Pillars Of North County Health & Rehab Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 13700 Old Halls Ferry Road, Florissant, Missouri 63033
- CMS Provider Number
- 265341
- Inspections on file
- 19
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pillars Of North County Health & Rehab Center, The during CMS and state inspections, most recent first.
Staff did not immediately report a resident's sexual abuse allegation against a CNA to administration, as required by facility policy. Instead, the incident was only disclosed to the DON and the resident's family after police were called for an unrelated wellness check. The resident, who had dementia and other conditions, later denied the allegation, but the delay in reporting constituted a deficiency in abuse prevention procedures.
A resident with a history of stroke, malnutrition, and a g-tube did not receive prescribed tube feedings and water flushes as ordered, and staff failed to follow standard practices for enteral nutrition management, including verifying tube placement, checking residuals, and accurately monitoring intake and weight. The feeding pump frequently malfunctioned, and incomplete feedings were not documented or reported to the physician. Facility leadership and the Medical Director were unaware of these issues, and family concerns about weight loss and inadequate care were not fully investigated.
Four residents with conditions requiring pureed diets, including those with dysphagia and neurological impairments, were served pureed chicken that was not prepared to the correct texture because dietary staff failed to follow the recipe and omitted the required thickener, resulting in an improper meal consistency.
Surveyors found that the facility did not keep the walk-in refrigerator at or below 41°F as required, with temperature logs missing for two days and thermometer readings above the standard. Additionally, three residents had water containers with visible brown substances, and staff confirmed that daily cleaning and proper supply of water pitchers were not consistently maintained.
Surveyors identified multiple deficiencies in environmental cleanliness and safety, including unclean bathroom vents with dust and cobwebs, plungers stored directly on the floor, urinals improperly stored on handrails, a missing bathroom light cover, and a broken bed footboard with exposed nails and screws. The Maintenance Director confirmed these issues during follow-up observations and stated that maintenance requests had not been received for these problems.
Two residents with significant medical conditions and fall risks were repeatedly observed with their call lights out of reach, despite staff acknowledging responsibility for ensuring accessibility. One resident's call light was clipped to a privacy curtain, while another's was draped over a wall fixture, leaving both unable to summon assistance as needed.
A resident with quadriplegia and intact cognition was not provided with his preferred shower and instead received bed baths, despite staff being aware of his preference. The care plan did not address his bathing choice, and staff cited a broken shower bed and an unsuitable shower chair as reasons for not accommodating his request.
A resident with multiple diagnoses and intact cognition reported being verbally abused by a CNA, but the allegation was not promptly reported or investigated according to facility policy. The Activity Director received the report but did not initiate an investigation or notify the Administrator, resulting in a delay in reporting the incident to the appropriate authorities.
A resident was admitted with psychiatric diagnoses including schizoaffective disorder, anxiety disorder, and major depressive disorder, but the facility did not complete a required Level Two PASARR assessment. The resident exhibited moderate cognitive impairment and behavioral issues, and staff interviews confirmed that the necessary assessment was not performed due to lack of notification and awareness.
Two residents did not have comprehensive care plans addressing their specific needs: one resident with pain and multiple pain medications lacked a care plan for pain management, while another resident with severe cognitive impairment and total dependence on staff for ADLs had no care plan for ADL assistance. These omissions were confirmed by the MDS Coordinator.
A resident who was fully dependent on staff for care and had moderate cognitive impairment was observed with excessively long fingernails on multiple occasions, despite a care plan requiring grooming. The resident stated a preference for trimmed nails, but staff interviews revealed confusion about responsibility for nail care, especially for hospice patients, resulting in the resident's needs not being met.
A resident with quadriplegia and other medical conditions was not properly notified of a scheduled physician appointment, resulting in the resident being unable to prepare in time and subsequently missing the appointment. Documentation of the appointment existed, but unclear staff responsibilities and communication breakdowns led to the deficiency.
A resident with ESRD missed a dialysis appointment due to transportation issues, and staff failed to administer the ordered as-needed Lokelma, document the missed appointment, or notify the physician. The LPN on duty was unaware of the as-needed order, and the DON was not informed of the incident.
A resident with a mouth infection and dental issues did not receive a dentist visit as ordered by the physician. Although antibiotics and pain relief were prescribed, there was no record of a dental appointment being scheduled or completed. Staff interviews revealed that the order for a dental visit was not communicated to the Social Services Director or receptionist, and the DON confirmed the resident was not seen by a dentist due to this lapse.
The facility did not ensure physician orders in the EMR were accurate and current for three residents, resulting in outdated orders for hospice, dialysis, and restorative services. In each case, orders remained active despite changes in the residents' care needs or service locations, and staff confirmed the inaccuracies and lack of timely updates.
Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for three residents on Enhanced Barrier Precautions, including wound care and incontinence care. Observations showed that a wound physician, a wound LPN, and two CNAs provided care without donning gowns, despite facility policy and posted signage requiring this protection for residents with open wounds or other qualifying conditions.
Two residents who had consented to receive influenza or pneumococcal vaccines were not administered the vaccines as required. Documentation in the EMR confirmed the lack of administration, and the Infection Preventionist acknowledged that these vaccinations were missed despite proper consent.
The facility failed to follow its pressure ulcer and wound care policies, resulting in deficiencies for two residents. One resident's wound care orders and dietician recommendations were not promptly implemented, and pressure ulcers on the feet were not identified or reported. Another resident was admitted with a pressure ulcer but lacked a treatment order for several days, and dietician recommendations were delayed. The facility's lack of communication and documentation led to inadequate care.
The facility failed to monitor a resident diagnosed with COVID-19 according to their policy. Despite changes in the resident's condition being reported, vital signs and assessments were not documented. The resident was found unresponsive and later pronounced dead, with the cause of death determined to be COVID-19. The Director of Nursing confirmed that the facility's policies were not followed.
Failure to Immediately Report Abuse Allegation to Administration
Penalty
Summary
Facility staff failed to follow the established Abuse Prevention Program policy, which requires immediate reporting of any incident, allegation, or suspicion of abuse to the administrator. In this case, a resident with diagnoses including dementia, heart failure, mood disturbance, anxiety, and psychotic disturbance accused a CNA of sexual assault while being assisted to bed. The CNA immediately informed two other CNAs of the allegation, but none of the staff reported the incident to administration as required. Instead, they dismissed the allegation, believing it to be untrue, and considered the matter resolved among themselves. The deficiency was discovered when the resident's family member, unaware of the abuse allegation, called the police for a wellness check due to concerns about the resident being soiled and not changed by staff. Upon the police's arrival, a CNA informed the family member about the previous day's abuse allegation, which was the first time the family and administrative staff became aware of the incident. The DON was then notified and initiated an investigation. The resident later denied the abuse allegation and stated a preference against care from staff of the opposite sex. The failure to report the allegation immediately to administration constituted noncompliance with the facility's abuse reporting policy.
Failure to Follow Physician Orders and Provide Adequate G-Tube Management
Penalty
Summary
The facility failed to provide services that meet professional standards by not following physician orders and not ensuring adequate management of a resident's enteral gastrostomy tube (g-tube). The resident, who had a history of cerebral infarction, hemiplegia, aphasia, myocardial infarction, severe protein-calorie malnutrition, and was admitted with a g-tube, was supposed to receive continuous tube feeding and regular g-tube flushes as ordered by the physician. However, documentation showed that the prescribed tube feedings and water flushes were not consistently administered, and there were no orders or documentation for essential aspects of g-tube care such as residual checks, placement verification, or monitoring intake and output. The facility also lacked clear policies and procedures for these standard practices. Observations and interviews revealed that the resident's feeding pump frequently malfunctioned, resulting in incomplete delivery of nutrition, and staff did not consistently document the amount of feeding received or notify the physician when feedings were missed or incomplete. The resident was observed lying flat in bed while receiving tube feeding, contrary to the requirement for head-of-bed elevation to reduce aspiration risk. Staff interviews indicated a lack of awareness and adherence to standard practices, such as checking tube placement and residuals, and there was confusion about proper documentation and communication with the physician regarding feeding issues. Additionally, the facility failed to accurately monitor the resident's weight, as weights were recorded without accounting for the weight of the wheelchair cushion, leading to inaccurate assessments of the resident's nutritional status. Family members reported concerns about the resident's weight loss, lack of nutrition, and inadequate care, which were not thoroughly investigated by facility leadership. The Medical Director and facility administration were unaware of the ongoing issues with the resident's enteral feeding and weight loss, and there was no evidence that standard practices for enteral nutrition management were being followed or that staff were properly trained in these procedures.
Failure to Prepare Pureed Chicken to Proper Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure that pureed chicken lunch entrees were prepared to the proper texture for four residents who required a pureed diet. Review of the dietary recipe for Maple Glazed Puree Chicken specified the use of a food thickener to achieve the correct consistency, but observation in the kitchen revealed that the pureed chicken contained water surrounding the chicken, indicating improper preparation. The Dietary Aide admitted to forgetting to add the thickener due to being busy, and the Dietary Manager acknowledged that the thickener gel could have been mixed in to correct the issue. The Dietary [NAME] confirmed that the thickener was not used for the puree chicken. The residents affected included individuals with significant medical needs such as quadriplegia, traumatic brain injury, cerebral palsy, malnutrition, and dysphagia, all of whom required a mechanically altered or pureed diet as documented in their medical records. The failure to follow the prescribed recipe and dietary orders resulted in the pureed chicken being served in an improper texture, which could make the meal unpalatable and difficult to swallow for these residents.
Failure to Maintain Safe Food Storage and Sanitary Water Containers
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at or below 41 degrees Fahrenheit as required by professional standards and facility policy. Observations revealed that the refrigerator temperature was not recorded for two days, and when checked, the thermometer read 46 degrees Fahrenheit in the morning and 42 degrees Fahrenheit in the evening. The Dietary Manager confirmed that temperatures were supposed to be checked and recorded daily, and that staff should have reported any temperature deviations for service. The Administrator also stated that staff were expected to monitor refrigerator temperatures daily. Additionally, the facility did not ensure that bedside water containers were cleaned and sanitized daily as per policy. Three residents were observed with water containers that had an unknown brown substance on the sides or handles, and one container was found in a bathroom on the back of a toilet tank. The Dietary Manager admitted that water pitchers were supposed to be cleaned every morning but was not fully up to date with all policies and acknowledged that the facility did not have two complete water container sets for each resident as required. The Activities Director confirmed that both nursing and dietary staff were responsible for ensuring the cleanliness of water containers.
Environmental Cleanliness and Safety Deficiencies Identified
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of unclean bathroom vents, improper storage of urinals and plungers, and unsafe or broken fixtures and equipment. Surveyors observed thick dust and cobwebs on bathroom vents in several resident rooms, with one instance of a spider hanging from a cobweb near a toilet. In multiple bathrooms, plungers were found in direct contact with the floor, and in one case, dead bugs were present in a light fixture cover. Additionally, urinals were found hanging on handrails without proper labeling or sanitary storage, and a bathroom light was missing its cover, exposing bulbs and mechanisms. Further observations revealed a broken bed footboard with sharp nails and screws exposed on top of a resident's dresser, creating a potential hazard. The Maintenance Director (MD) confirmed these issues during follow-up observations and stated that housekeeping staff were expected to clean vents and that plungers should be stored in plastic tubs to prevent contact with the floor. The MD also acknowledged that urinals should be stored in bags for sanitation and that the broken bed footboard posed a risk of accident. The MD reported that maintenance requests are typically submitted via a mailbox and paperwork slips, but no requests had been received for the observed issues. The facility's policy on routine maintenance assigns responsibility to maintenance staff for ensuring preventative and routine maintenance in compliance with life safety standards. However, a housekeeping policy was requested but not provided before the survey exit. The deficiencies were identified for 11 out of 26 residents observed for environmental conditions, with direct observations and confirmations by the MD, but without evidence of timely maintenance or housekeeping intervention prior to the survey.
Failure to Ensure Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents who were at risk for falls and had significant medical conditions. One resident, who had end stage renal disease and chronic obstructive pulmonary disease, was observed on multiple occasions with her call light clipped to the privacy curtain approximately three feet out of reach. She was unaware of the location of her call light, and her daughter reported that it was usually clipped to the curtain when she visited. This resident had a documented history of multiple falls during her stay, including unwitnessed falls resulting in a bruise to the face. Another resident, with a history of a right femur fracture and epilepsy, was also observed on several occasions with his call light draped over a wall light fixture, out of his reach and sight. This resident was moderately cognitively impaired and had a recent history of falls. Staff interviews confirmed that call lights should be within reach of residents and that all staff were responsible for ensuring this, but observations showed that this was not consistently done for these residents.
Failure to Honor Resident Bathing Preference Due to Equipment Issues
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for bathing type, specifically not providing the resident with a shower as requested. The resident, who was cognitively intact with a BIMS score of 14 and had quadriplegia (C5-C7 incomplete), depression, and hypertension, had indicated that having a bath of his choice was very important. Despite this, the resident's care plan did not address his bath or shower preferences, and records showed he consistently received bed baths on scheduled days. Multiple staff interviews confirmed awareness of the resident's preference for showers over bed baths. However, staff reported that the shower bed was broken, and the resident was unable to use the available shower chair due to lack of leg rests, which was problematic given his lack of leg control. Maintenance records indicated the shower bed was out of service for a period due to missing wheels, but there was no documentation of concerns prior to the incident. As a result, the resident's right to make choices and have preferences honored was not supported.
Failure to Timely Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an allegation of abuse involving one resident. According to the facility's policy, any incident of alleged abuse, neglect, exploitation, or mistreatment must be reported to the State Survey Agency (SSA) and the facility Administrator immediately, or within specified timeframes depending on the severity. A resident with diagnoses including COPD, vascular dementia, fibromyalgia, depression, and anxiety, who was cognitively intact, reported that a night shift CNA had verbally abused her by cursing at her. The resident stated she reported this incident to the Activity Director (AD) but could not recall the CNA's name or the exact date of the incident. The AD confirmed that the resident had reported the allegation during a Resident Council meeting but did not take further action to investigate or report the incident, instead sharing the information with the Social Services Director (SSD) for follow-up. The SSD did not learn of the allegation until several days later and only then informed the Administrator, who was unaware of the incident until that point. The Administrator stated that her expectation was for such allegations to be reported to her immediately for appropriate follow-up and notification to the SSA. The delay in reporting and investigating the allegation resulted in noncompliance with the facility's abuse reporting policy.
Failure to Obtain Level Two PASARR Assessment for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to obtain a Level Two Pre-Admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with psychiatric diagnoses, including schizoaffective disorder, anxiety disorder, and major depressive disorder. Documentation in the electronic medical record showed that the resident's Level One PASARR, completed prior to admission, did not reflect these psychiatric diagnoses. The resident was later noted to have moderate cognitive impairment and exhibited behaviors such as wandering, paranoia, exit seeking, and combativeness, which resulted in a transfer to a psychiatric hospital for evaluation. Interviews with facility staff revealed that the Social Service Director was not notified to redo the PASARR for the resident, despite suspecting that the psychiatric diagnoses were present before admission. The Administrator was unaware that the resident had been admitted with diagnoses that would have required a Level Two PASARR assessment. The lack of coordination and communication led to the failure to complete the required assessment, as identified through record review and staff interviews.
Failure to Develop Comprehensive Care Plans for Pain and ADL Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy. One resident, who had diagnoses including arthritis, pain in the left hip and right hand, muscle weakness, and general pain, was receiving both morphine and acetaminophen for pain management. Despite an increase in pain reported by the resident and the presence of physician orders for pain medications, there was no care plan in place addressing pain management, non-pharmacological interventions, or the use of pain medications. The MDS Coordinator confirmed that a pain care plan should have been developed but was omitted. Another resident, admitted with diagnoses such as congestive heart failure, anxiety, glaucoma, and adult failure to thrive, was found to have severely impaired cognition and was dependent on staff for all activities of daily living (ADLs), including oral hygiene, toileting, showering, dressing, personal hygiene, eating, bed mobility, transfers, and mobility. However, there was no care plan addressing the resident's need for assistance with ADLs. The MDS Coordinator acknowledged that the resident's total dependence on staff for ADLs should have been included in the care plan.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on nursing staff for all aspects of care and had moderate cognitive impairment, was observed to have fingernails extending more than half an inch beyond the fingertips. The resident, who had a history of a right femur fracture, chronic obstructive pulmonary disease, and epilepsy, was admitted to the facility and had a care plan stating the resident would be kept well-groomed. Despite this, observations on two consecutive days confirmed that the resident's nails remained untrimmed, and the resident expressed a preference for having them trimmed. Interviews with staff revealed confusion regarding responsibility for nail care, particularly for residents on hospice. One LPN initially stated that the hospice aide should have trimmed the nails, but acknowledged that facility staff were responsible if hospice did not perform the task. CNAs and another LPN confirmed that facility staff were responsible for nail care unless the resident was diabetic, in which case a nurse would perform the task. The failure to provide nail care resulted in the resident having unmet care needs.
Failure to Notify Resident of Scheduled Physician Appointment
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, depression, and hypertension was not properly notified of a scheduled physician's appointment. The resident, who was cognitively intact, was informed of the appointment at the last minute, leaving insufficient time to prepare. The resident subsequently refused to attend the appointment due to not being ready. The appointment had been rescheduled weeks prior, and the information was documented in both the master notebook at the reception desk and the appointment book at the nurses' station. Interviews revealed that the process for notifying residents of appointments was unclear, with no specific staff member assigned to this responsibility. The assigned RN was unaware of the appointment due to a contract nurse working the previous night and not being familiar with the appointment notification process. The lack of a clear notification protocol led to the resident missing the scheduled medical appointment.
Failure to Provide Ordered As-Needed Medication and Notify Physician After Missed Dialysis Appointment
Penalty
Summary
A resident with end-stage renal disease (ESRD) who required regular dialysis missed a scheduled dialysis appointment due to transportation issues. The facility's policy for care of residents with ESRD did not address procedures for missed dialysis appointments. The resident had a physician's order for Lokelma, to be administered as needed on missed dialysis days, but this medication was not given when the appointment was missed. There was also no documentation in the electronic medical record (EMR) regarding the missed appointment, and the physician was not notified of the incident. Interviews with facility staff revealed that the LPN responsible for the resident on the day of the missed appointment was unaware of the as-needed order for Lokelma and did not check for such orders, as they were not scheduled medications. The Director of Nursing stated that she was not aware of the missed appointment and would have expected documentation, physician notification, and administration of Lokelma as ordered. The resident's care plan included instructions to inform a family member if transportation had not arrived by the scheduled time, but there was no evidence this was done.
Failure to Arrange Dental Visit Following Physician Order
Penalty
Summary
The facility failed to ensure that a resident received a dental visit as ordered by the physician to address a mouth infection. The resident, who had diagnoses including ulcerative oral mucositis and cirrhosis, was observed to have several missing teeth and a broken tooth, and reported pain and difficulty eating. The physician had prescribed antibiotics and ordered a dental appointment as soon as possible due to a tooth and gum infection. However, there was no documentation of a dental visit in the resident's medical record or hard chart. Interviews with facility staff revealed a breakdown in communication regarding the dental appointment order. The Social Services Director was unaware of the physician's order, and the receptionist had not received any request to schedule a dental appointment. The DON confirmed that the nurse responsible for reviewing the physician's order did not communicate the need for a dental appointment to the appropriate staff for follow-up, resulting in the resident not being seen by a dentist.
Failure to Maintain Accurate Physician Orders in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date physician orders for three residents, resulting in discrepancies in the provision of hospice, dialysis, and restorative services. For one resident with chronic obstructive pulmonary disease and moderate cognitive impairment, hospice orders remained active in the electronic medical record (EMR) even after services were discontinued, as confirmed by the administrator. Another resident with end-stage renal disease and other comorbidities continued to have an active physician order for dialysis at a clinic that had closed, despite receiving dialysis at a different center for several months. The administrator acknowledged the inaccuracy and the need to update the EMR. A third resident, who had a history of cerebral infarction and required substantial assistance for self-care, had outdated orders in the EMR for restorative therapy and splint use, even though the resident no longer used splints and the facility no longer had a restorative therapy program. The administrator confirmed that the range of motion exercises were not being performed as ordered and that the order should have been discontinued. These findings were based on interviews, record reviews, and policy review, and were corroborated by staff and external providers.
Failure to Ensure Staff Use of PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) as required under Enhanced Barrier Precautions (EBP) for three of five residents reviewed. According to the facility's policy, EBP requires staff to wear gowns and gloves during high-contact care activities for residents with certain conditions, such as open wounds or indwelling medical devices. Observations revealed that staff did not consistently follow these requirements during care activities for residents with pressure ulcers and other qualifying conditions. For one resident with stage three pressure ulcers, a wound physician and a wound LPN entered the resident's room, which had EBP signage, and performed wound care using only gloves and not gowns. Both staff members confirmed in interviews that they did not wear gowns, with the physician stating that gowns were not available at the time. The infection preventionist later confirmed that these staff members had not received EBP training and that gowns should have been worn during such care. In another instance, a CNA from an agency provided incontinence care and changed bed linens for a resident with a pressure ulcer, wearing only gloves and not a gown. The CNA stated it was her first day at the facility and that gowns were not available in the room. The infection preventionist confirmed that the resident required EBP and that the CNA should have worn a gown. Additionally, another CNA was observed attempting to dress a resident with EBP signage on the door without donning any PPE. These failures were observed despite the facility's policy and posted signage indicating the need for EBP.
Failure to Administer Consented Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that two of five residents reviewed for vaccinations, who had provided consent, were administered the appropriate flu or pneumonia vaccines. One resident, admitted with dementia and a right lower leg fracture, had signed a consent form to receive the pneumococcal vaccine, but there was no documentation in the electronic medical record (EMR) that the vaccine was administered. The Infection Preventionist confirmed during an interview that the resident had consented and the vaccine should have been given, but it was missed. Similarly, another resident admitted with a left heel pressure ulcer had consented to receive the influenza vaccine, as documented in the consent form. However, the EMR contained no record of the vaccine being administered. The Infection Preventionist acknowledged that the resident had been missed and that the vaccine should have been given in a timely manner after consent was obtained. These findings were based on record review, interviews, and policy review.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its pressure ulcer and wound care policies, resulting in deficiencies in the care of two residents with pressure ulcers. For one resident, the facility did not initiate the wound care physician's orders or follow the registered dietician's recommendations promptly. The resident had a pressure ulcer on the coccyx, which was not properly documented or treated according to the physician's orders. Additionally, the resident developed pressure ulcers on both feet/heels, which were not identified, assessed, or reported to the physician in a timely manner. The facility's failure to update the resident's care plan to reflect the presence of pressure ulcers further contributed to the deficiency. Another resident was admitted with a pressure ulcer on the coccyx, but the facility did not have a treatment order in place until several days after admission. The resident's pressure ulcer was not treated according to the wound care physician's orders, and the registered dietician's recommendations for nutritional supplements were not implemented promptly. The facility's lack of communication and documentation regarding the resident's treatment orders and care plan updates led to inadequate care for the resident's pressure ulcer. The facility's wound management program policy outlines procedures for assessing and treating pressure ulcers, but these procedures were not followed. The facility failed to ensure that new treatment orders from the wound care physician were implemented promptly and that registered dietician recommendations were acted upon within a reasonable timeframe. The lack of communication and documentation among staff members, including CNAs, LPNs, and RNs, contributed to the deficiencies in pressure ulcer care for the residents.
Failure to Monitor COVID-19 Positive Resident
Penalty
Summary
The facility failed to monitor a resident diagnosed with COVID-19 in accordance with their policy. The resident, who had moderate cognitive impairment and was dependent on activities of daily living, tested positive for COVID-19. Despite the facility's policy requiring increased clinical monitoring, including assessments of symptoms, vital signs, oxygen saturation levels, and respiratory exams every shift, there was no documentation of these assessments in the resident's medical record. The resident's care plan also lacked documentation of the COVID-19 diagnosis. Interviews with staff revealed that the resident exhibited changes in condition, such as being more down and depressed, and not eating breakfast, which were reported to the registered nurse. However, the registered nurse did not document the vital signs in the resident's medical record. Subsequent shifts also failed to document vital signs or monitor the resident's condition as required. The resident was found unresponsive during perineal care, and CPR was initiated but was unsuccessful. The cause of death was determined to be COVID-19. The Director of Nursing confirmed that the facility's COVID-19 and Change in Condition policies were not followed. The expectation was for the charge nurse to obtain and document vital signs each shift to monitor the resident's condition and notify the physician of any changes. The failure to adhere to these policies resulted in a lack of proper monitoring and documentation for the resident diagnosed with COVID-19.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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