions showed the resident in the room with an EBP sign on the door, but no PPE was located near the door. Staff interviews stated that residents with g-tubes, wounds, catheters, or tracheostomies should have active EBP orders followed and that gowns and gloves were expected for direct care, while the DON and Administrator stated PPE should be available at or near the room door for residents with EBP orders.
Failure to Post Ombudsman and Survey Agency Contact Information
Penalty
Summary
The facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program or the State Survey Agency hotline number that was readily available to residents without assistance. With a census of 53, observations on 5/4/26, 5/5/26, 5/6/26, and 5/7/26 showed no posted information for the Ombudsman program or the State Survey Agency hotline number in the facility entrances, dining room, or halls of each unit. During a group interview on 5/6/26 at 11:30 A.M., nine out of nine residents said they did not know where the information regarding the State Long-Term Care Ombudsman program and/or the State Survey Agency hotline number was located. On 5/7/26 at 1:30 P.M., the Administrator stated the contact information was posted on a sheet of paper across from the elevator, and observation later that day showed a white 8 x 11 inch sheet of paper across from the first-floor elevator with several contact numbers listed. The Administrator also stated the Resident's Rights could have been removed from the area, but it was in the admission packet, and he would have expected the information to have been posted.
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,062 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near University City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| U-city Forest Manor | 1.2 mi | ★★★★★ | 23 | 0 |
| Delhaven Manor | 1.5 mi | ★★★★★ | 1 | 0 |
| Normandy Nursing Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Oak Park Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Barnes-jewish Extended Care | 2.4 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.