Oak Knoll Skilled Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ferguson, Missouri.
- Location
- 37 North Clark Avenue, Ferguson, Missouri 63135
- CMS Provider Number
- 265680
- Inspections on file
- 18
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oak Knoll Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with significant cognitive and physical impairments was transferred to the hospital for leg pain and swelling, where second-degree burns with blistering were discovered on both hands and the thigh. Facility staff failed to assess, document, or report these injuries prior to transfer, and no investigation was initiated as required by policy. The DON and administrator confirmed that staff did not follow procedures for reporting and investigating injuries of unknown origin.
A resident with severe cognitive impairment and behavioral symptoms was involved in a physical altercation with a housekeeper, during which the resident was reportedly hit in the face. Another resident witnessed the incident and eventually reported it to the receptionist. Several staff members observed or heard about the altercation but did not report it immediately, contrary to the facility's abuse and neglect policy requiring prompt reporting and investigation.
A CNA physically abused a resident with dementia and right-sided weakness by pulling the resident's hair multiple times after being struck during care. The incident, captured on video, occurred in the presence of other staff who did not intervene. The resident was dependent on staff for daily care and had a care plan requiring supportive interventions for distress, which were not followed. The abuse was not reported by staff at the time and was only discovered after another resident brought it to management's attention.
The facility failed to maintain complete and individualized care plans for several residents, omitting critical information such as the use of bed rails and code status. Observations showed discrepancies between the care plans and the actual needs of the residents, such as the presence of raised side rails not documented in the care plans. The Director of Nursing noted inconsistencies in the role of the MDS Coordinator, contributing to the lack of updated care plans.
The facility failed to assess and document the use of bed rails for several residents, contrary to its policy. Observations showed residents with cognitive impairments using bed rails without proper assessments or documentation in their care plans. Staff interviews revealed a lack of awareness regarding the need for assessments, with some believing side rails were standard with beds. The Administrator and DON acknowledged the need for assessments, but this was not consistently practiced.
The facility did not provide RN coverage for eight hours a day, seven days a week, despite having a census of 66 residents. The daily assignment sheets showed no RN scheduled on several dates. Interviews revealed that RN B worked part-time, and another RN worked every other weekend. The DON, who worked weekdays and weekends if needed, acknowledged she could not be considered a staff RN due to the census. The Administrator and DON agreed on the requirement for RN coverage.
The facility failed to maintain accurate records for controlled substances, with numerous blanks in the inventory logs from March to May 2024. The DON acknowledged that agency staff often neglected to sign the forms, which compromised the facility's ability to reconcile controlled substances accurately.
The facility failed to secure medication storage as required, with an LPN leaving the medication cart unlocked multiple times while administering medications, and the medication room door left open without supervision. Staff interviews confirmed that medication carts and rooms should be locked when unattended.
The facility did not maintain sanitary conditions in the kitchen by failing to label and date opened food items, including frozen meats and mixed fruit. This was observed during inspections, and both the Dietary Manager and DON confirmed the expectation for staff to label and date food. This issue had the potential to impact all 66 residents consuming food from the facility.
The facility failed to maintain complete and accurate medical records for several residents, resulting in numerous blank entries in the MAR/TAR for medications and treatments. This deficiency was observed across multiple residents with various medical conditions, and staff interviews confirmed that undocumented medications might not have been administered.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to Enhanced Barrier Precautions (EBP) by not wearing required PPE during high-contact activities with residents. Additionally, the facility did not implement a proper water management program to prevent the spread of pathogens like Legionella, lacking a water management team and a comprehensive understanding of the water systems.
The facility failed to conduct routine inspections of bed rails, leading to potential safety risks for several residents. Observations showed that side rails were used without proper assessments or documentation in medical records. Staff interviews revealed a lack of awareness and uncertainty about the use of side rails. The DON and Maintenance Director acknowledged the absence of routine maintenance checks, and the Administrator confirmed that assessments were not being conducted as required.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was sent to the hospital with swelling and pain in the left hip. The resident, who had diagnoses including Alzheimer's disease, hypertension, and pneumonia, required significant assistance with activities of daily living and had no documented open areas or bruises prior to the incident. Upon transfer to the hospital, staff there identified second-degree burns with blistering on both hands and the thigh, which had not been previously documented or reported by facility staff. Interviews revealed that the charge nurse on duty was focused on the resident's leg pain and swelling and did not assess or document the skin changes, specifically the blister on the left hand, which was only noticed by a CNA and an LPN as the resident was being transferred. Neither the charge nurse nor the LPN documented the blister or reported it to the Director of Nursing (DON). The DON, upon being notified by the hospital, stated she was unaware of how the burns occurred and had not interviewed nurse aides as part of the investigation, despite facility policy requiring comprehensive investigation and documentation of injuries of unknown origin. The administrator acknowledged that staff failed to report the skin changes prior to the resident's transfer, which prevented an investigation from being initiated. Facility policy required that all changes in a resident's condition, including skin injuries, be reported, assessed, documented, and investigated to determine the cause, but these steps were not followed in this case.
Failure to Protect Resident from Physical Abuse and Ensure Timely Reporting
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, schizophrenia, anxiety, and depression was involved in a physical altercation with a staff member. The resident, who had a history of verbal and physical behavioral symptoms, was reported to have been forcefully removed from a couch by a housekeeper. The resident did not recall the event and showed no physical injuries upon assessment, but later stated that the housekeeper hit them in the face near the left eye. Another resident, who had no cognitive impairment, witnessed the incident and reported seeing the housekeeper and the resident pushing each other, with the housekeeper hitting the resident in the eye. This witness was initially unsure about reporting the incident but eventually informed the receptionist. Additional staff interviews revealed that some staff heard or observed parts of the altercation but did not immediately report the incident, believing it had been resolved or that others would report it. The facility's abuse and neglect policy required immediate reporting and investigation of any suspected abuse. However, multiple staff members failed to report the incident promptly, and the housekeeper involved was later terminated for failing to report the altercation. The deficiency was identified through observation, interviews, and record review, confirming that the facility did not ensure the resident was free from physical abuse by a staff member.
Physical Abuse of Resident by CNA During Care
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) pulled a resident's hair multiple times while assisting the resident back to their room for hygiene care. The incident was captured on facility video footage, which showed the resident, who has dementia, right-sided weakness, aphasia, and other medical conditions, in a wheelchair in the dining room. After the resident struck the CNA in the face, the CNA followed and grabbed the resident's hair, with the action repeated two more times as the resident was pushed down the hallway. Two other staff members present did not intervene during the incident. The resident involved was dependent on staff for daily care due to cognitive loss and physical limitations, as documented in their care plan. The care plan specified that staff should provide assistance with transfers, toileting, bathing, and other care needs, and to use calming interventions if the resident showed signs of distress. Despite these directives, the CNA responded to the resident's behavior by physically grabbing the resident's hair, which constitutes physical abuse as defined by the facility's abuse/neglect policy. Interviews with staff present during the incident revealed that they did not witness or did not recall the altercation, and no immediate intervention was made to protect the resident. The CNA involved acknowledged that grabbing the resident's hair was wrong and stated it was a reaction to being scratched. The incident was not reported by staff at the time it occurred, and only came to management's attention after another resident reported it the following day.
Deficient Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure complete, accurate, and individualized care plans for five of the 18 sampled residents. The care plans did not address specific needs such as the use of bed rails and code status, which are critical for the safety and well-being of the residents. For instance, Resident #2's care plan did not include any information about the use of bed rails, despite observations showing the resident lying in bed with a quarter-length bed rail raised. Similarly, Resident #36's care plan lacked information regarding bed rails, even though observations noted the presence of raised side rails. Resident #34's care plan did not include information about the resident's code status, which is essential for emergency medical procedures. The facility's emergency medical procedures require that basic cardiac resuscitation be initiated in the event of a medical emergency, but the care plan did not reflect this information. Additionally, Resident #26's care plan did not address the use of side rails, despite observations of the resident lying in bed with side rails up. This lack of documentation and assessment poses a risk to the residents' safety and care. The Director of Nursing acknowledged that the MDS Coordinator was responsible for updating care plans, but there had been inconsistency in this role following the previous coordinator's departure. The care plans should reflect the residents' current needs, including the use of hospice, side rails, and other specific requirements. The facility's failure to maintain accurate and comprehensive care plans indicates a significant oversight in meeting the residents' needs and ensuring their safety.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that bed rails were accurately assessed as necessary devices prior to their installation and use for five of the 18 sampled residents. The facility's policy on the proper use of side rails, revised in October 2010, mandates that side rails should only be used to treat a resident's medical symptoms or assist with mobility and transfer. However, observations and interviews revealed that bed rails were used without proper assessments, documentation, or informed consent. For instance, Resident #62 had severe cognitive impairment and was observed with a U-shaped side rail raised, yet there was no documentation or assessment for its use in the care plan. Similarly, Resident #36, who also had severe cognitive impairment, was observed with quarter-length side rails raised on both sides of the bed without any physician's order or assessment documented. Resident #26, with severe cognitive impairment and schizophrenia, was observed with the top two quarter side rails up, despite the side rail use and risk assessment indicating no side rail was needed. These instances highlight a pattern of non-compliance with the facility's policy and federal regulations regarding the use of bed rails. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and responsibility for assessing the need for side rails. Some staff members believed that side rails were included with the beds and were used for positioning and turning, without recognizing the need for assessments or documentation. The Administrator and DON acknowledged that the use of side rails should be assessed by nursing staff before installation and included in the care plan, but this was not consistently practiced, leading to the deficiencies noted in the report.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, despite maintaining a census of 66 residents. Review of the facility's daily assignment sheets from 4/20/24 through 5/20/24 revealed that no RN was scheduled on multiple specific dates. Interviews with RN B and the Director of Nursing (DON) confirmed that RN B worked part-time on Tuesdays, Thursdays, and some weekends, while another RN worked every other weekend only. The DON, who worked Monday to Friday and weekends if needed, acknowledged that due to the facility's census, she could not be considered as a staff RN. The Administrator and DON agreed that the facility was required to have RN coverage for eight hours a day, seven days a week.
Deficiency in Controlled Substance Documentation
Penalty
Summary
The facility failed to establish a comprehensive system of records for controlled drugs, which is essential for accurate reconciliation. This deficiency was identified during an interview and record review, where it was found that the facility's controlled substance inventory records contained numerous blanks. These blanks indicated that the required documentation of controlled substance counts was not consistently completed. The facility's Controlled Substance Policy mandates that controlled substances must be counted upon delivery, with both the receiving nurse and the person delivering the medication order signing the designated narcotic record. However, the review of the inventory records from March to May 2024 showed multiple instances where the required signatures were missing, suggesting a lapse in adherence to the policy. During interviews, the Director of Nursing (DON) acknowledged that the controlled substances should be counted and documented by both the incoming and outgoing nurses at each shift change. The DON noted that the blanks in the inventory records were primarily due to agency staff failing to sign the forms. This oversight in documentation had the potential to affect all residents with controlled substance orders, as it compromised the facility's ability to accurately track and reconcile controlled substances, which is critical for ensuring the safety and proper management of medications for the residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely in accordance with professional principles. Observations revealed that a Licensed Practical Nurse (LPN) left the medication cart unlocked multiple times while administering medications to residents. The LPN walked away from the cart, leaving it unattended and unlocked, allowing residents to pass by it. This occurred on the 100 and 200 halls, with the LPN being away from the cart for several minutes at a time. Additionally, the medication room on the 200 hall was found to be left partially open without staff present at the nurse's station. A Registered Nurse (RN) also left the medication cart unlocked and unattended. During this time, a physical therapist entered the medication room unsupervised. Interviews with staff, including Certified Medication Technicians (CMTs) and the Director of Nursing (DON), confirmed that the medication carts and rooms should be locked when not in use, and only authorized staff should have access to the medication room.
Failure to Label and Date Opened Food in Kitchen
Penalty
Summary
The facility failed to maintain food under sanitary conditions by not ensuring that food was labeled and dated after being opened. This deficiency was observed during multiple inspections of the kitchen, where several opened and undated food items were found, including frozen hamburger, pork chops, hash browns, taco meat, buns, and bowls of mixed fruit covered with plastic wrap. The Dietary Manager and the Director of Nursing both acknowledged that the expectation was for staff to label and date food once the package had been opened. This oversight had the potential to affect all 66 residents who consumed food from the facility kitchen.
Incomplete Medication and Treatment Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for six residents, leading to a deficiency in maintaining medical records in accordance with accepted professional standards. The report highlights multiple instances where the Medication Administration Records (MAR) and Treatment Administration Records (TAR) contained blank entries, indicating that medications and treatments were either not administered or not documented properly. This issue was observed across several residents, each with specific medical conditions and treatment regimens that required precise documentation. For Resident #13, the MAR/TAR showed numerous blank entries for various medications and treatments, including nutritional supplements, iron tablets, anticonvulsants, and wound care treatments. Despite having a care plan that required specific interventions, the documentation was incomplete, with no explanations provided in the progress notes for the missing entries. Similarly, Resident #30's records showed blank entries for medications such as inhalers, anticonvulsants, and blood thinners, with only partial explanations in the progress notes for some of the missed documentation. Other residents, including Resident #26, Resident #2, Resident #51, and Resident #24, also had significant gaps in their MAR/TAR documentation. These residents had various diagnoses, including cognitive impairments, high blood pressure, schizophrenia, and Parkinson's disease, which necessitated consistent medication administration and documentation. The facility's failure to document these treatments accurately was confirmed through interviews with staff, who acknowledged that if a medication was not documented, it might not have been administered. The Director of Nursing and other administrative staff expressed their expectation for complete and accurate medical records, highlighting the deficiency in the facility's current practices.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to the Enhanced Barrier Precautions (EBP) policy during high-contact activities with residents. Specifically, staff did not wear the required personal protective equipment (PPE), such as gowns, when transferring residents with multidrug-resistant organisms (MDROs) or indwelling medical devices. For instance, two certified nurse aides (CNAs) were observed transferring a resident with a pressure ulcer without wearing gowns, despite the presence of an EBP sign on the resident's door. This oversight was repeated in another instance where a CNA failed to wear a gown while administering medications via a gastrostomy tube to a resident. Additionally, the facility did not properly implement its water management program to prevent the spread of waterborne pathogens like Legionella. Interviews revealed that the facility lacked a water management team, a water flow diagram, and a comprehensive understanding of the facility's water systems. The Maintenance Director was unaware of the potential respiratory infections caused by Legionella and did not have a structured approach to managing water safety, relying instead on monthly temperature checks and communication with the water company. The deficiencies in infection control practices and water management had the potential to affect all residents in the facility. The facility's Infection Preventionist and Director of Nursing acknowledged the importance of following infection control policies and procedures, including the need for a water system plan specific to the facility. However, the lack of adherence to established protocols and the absence of a structured water management program highlighted significant gaps in the facility's infection prevention efforts.
Failure to Conduct Routine Bed Rail Inspections
Penalty
Summary
The facility failed to ensure routine inspections of bed/side rails as part of a regular maintenance program, leading to potential safety risks for five residents. The facility's policy on the proper use of side rails, revised in October 2010, mandates that side rails should only be used to treat a resident's medical symptoms or assist with mobility and transfer. However, observations and interviews revealed that side rails were used without proper assessments or documentation in the medical records for several residents, including those with severe cognitive impairments and various medical conditions such as cancer, high blood pressure, and dementia. For Resident #62, observations showed a U-shaped side rail was used without a maintenance assessment, and staff interviews indicated a lack of awareness about the side rail's presence or use. Similarly, Resident #36 was observed with quarter-length side rails raised, but no maintenance assessment was documented. Resident #26, with severe cognitive impairment and schizophrenia, was also observed with side rails up, yet no maintenance assessment was found in the medical record. Resident #2, dependent on staff for all activities of daily living, had a bed rail raised without a physician's order or care plan direction, and staff interviews revealed uncertainty about the rail's use. The Director of Nursing and Maintenance Director acknowledged the lack of routine maintenance checks and assessments for side rails. The Maintenance Director admitted to only measuring the rails when initially installed and was unaware of a program to assess entrapment risks. The Administrator and DON confirmed that maintenance assessments for side rails were supposed to be conducted quarterly and as needed, but this was not being done, leading to the deficiency identified by the surveyors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
