Pine Grove Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 4359 Taft Avenue, Saint Louis, Missouri 63116
- CMS Provider Number
- 265828
- Inspections on file
- 15
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Pine Grove Manor during CMS and state inspections, most recent first.
The facility failed to follow physician orders and maintain accurate MAR/TAR documentation for multiple residents. A resident with anxiety and bipolar disorder did not receive a scheduled clonazepam dose even though an LPN documented it as given, and the controlled substance count confirmed the dose was not removed. Another resident with dementia, hemiplegia, and multiple comorbidities had numerous undocumented opportunities for scheduled lorazepam, behavior and side-effect monitoring, assistance with dressing, weekly skin assessments, and topical treatments across MAR, NAR, and TAR records. Two additional residents with diabetes, schizophrenia, and bipolar disorder had physician-ordered weekly skin assessments that were not documented on the ordered shifts, and the EMR assessment tab showed no current assessments corresponding to those orders.
The facility failed to provide adequate ADL care, including toileting, bathing, and grooming, to several residents. A resident who was severely cognitively impaired, incontinent, and fully dependent on staff was found at midday lying in urine-saturated linens with strong urine and body odor and open buttock wounds without dressings after not being checked since early morning, despite staff expectations for two-hour checks. Another cognitively intact resident with multiple comorbidities and incontinence was repeatedly observed with strong body odor, oily uncombed hair, and an unshaven face, reported that a cluttered shower room and lack of staff assistance prevented showers, and stated that poor hygiene worsened depression, while a CNA believed the resident managed hygiene independently. A third resident with severe cognitive impairment and an order for twice-weekly showers missed at least two scheduled showers and was observed with a strong sweat odor. Additionally, a cognitively intact resident dependent on staff for personal hygiene was repeatedly seen with long chin hairs despite expressing a desire for their removal, even though CNAs, LPNs, and leadership acknowledged staff were responsible for assisting with unwanted facial hair removal and grooming preferences.
Surveyors found that the facility did not complete activity assessments or develop care plan interventions for multiple residents with conditions such as dementia, bipolar disorder, stroke, MS, and schizophrenia, despite a policy requiring individualized activity programming. An outdated activity calendar was posted, but no group activities were observed over several days, and several cognitively intact residents reported that there were not enough activities, that they were bored, and that activity staff were insufficient. Some residents described doing nothing all day except for medical appointments or paying out-of-pocket for outings. Records for residents identified as needing 1:1 activities showed they were scheduled on specific days, yet there was no documentation of 1:1 activities being offered or provided, and observations confirmed these residents were not engaged in such activities. The Activity Director stated she had just started employment and had not yet created a current calendar or begun 1:1 activities, while the Administrator and DON stated they expected activities and 1:1 services to be provided and reflected in care plans.
The facility did not ensure that second-floor bathrooms were routinely cleaned, as required by its housekeeping policy. Surveyors observed multiple bathrooms with brown and yellow matter on toilet seats, strong bowel movement odors, unflushed toilets with urine and toilet paper, and shower floors with dark stains and hair. A cognitively intact resident with MS and insomnia reported that the bathrooms were dirty and not cleaned often enough, and that only one shower room was open and sometimes dirty. An LPN and a housekeeper confirmed that housekeeping was responsible for bathroom cleaning, with typically one housekeeper assigned to the floor and bathrooms expected to be cleaned each shift, while the Administrator and DON stated they expected bathrooms to be clean and maintained at least daily and as needed.
The facility failed to follow its own policies requiring that eligible residents be offered pneumococcal and annual influenza vaccines, receive education, and have all offers, consents, refusals, and administrations documented. Record review showed that two residents with COPD and other chronic conditions had no documentation of receiving, being offered, or being educated about the pneumococcal vaccine, and another medically complex resident had no documentation of receiving, being offered, or being educated about the influenza vaccine. The DON/IP acknowledged that all residents should be offered these vaccines if eligible and that all related actions should be recorded in the medical record, which did not occur.
A resident experienced a delay of up to nine minutes in receiving rescue breaths and oxygen during CPR because the Ambu bag mask was missing from the crash cart and staff were unable to operate the suction machine. Chest compressions were started promptly, but rescue breaths and suctioning were delayed due to missing supplies and lack of staff knowledge. When EMS arrived, staff stopped CPR before EMS was ready to take over, resulting in a lapse in compressions. The resident, who had severe cognitive impairment and multiple medical conditions, expired as a result.
Staff failed to prime pre-filled insulin pens before administering insulin to two residents with diabetes and other health conditions. In both cases, LPNs administered insulin without following manufacturer guidelines for priming, and the DON confirmed that this step is necessary to ensure accurate dosing. The facility's policy did not address insulin pen use, contributing to these significant medication errors.
A resident with severe cognitive impairment and total dependence on staff was found with their long-sleeve shirt sleeves tied together at the wrists, restricting hand movement and constituting a physical restraint. Staff interviews confirmed the knot was intentional and not accidental, and there was no documentation or care plan directive for restraint use. Facility leadership was unable to determine who was responsible for tying the sleeves.
A resident with multiple chronic conditions and recent cellulitis did not receive prescribed wound care due to failure to transcribe physician orders into the electronic medical record. The resident's wounds were observed without dressings or compression socks, and staff interviews revealed a lack of awareness and responsibility for entering and implementing the wound care orders. The Wound Doctor confirmed that his treatment orders were not followed.
The facility did not maintain safe water temperatures in resident rooms on the North and South halls, with temperatures ranging from 141 to 153 degrees Fahrenheit, exceeding the safe range of 105-120 degrees Fahrenheit. This affected 16 out of 31 sampled residents, posing a risk of scalding and burns. The Maintenance Director adjusted water heater temperatures based on resident complaints about cold water without verifying actual room temperatures. The facility's Safety of Water Temperatures Policy was not effectively implemented. Staff, including the Maintenance Director, DON, and Corporate Regional Nurse, were unaware of the high temperatures and used inappropriate methods for temperature checks. Residents with cognitive impairments and mobility issues were at increased risk.
The facility failed to provide meaningful activities or one-on-one activities for residents dependent on staff for their needs. The activity calendar showed limited variety, primarily focused on bingo and cards. Residents expressed dissatisfaction, and the Activities Director confirmed the lack of a regular activities program. The AD had limited formal training and was the only one responsible for activities, leading to the deficiency identified.
The facility failed to ensure the activity program was directed by a qualified professional. The Activity Director had not received formal training and had not started the required state-approved course, despite being enrolled since September 2023. The facility's job description required specific qualifications that the current Activity Director did not meet.
The facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. Observations showed a gray plastic tube extending from the ice machine into a PVC drain pipe connected to the floor drain without an air gap. The Dietary Manager and Administrator were aware of the requirement but did not ensure compliance.
The facility failed to follow infection control standards during perineal and wound care for several residents. Staff did not perform proper hand hygiene or change gloves appropriately, increasing the risk of cross-contamination and infection. Interviews confirmed that facility policies were not adhered to, leading to these deficiencies.
The facility failed to complete pre and post dialysis assessments and did not maintain an accurate care plan for a resident requiring dialysis services. The dialysis communication forms were often incomplete, and the facility did not consistently document or follow up on the resident's assessments.
Failure to Follow Physician Orders and Accurately Document Medications and Skin Assessments
Penalty
Summary
The facility failed to ensure physician orders were followed and that services met professional standards of quality, as evidenced by multiple documentation and administration errors for several residents. One cognitively intact resident with anxiety, depression, and bipolar disorder had an order for clonazepam 0.5 mg to be given every evening at 4:00 p.m. The March MAR showed clonazepam documented as administered on a specific date at 4:00 p.m., but the controlled drug administration record showed the last actual administration occurred the previous day and that 11 tablets remained. The resident reported not receiving the clonazepam dose on that date, stated they informed night shift staff, and was told the medication was documented as given. Observation of the narcotic box with an LPN confirmed 11 tablets remained, and the LPN stated they thought they had given the dose but must have signed it off in the electronic record without actually administering it. Another resident with dementia, hypertension, hyperlipidemia, dysphagia, seizures, depression, hemiplegia, and major depressive disorder had multiple active orders, including scheduled lorazepam oral concentrate for anxiety every six hours, behavior and side-effect monitoring every shift, assistance with dressing and undressing every shift, weekly skin assessments, and topical anti-itch lotion and barrier cream. Review of the MAR and nurse’s administration record for February showed numerous blank entries where lorazepam doses, behavior observations, side-effect monitoring, and assistance with dressing were ordered but not documented, with missed documentation across dozens of opportunities. The treatment administration record for the same period also contained blank entries for weekly skin assessments and for the ordered topical anti-itch lotion and barrier cream, again with multiple missed documentation opportunities. Similar gaps continued into March, with additional blank entries for lorazepam administration, weekly skin assessments, and topical treatments. Two additional residents with diagnoses including diabetes, hearing loss, schizophrenia, dementia, and bipolar disorder had physician orders for weekly skin assessments on specified shifts. For one cognitively intact resident, the March MAR showed weekly skin assessments ordered on Wednesday night shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab predated those dates. For another resident with moderately impaired cognition, the March MAR showed weekly skin assessments ordered on Monday evening shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab also predated those dates. In an interview, the Administrator and DON stated they expected weekly skin assessments to be completed and documented in both the assessment tab and MAR when ordered, and that medications should be administered per physician orders with documentation of reasons and physician notification when not administered.
Failure to Provide Adequate ADL, Hygiene, and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate activities of daily living (ADL) care, including toileting, bathing, and personal hygiene, to multiple residents. One resident with severe cognitive impairment, hemiplegia, and dependence on staff for toileting, bathing, dressing, and personal hygiene was observed in bed at midday with a strong urine and body odor. When CNAs turned the resident, the brief, two quilted bed pads, and fitted sheet were saturated with urine, and the resident had open wounds on both buttocks without dressings. A CNA reported last checking the resident around 8:00 A.M. and stated they did not want to disturb the resident due to sleep and frequent pain, while nursing staff and the DON stated incontinent residents were expected to be checked and repositioned every two hours. Another resident, cognitively intact but with a history of stroke, dementia, diabetes, kidney failure, Parkinson’s disease, and myasthenia gravis, required partial to moderate assistance with bathing, personal hygiene, and toilet hygiene and was frequently incontinent of bladder and occasionally of stool. This resident was repeatedly observed in bed with strong body odor, uncombed oily hair, and an unshaven face with approximately half an inch of facial hair. The resident reported being willing to walk with a walker to the shower room but described the shower room as usually cluttered with equipment, which he could not move, and stated that staff did not help him get set up in the shower despite his requests. A CNA stated the resident “did his own thing,” was not known to need help with showers, and provided his own care, while the DON stated all residents required staff assistance with hygiene and were expected to be clean, dry, and odor free. A third resident with severe cognitive impairment, type 2 diabetes, schizophrenia, and cerebral palsy had a care plan indicating an ADL self-care performance deficit and a need for maximum staff assistance with personal hygiene. The MAR showed an order for showers twice weekly on the evening shift, but two scheduled showers in the review month were not documented as given, and the resident was observed on two occasions with a strong sweat-like odor. Additionally, a cognitively intact resident with type 2 diabetes, hearing loss, and schizophrenia, care planned as dependent on staff for personal hygiene and oral care, was observed multiple times with long white curly hairs on the chin. This resident stated a desire to have the chin hairs removed. Nursing and CNA staff, as well as facility leadership, acknowledged that both CNAs and LPNs could assist with removal of unwanted facial hair and that staff should ask residents about grooming preferences, but this assistance had not been provided.
Failure to Provide Individualized Activities and Scheduled 1:1 Programming
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assess residents’ activity preferences and to provide an ongoing activity program consistent with those preferences, as well as a failure to provide scheduled 1:1 activities to certain residents. The facility’s Activities Program policy, dated 6/2020, stated that the facility would provide an activity program designed to meet residents’ needs, interests, and preferences, with assessments completed within seven days of admission and individualized care plans developed and implemented. Observations on multiple days showed Mardi Gras decorations and an outdated February activity calendar posted, but no activities were observed being provided to residents at various times on several dates. The Activity Director reported that her first day was during the survey period, that the March activity calendar had not yet been created, and that she expected activities to be scheduled and calendars distributed and posted. Multiple residents who were cognitively intact and had various diagnoses reported that there were not enough activities and that they were bored. One resident with anxiety, depression, bipolar disorder, schizophrenia, and PTSD stated there were no activities taking place, that the previous Activities Director had left about two weeks earlier, and that the resident paid for a car ride to a store just to get out of the facility. Another resident with stroke, dementia, diabetes, kidney failure, and depression reported doing nothing all day except going to dialysis, expressed interest in puzzles, and recalled that the facility previously had a small bus for outings. Additional residents with diagnoses including diabetes, hearing loss, schizophrenia, multiple sclerosis, insomnia, hypertension, anemia, dementia, and bipolar disorder similarly stated that there were not enough activities, that there were not enough activity staff, and that they were bored most of the time. For several of these residents, record review showed no activity assessments and no care plan documentation related to activity participation or preferences, despite the facility’s policy and the Administrator and DON’s expectation that care plans reflect activity preferences. The survey also found that residents identified by the facility as needing 1:1 activities were not receiving them. A facility 1:1 Activity List showed three residents scheduled for 1:1 activities on specific days of the week, but their medical records contained no documentation of activities offered or provided. These residents had significant cognitive and neurological conditions, including dementia, bipolar disorder, hypertension, malnutrition, Alzheimer’s disease, stroke, hemiplegia, seizure disorder, anxiety disorder, aphasia, mild cognitive impairment, malnutrition, and Rett’s syndrome. Observations of these residents throughout the survey period showed them not engaged in any 1:1 activities. The Activity Director acknowledged that she had not started conducting 1:1 activities for residents on the 1:1 list, and the Administrator and DON stated they expected 1:1 activities to be provided to residents determined to benefit from them.
Failure to Maintain Clean and Sanitary Second-Floor Bathrooms
Penalty
Summary
The facility failed to maintain clean and sanitary second-floor bathrooms in accordance with its housekeeping policy, which requires all rooms to be kept clean and as free as possible of germs and other contaminating agents at all times. Surveyor observations on 3/9/26 showed that the toilet in the bathroom by the emergency exit door had brown and yellow matter on the seat with a strong bowel movement odor, the shower room floors had various dark stains and small hairs on the shower floor, and the toilet seat in the shower room had brown matter smeared on it. The bathroom across from the nurse's station also had a strong bowel movement odor, a dirty toilet seat with dark matter smeared on it, and toilet paper with a brown substance in the bowl. On 3/12/26, further observations of the same area showed the shower room toilet unflushed with toilet paper and urine in and on the toilet, and the shower floor with hairs and dark matter stains. Later that day, the shower room toilet again had brown smears and a strong bowel movement odor, with hair and dark matter stains on the shower floor. A cognitively intact resident with multiple sclerosis and insomnia reported that the second-floor bathrooms were dirty, not cleaned often enough, and that only one shower room was open and sometimes dirty. An LPN stated that bathrooms were expected to be clean but believed there were not enough housekeeping staff, and a housekeeper reported that normally one housekeeper is assigned to the second floor and that bathrooms are expected to be cleaned each shift. The Administrator and DON stated they expected bathrooms to be clean to prevent infection control issues and that housekeeping staff were responsible for cleaning bathrooms at least once daily and as needed.
Failure to Offer and Document Pneumococcal and Influenza Vaccinations for Eligible Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal and influenza vaccination policies. The facility’s written policies, last revised in June 2020, require that all eligible residents be offered pneumococcal and annual influenza vaccines, receive education on benefits and potential side effects, and that informed consent or refusal, as well as vaccine administration, be documented in the medical record. Record review showed that these steps were not followed for several residents, despite the policies specifying that refusals and any education provided must be documented. For one resident with heart failure, COPD, and kidney disease, and another resident with COPD and high blood pressure, there was no documentation that the pneumococcal vaccine was received, offered, or that vaccine education was provided. For a third resident with kidney disease, Parkinson’s disease, Myasthenia Gravis, diabetes, and bladder cancer, there was no documentation that the influenza vaccine was received, offered, or that vaccine education was provided. During interview, the DON/IP confirmed that all residents should be offered influenza yearly and pneumococcal vaccine if eligible, and that all offers, refusals, education, and administrations should be documented in the medical record, which did not occur for these residents.
Failure to Provide Effective CPR Due to Missing Equipment and Staff Incompetency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who was identified as a full code, resulting in a delay of up to nine minutes before rescue breaths and oxygen could be administered. When the resident stopped breathing and had no pulse, the DON initiated chest compressions, but no rescue breaths were given initially because the Ambu bag mask was missing from the crash cart. Staff searched for the necessary equipment, with one LPN retrieving the mask from the nurse's desk and another attempting to set up the oxygen tank but unable to locate the key immediately. The oxygen was eventually connected, but only after a delay due to the missing mask and difficulty finding the key. During the code, staff also attempted to use the suction machine to clear the resident's airway, as the resident had significant secretions and a history of dysphagia and aphasia. However, staff were not knowledgeable about operating the suction machine, and it was never successfully used on the resident. The crash cart checklist had been marked as complete, but the required mask was not present at the time of the emergency, indicating a failure in equipment checks and readiness. The AHA guidelines and facility policy required rescue breaths and suctioning as part of CPR, but these were not provided in a timely manner due to missing supplies and lack of staff competency with the equipment. Additionally, when EMS arrived, staff stopped CPR before EMS personnel were ready to take over, resulting in a lapse in compressions. EMS had to ask if CPR was still needed and then resumed compressions upon entering the room. The resident, who had severe cognitive impairment and multiple medical diagnoses including sepsis and pressure ulcers, ultimately expired. The deficiency was identified through observation, interviews, and record review, and was determined to be at the immediate jeopardy level due to the failures in emergency response, equipment availability, and staff competency.
Failure to Prime Insulin Pens Results in Significant Medication Errors
Penalty
Summary
Staff failed to ensure residents were free from significant medication errors by not priming pre-filled insulin pens before administering insulin to two residents. For one resident with diabetes, kidney disease, obesity, and other conditions, an LPN administered insulin aspart without priming the pen, contrary to manufacturer guidelines that require priming to ensure accurate dosing. The LPN was unable to confirm whether the pen was primed prior to administration. The resident's care plan included monitoring for complications related to diabetes, but the insulin was given while the resident was eating, and the necessary step of priming was omitted. For another resident with diabetes, kidney disease, and additional diagnoses, a different LPN also failed to prime a Basaglar KwikPen before administering the prescribed insulin glargine. The LPN admitted to not priming the pen, despite manufacturer instructions and facility expectations to do so. The DON confirmed that priming is necessary to avoid administering air instead of the correct insulin dose. The facility's insulin administration policy did not specifically address the use of insulin pens, contributing to the medication errors observed.
Resident Found with Restrictive Clothing Used as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident was found with the sleeves of their long-sleeve shirt tied together at the wrists, restricting the use of their hands and limiting freedom of movement. This action constituted the use of a physical restraint, as defined by the facility's own policy, which prohibits restraints unless necessary to treat a specific medical symptom and only after less restrictive interventions have failed. There was no documentation or physician order for the use of any restraint for this resident, nor was restraint use addressed in the resident's care plan. The resident involved had severe cognitive impairment, was rarely or never understood, and was totally dependent on staff for all activities of daily living. The resident had a history of non-traumatic brain dysfunction, hemiplegia, malnutrition, and anxiety disorder, and exhibited behavioral symptoms such as agitation, resistance to care, and repetitive movements like rubbing the scalp. Staff interviews confirmed that the resident could not have tied the sleeves themselves and that the knot was intentional, not accidental. The resident was unable to communicate what had happened and did not appear to be in distress at the time of discovery. Multiple staff, including CNAs and LPNs, reported that they were unaware of how or when the sleeves were tied, and no one took responsibility for the action. The facility's leadership, including the Interim Administrator and DON, acknowledged that it was never determined who tied the resident's sleeves. The care plan did not include any interventions involving restraints, nor did it address the resident's repetitive behaviors. The incident was identified through observation, interview, and record review, confirming a failure to protect the resident's right to be free from physical restraints.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care treatment orders for a resident were appropriately transcribed and implemented according to physician instructions. The resident, who had multiple diagnoses including peripheral vascular disease, diabetes, and a recent diagnosis of cellulitis, was assessed by the Wound Doctor, who ordered daily dressing changes and specific wound care interventions for venous insufficiency ulcers on both lower legs. However, these orders were not transcribed into the electronic Physician Order Sheet (ePOS) or the Medication Administration Record (MAR), and there was no documentation of the wounds in the resident's care plan. Observations revealed that the resident had visible wounds on both legs, which were not covered with dressings or compression socks as ordered. The resident reported having wounds for one to two months and stated that a doctor had prescribed medication nine days prior, but the treatment had not been received. Interviews with staff indicated confusion regarding responsibility for transcribing and implementing physician orders, with the desk nurse responsible for order entry but failing to transcribe the wound care orders into the electronic medical record. The Director of Nursing was unaware of the new wound care orders, and the LPN involved stated that only an order for the resident to be seen by the Wound Doctor had been entered. The Wound Doctor confirmed that he expected his orders to be followed and that the treatments he prescribed had not been administered. This sequence of events resulted in the resident not receiving necessary wound care as ordered by the physician.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not ensuring safe water temperatures in resident rooms on the North and South halls. The hot water temperatures in the resident room bathrooms were found to be between 141 to 153 degrees Fahrenheit, significantly exceeding the safe range of 105-120 degrees Fahrenheit. This deficiency was identified during a survey where 16 out of 31 sampled residents were affected by the excessively high water temperatures, posing a risk of scalding and burns. Observations revealed that the Maintenance Director had been adjusting the water heater temperatures in response to resident complaints about cold water, without verifying the actual water temperatures in the rooms. The facility's Safety of Water Temperatures Policy, which mandated water temperatures to be maintained within a safe range to prevent scalding, was not being effectively implemented. Residents with varying levels of cognitive impairment and mobility were exposed to dangerously high water temperatures, as evidenced by specific examples such as Resident #49, Resident #14, Resident #12, and Resident #15, among others. Interviews with staff members, including the Maintenance Director, Director of Nursing, and Corporate Regional Nurse, highlighted a lack of awareness regarding the high water temperatures and the inappropriate use of a laser thermometer for temperature checks. The report also noted that residents who wandered and had access to the bathrooms were at increased risk of being harmed by the hot water. The deficiency was classified as an immediate jeopardy (IJ) level K violation, indicating a serious threat to resident safety due to the failure to maintain safe water temperatures in the facility.
Lack of Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities or one-on-one activities for residents dependent on staff for their needs. The activity calendar showed a limited range of activities, primarily focused on bingo, cards, and occasional parties. Residents expressed dissatisfaction with the lack of variety and meaningful engagement in the activities offered. The Activities Director (AD) confirmed that most activities were self-governed, and there was no regular activities program in place. The AD also mentioned that she was the only one responsible for activities and had limited formal training. Resident #27, who was cognitively moderately impaired and had a history of schizophrenia, heart disease, stroke, and cancer, expressed a desire for outdoor activities and Bible study, which were not provided. Resident #5, who was cognitively intact and had diagnoses of diabetes, anxiety, depression, and schizophrenia, did not participate in activities due to the lack of variety and choices. Resident #28, who was also cognitively intact and had schizophrenia, expressed a similar sentiment, stating that the facility only offered bingo, which did not interest them. Resident #33, who had cancer and schizophrenia, also reported a lack of activities beyond bingo. The AD's work hours were limited to weekdays, and there were no structured activities on weekends. The AD relied on a resident volunteer to help with activities, and there was no documentation of one-on-one activities for residents. The Administrator acknowledged that the AD lacked formal training and that resident activities should be specific to their preferences and documented in progress notes. The facility's failure to provide a diverse and meaningful activities program led to the deficiency identified in the report.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional. The Activity Director, who had been employed at the facility for about two years and transferred to the activity program a year ago, had not received any formal training on how to run an activity program. Although she was enrolled in a state-approved activities director course, she had not started the program yet. The Administrator confirmed that the Activity Director did not have any formal training and had been enrolled in the class since September 2023 but had not started the classes because the facility wanted to see if she would remain consistent with the activity program. The facility's job description for the Activity Director required a high school diploma, completion of a state-approved activities director course, and one year of experience in a resident activities program in a healthcare setting, which the current Activity Director did not meet.
Ice Machine Lacks Required Air Gap
Penalty
Summary
The facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. Observations on multiple dates showed a gray plastic tube extending from the back of the ice machine into a white PVC drain pipe, which was connected to the floor drain without an air gap. The area where the gray tubing was inserted into the PVC drain pipe was covered with dirt and debris. This deficiency had the potential to affect all residents who consumed drinks with ice, given the facility's census of 55 residents. During an interview, the Dietary Manager acknowledged awareness of the requirement for an air gap but was unaware that the ice machine did not have one. The Administrator also confirmed the expectation for an air gap to be present at the ice machine. The facility's Air Gap Policy for Ice Machine Draining Pipe outlined the necessity of an air gap to prevent backflow contamination, but this policy was not adhered to in practice, leading to the observed deficiency.
Infection Control Deficiencies in Perineal and Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection control during perineal care and wound care for several residents. For Resident #28, a Certified Medication Technician (CMT) improperly wiped the resident's anal area from top to bottom while the resident was standing, using the same wipe multiple times without turning it. The CMT admitted to not regularly providing personal care due to their primary task of administering medications. Similarly, Resident #35 received improper perineal care from a Certified Nurse Aide (CNA) who did not separate the labia while wiping from front to back. Both staff members failed to change gloves appropriately during the care process, increasing the risk of cross-contamination and infection. In another instance, Resident #258, who had a surgical wound, received wound care from a Registered Nurse (RN) who did not perform hand hygiene before changing gloves multiple times during the procedure. The RN removed and replaced gloves without washing hands, thereby compromising the sterility of the wound care process. Additionally, Resident #46, who had an ingrown toenail, was assisted by the same RN who failed to change both gloves and perform hand hygiene after assisting another resident. The RN handled treatment supplies and touched the resident's wounds without proper glove changes and hand hygiene, further risking cross-contamination. Interviews with staff, including the Director of Nursing (DON), confirmed that the facility's policies and procedures for hand hygiene and glove changes were not followed. The DON acknowledged that failing to change both gloves and perform hand hygiene could lead to cross-contamination or infection. The Administrator also expected staff to adhere to the facility's policies and procedures, which were not followed in these instances, leading to the deficiencies observed during the survey.
Failure to Complete Dialysis Assessments and Maintain Accurate Care Plan
Penalty
Summary
The facility failed to complete pre and post dialysis assessments and did not have an accurate care plan for a resident requiring dialysis services. The resident, who was cognitively intact and diagnosed with end-stage renal disease (ESRD), received dialysis at an outside facility. The care plan did not reflect the current dialysis site location, and there were multiple instances where the dialysis communication forms were incomplete or missing vital information. Specifically, on several dates, the dialysis center information and post-dialysis assessments were either blank or not documented, and there was no record of the resident refusing these assessments or the facility contacting the dialysis center to obtain the necessary information. Interviews with the facility staff, including a registered nurse (RN) and the Director of Nursing (DON), revealed that the expected protocol was for pre and post dialysis assessments to be completed and documented on the dialysis communication form. These assessments included checking the graft site, vital signs, and observing for any complications. However, it was noted that sometimes the resident forgot to take the communication form to the dialysis center, or the dialysis center did not return the form. Additionally, if the resident refused the assessment, it was supposed to be documented, but this was not consistently done. The Director of Nursing confirmed that the dialysis communication forms were often incomplete and that the facility's policies and procedures were not always followed. The Administrator also stated that he expected the staff to adhere to the facility's policies and procedures. The lack of proper documentation and adherence to protocols led to the deficiency in providing safe and appropriate dialysis care for the resident.
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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