Quarters At Des Peres, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Peres, Missouri.
- Location
- 13230 Manchester Road, Des Peres, Missouri 63131
- CMS Provider Number
- 265834
- Inspections on file
- 33
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Quarters At Des Peres, The during CMS and state inspections, most recent first.
A medication technician failed to administer multiple prescribed medications to two residents, including eye drops, nasal spray, diuretics, and a laxative, and inaccurately documented these as given in the eMAR. Both residents were cognitively intact and confirmed the omissions. The technician later admitted to forgetting the medications and initially provided false information about their administration. Facility policy requiring accurate medication administration and documentation was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
Two residents were not protected from accident hazards when staff failed to follow proper assessment and transfer protocols after a fall and during a mechanical lift transfer. One resident was manually lifted after an unwitnessed fall despite showing signs of injury, resulting in fractures, while another was unsafely transferred with a Hoyer lift without proper adjustment or support, contrary to facility policy.
Staff failed to follow infection prevention protocols, including not changing gloves, performing hand hygiene, or wearing gowns during high-contact care for residents on Enhanced Barrier Precautions, and placed soiled linens and gloves on the floor. Multi-use equipment such as blood glucose machines was not properly disinfected between residents. Additionally, most newly hired employees lacked complete documentation of the required two-step TB screening.
A resident with cognitive impairment and a history of multiple falls did not receive or have documented post-fall neurological assessments and every-shift follow-up as required by facility policy. Despite staff noting that checks were performed, the necessary documentation was missing or incomplete for most required intervals, as confirmed by interviews with nursing and administrative staff.
A resident with multiple pressure ulcers, including a Stage IV sacral ulcer and bilateral heel DTIs, did not receive timely wound assessments or documentation upon admission. Staff failed to consistently administer or document physician-ordered wound care treatments, with several missed entries on the TAR and no documentation of wound descriptions as required by facility policy. Interviews confirmed that these lapses were not communicated to the physician, and the facility's own policies for wound management and skin integrity were not followed.
A resident with HIV did not receive prescribed Triumeq for an extended period due to delays in insurance authorization and lack of timely follow-up by staff. Facility staff failed to consistently notify the prescribing ID physician or the resident's representative about the missed doses, and documentation of actions taken was incomplete. The resident's lab results later showed a high viral load and low CD4 count, confirming the medication was not administered as ordered.
Staff did not provide timely incontinence care or assistance with personal hygiene for several dependent residents, resulting in some being left wet for extended periods and not being checked every two hours. Additionally, fresh ice water was not provided to some residents as required.
Staff did not respond promptly to call lights, leading to one resident with a cardiac history calling 911 for chest pain after waiting 10 minutes without assistance, and EMS found a staff member asleep. Another resident returning from the hospital with EMS could not find staff available, and a third resident reported being left on the toilet for three hours, resulting in pain and stiffness.
The facility did not provide enough nursing staff to meet residents' needs, leading to delays in incontinence care for several residents, prolonged wait times for call light responses, and situations where EMS could not locate staff during emergencies. One resident with a cardiac history had to call EMS after staff failed to respond to chest pain, and another was left on the toilet for hours, resulting in pain.
Surveyors identified that the facility did not maintain a medication error rate below 5%, with eight errors observed out of 30 opportunities, resulting in a 26.66% error rate involving two residents.
The facility failed to provide adequate incontinence care and timely response to call lights, affecting multiple residents. Residents were found wearing saturated briefs, and staff shortages led to neglect in regular checks. One resident with chest pains called 911 after staff failed to respond, and EMS struggled to locate staff. Another resident was left on the toilet for hours, leading to pain. The ADON acknowledged inappropriate practices, and residents reported not receiving regular ice water. These issues had the potential to affect all residents.
The facility failed to provide timely incontinence care and maintain personal hygiene for residents, leaving them in soiled briefs for extended periods. Observations revealed residents lying in urine-soaked sheets, sometimes wearing two briefs, which hindered proper care. Staff admitted to not changing residents during the night shift, citing inadequate staffing. Residents reported delayed call light responses and lack of fresh ice water. The administration acknowledged these issues, but no corrective actions were mentioned.
The facility failed to follow physician orders and perform wound treatments for residents, leading to deficiencies in care. A resident with peripheral vascular disease did not receive scheduled dressing changes, while another with a skin tear after a fall did not have the injury documented or treated properly. Additionally, a resident with severe cognitive impairment had undated dressings, and a resident with a hip fracture did not receive a proper assessment of a surgical wound upon admission.
The facility failed to provide sufficient nursing staff, resulting in delayed and inadequate care for residents. Several residents were left wet for extended periods, and it often took hours for staff to respond to call lights. One resident with a history of bypass surgeries experienced chest pains and contacted EMS after staff did not respond to his call light. Observations revealed residents wearing two soaked briefs and lying in urine-soaked bedding, with staff confirming the lack of adequate staffing made it difficult to provide necessary care.
A facility failed to provide adequate nursing coverage and falsely documented care on a specific hall. The DON was not present during the day shift but documented that they administered medications and treatments, affecting multiple residents. Blood glucose levels and insulin administration were also falsely recorded by the DON, impacting resident care.
A resident with severe cognitive impairment and dysphagia experienced a significant decline in health, including unresponsiveness and slow, shallow breaths. Despite the speech therapist's concerns about the resident's swallowing abilities and increased confusion, the facility staff failed to notify the physician in a timely manner. The resident was eventually transported to the hospital, but only after a significant delay in communication and action by the staff.
Two residents experienced discomfort due to cold room temperatures, with one resident's thermostat malfunctioning and the other experiencing continuous cold air despite the air conditioner being off. The maintenance staff was aware of the issues but delayed addressing them, causing prolonged discomfort for the residents.
A facility failed to re-admit a resident after hospitalization, violating its policy. The resident was transported to the hospital without a documented transfer order and was refused re-entry by facility staff upon return, despite being medically cleared. The facility's nurse cited system issues and lack of information as reasons for refusal. There was no documentation of the transfer, updates, or discharge notice, and the facility's administration was unaware of the resident's status.
A facility failed to develop a comprehensive and individualized care plan for a resident within the required timeframe. The resident, who was cognitively intact and had multiple medical conditions, did not have an updated care plan reflecting their current needs. The MDS/Care Plan Coordinator acknowledged the delay, and the DON and Administrator confirmed the expectation for timely care plan completion.
The facility failed to update care plans for two residents, one requiring aspiration precautions after returning from the hospital and another needing fall interventions. Staff were unaware of the necessary precautions, leading to inappropriate meal supervision and inconsistent fall prevention measures.
A facility failed to follow aspiration precautions for a resident with aspiration pneumonia, leaving them unsupervised during meals despite hospital discharge orders. Additionally, another resident with a history of falls did not have fall mats on both sides of the bed, and the bed was not kept in the lowest position when unattended. Staff were unaware of these precautions, and care plans were not updated accordingly.
A long-term care facility was found to have a medication error rate of 26.66% due to improper medication administration practices. A resident received medications that were improperly crushed and stored, while another resident was given an unprimed inhaler and incorrect aspirin form. Staff interviews revealed a lack of adherence to facility policies and proper documentation, contributing to the deficiencies.
A resident received two different blood thinners simultaneously due to a transcription error in physician orders. The resident, with multiple health conditions, was supposed to start apixaban on a specific date and receive Lovenox for a limited period, but these instructions were not followed. The DON and Medical Director were unaware of the error until after it occurred, and the LPN stated that orders should be transcribed as written.
Two residents receiving dialysis were served meals with restricted items like potatoes, despite clear dietary orders. The dietary restrictions were not reflected in care plans, and staff failed to adhere to menu slips specifying necessary substitutions. The facility's Administrator and DON expected compliance with physician orders, but this was not consistently practiced, leading to the deficiency.
A facility failed to maintain accurate medical records for a resident who was hospitalized due to a change in condition. The resident, admitted to skilled services, experienced chest pain and was sent to the ER without proper documentation of a hospital transfer order or physician notification. The Administrator and DON were unaware of the resident's status, and necessary documentation was missing, indicating a lapse in record-keeping standards.
Medication Error Rate Exceeds 5% Due to Omitted Doses and Inaccurate Documentation
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a 13.2% error rate with 7 errors out of 53 observed opportunities. Certified Medication Technician (CMT) X was observed on one morning medication pass to have omitted several prescribed medications for two cognitively intact residents. For one resident, the omitted medications included artificial tears, Fluticasone Propionate nasal spray, Furosemide, MiraLAX, and Omeprazole. For the second resident, artificial tears and MiraLAX were not administered. Despite these omissions, the electronic Medication Administration Record (eMAR) was marked as if the medications had been given. Interviews with the residents confirmed that the omitted medications were not administered as scheduled. One resident specifically stated that the morning eye drops were not provided. CMT X later admitted during an interview that the medications, including MiraLAX for both residents, were not given due to nervousness and forgetfulness. CMT X also initially provided inaccurate information regarding the administration of eye drops and Flonase, later admitting dishonesty when questioned by surveyors and facility leadership. The facility's policy requires that medications be administered as prescribed, with accurate documentation on the MAR, and that any omissions or refusals be properly documented and communicated. In these instances, the required documentation and communication did not occur. The Regional Director of Operations confirmed that the MARs did not accurately reflect the omission or administration of medications and that the staff member involved did not follow established medication administration procedures.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In the first incident, a cognitively intact resident with significant mobility assistance needs experienced an unwitnessed fall while attempting to reach an item from the bedside table. After the fall, the resident was found on the floor, expressed pain, and refused the use of a mechanical lift for transfer. Despite showing signs of injury and vocalizing pain, staff, including agency CNAs, manually lifted the resident by the arms and legs to return them to bed, without performing a full assessment or obtaining vital signs. The resident later was found to have sustained fractures to the left humerus and femur, with ongoing complaints of pain and repeated refusals for hospital transfer until eventually agreeing to be sent out for further care. Interviews with staff and the resident confirmed that the transfer was performed without the use of a mechanical lift, contrary to facility policy, and that the resident's pain was not adequately assessed prior to movement. Staff present at the time, including agency personnel, did not perform range of motion checks or vital signs, and the nurse on duty failed to call EMS despite the resident's complaints of pain and visible distress. Facility leadership, including the DON and Medical Director, later confirmed that the appropriate response would have been to contact EMS and not move the resident if injury was suspected. In a separate observation, another resident with moderate cognitive impairment, paraplegia, and total dependence for transfers was not transferred safely using a mechanical lift. During a Hoyer lift transfer, staff failed to properly adjust the resident in the sling, did not position the wheelchair correctly, and allowed the resident to dangle and spin in the air without adequate support. Only one staff member operated the lift and attempted to adjust the resident simultaneously, while the other did not provide necessary spotting or support. Interviews with staff and facility leadership confirmed that these actions were not in accordance with the facility's mechanical lift policy, which requires two staff to ensure resident safety and proper technique during transfers.
Failure to Maintain Infection Control and Employee TB Screening
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to established protocols for Enhanced Barrier Precautions (EBP) and general infection control. Staff were observed failing to change gloves, perform hand hygiene, and wear gowns during high-contact care activities for residents on EBP, including those with multidrug-resistant organisms, wounds, catheters, and feeding tubes. In several cases, staff placed soiled gloves and linens directly on the floor rather than in designated bags, and did not consistently use required personal protective equipment (PPE) such as gowns during resident transfers, wound care, and hygiene assistance. Specific observations included a certified nurse aide providing peri care and handling soiled briefs without wearing a gown and placing contaminated items on the floor. A nurse was seen changing wound dressings and handling linens without a gown, and also placed dirty linens on the floor. In another instance, both a nurse and a CNA transferred a resident using a mechanical lift without donning gowns, and staff were observed touching multiple surfaces and resident care items with the same pair of gloves, including after contact with urinary catheters and resident faces. Additionally, a blood glucose testing machine was used on multiple residents without proper disinfection between uses or placement of a barrier on the medication cart, contrary to facility expectations. The facility also failed to ensure that newly hired employees completed the required two-step Mantoux tuberculin skin test (TST) for latent tuberculosis infection. Review of employee records revealed missing documentation for both the dates and results of the first and second steps of the TST for the majority of sampled new hires. The infection control preventionist indicated that human resources was responsible for notifying nursing staff about TB testing needs, but records were incomplete or missing for nine out of ten sampled employees.
Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice by not performing and documenting post-fall neurological assessments and completing post-fall assessments according to its own policy for a resident with a history of multiple falls. The facility's Fall Management policy required a complete neurological evaluation after unwitnessed falls or potential head injuries, as well as post-fall evaluation and documentation on every shift for 72 hours. However, review of the resident's records showed that, following several unwitnessed falls, neurological checks and every-shift documentation were either missing or incomplete for the majority of required intervals. The resident involved had moderately impaired cognition, was frequently incontinent, required substantial to maximal assistance for activities of daily living, and used a wheelchair. The care plan identified the resident as being at risk for falls due to confusion, deconditioning, and gait/balance problems, with multiple falls documented over a two-month period. Despite these risks and repeated incidents, the facility did not consistently document the required post-fall neurological assessments or every-shift follow-up as outlined in their policy. Interviews with staff, including an LPN, the Administrator, the DON, and a Corporate Nurse, confirmed that neurological checks were expected to be completed and documented per policy after unwitnessed falls. The Administrator acknowledged that neurological check sheets for the resident could not be found, and staff had only documented that checks were done without providing the required detailed documentation. This lack of adherence to policy and incomplete documentation constituted the deficiency identified by surveyors.
Failure to Timely Administer and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer management for one resident. Upon admission, staff did not document a description of the resident's wounds, including location, stage, size, or other required characteristics, as outlined in the facility's wound management and skin integrity policies. The baseline care plan for the resident was left blank regarding skin issues, and progress notes lacked any wound description upon admission. The resident was admitted with significant medical conditions, including paraplegia, diabetes, heart failure, and multiple pressure ulcers: two suspected deep tissue injuries (DTIs) on the heels and a Stage IV pressure ulcer on the sacrum, all present on admission. Physician orders for wound care were not timely administered or documented. The Treatment Administration Record (TAR) showed multiple missed or undocumented treatments for the resident's wounds, including the sacral pressure ulcer and both heel DTIs. There were no entries for some ordered treatments on specific dates, and staff failed to document reasons for missed treatments. Interviews with nursing staff, the wound nurse, and the DON confirmed that a blank on the TAR indicated the treatment was not done, and there was no documentation that the physician was notified of delays or missed treatments. The wound doctor and corporate nurse both stated that staff were expected to follow physician orders and facility policies, but were unaware of the lapses in documentation and administration until after the fact. The facility's policies required comprehensive skin assessments and timely documentation of wound characteristics and treatments, as well as prompt notification of the physician and other relevant parties when wounds were identified or when treatment orders were absent. Despite these policies, the resident's wounds were not properly assessed or documented on admission, and there were significant gaps in the administration and documentation of prescribed wound care treatments. These failures were confirmed through record review, staff interviews, and review of the facility's own policies and procedures.
Failure to Administer HIV Medication and Notify Physician and Responsible Party
Penalty
Summary
A resident with a diagnosis of HIV and impaired immunity was admitted to the facility and had a physician order for Triumeq, an antiretroviral medication critical for managing HIV. Upon admission, the resident did not receive Triumeq as ordered for an extended period due to issues with medication availability, insurance authorization, and lack of timely follow-up by facility staff. Documentation shows that the medication was not administered on multiple occasions, with staff marking 'not administered' (NA) on the Medication Administration Record (MAR) but failing to consistently document actions taken to resolve the issue or notify the prescribing Infectious Disease (ID) physician, the resident, or the resident representative (RR) about the missed doses. The facility's policies required staff to notify the physician and document actions taken when a vital medication was not available, but interviews and record reviews revealed that these procedures were not followed. Staff often did not document communication with the physician or RR regarding the medication gap, and there was no evidence that the ID physician was informed in a timely manner about the ongoing lack of medication. The resident's care plan identified the risk of infection due to immune deficiency, but interventions to monitor and report complications were not effectively implemented in relation to the missed medication. The facility also lacked a process to ensure timely follow-up on prior authorizations, resulting in prolonged delays in obtaining the medication. As a result of these failures, the resident missed multiple doses of Triumeq over a period of more than a month, which was confirmed by laboratory results showing a significantly elevated viral load and low CD4 count, indicating the medication was not being administered as required. The ID office and RR were not made aware of the medication gap until after the resident's condition had deteriorated. Interviews with facility staff, pharmacy, and the ID office confirmed that communication and documentation were insufficient, and the facility did not provide evidence of timely notification or adequate follow-up to ensure the resident received the prescribed medication.
Failure to Provide Timely Incontinence Care and Personal Hygiene Assistance
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living for residents who were dependent, specifically in the areas of toileting and incontinence care. Four residents who were incontinent of bowel and/or bladder did not receive timely incontinence care, as staff did not provide care as needed to maintain good personal hygiene. Additionally, two other residents reported that staff frequently did not check them for incontinence every two hours and did not respond to their call lights in a timely manner when they needed to be changed, resulting in them being left wet for extended periods. The facility also did not provide fresh ice water to three residents, as observed during the survey. These deficiencies were identified through observation, interviews, and record review, affecting multiple residents with a census of 118. The report documents that the facility did not ensure dependent residents received timely and adequate care for incontinence and personal hygiene, and failed to provide fresh ice water to some residents, as required.
Failure to Respond Timely to Call Lights and Resident Needs
Penalty
Summary
Facility staff failed to respond promptly to residents' call lights, resulting in delayed care for multiple residents. One resident with a history of bypass surgeries experienced chest pain, activated the call light, and after waiting 10 minutes without a response, called 911. Emergency Medical Services (EMS) arrived and were unable to locate facility staff until they found one staff member asleep on a couch. The resident was subsequently admitted to the hospital with atrial fibrillation. At the same time, another resident was returning from the hospital with EMS, and the EMS crew also could not find staff readily available. Additionally, a hospital Emergency Department report indicated that another resident called 911 after being left on the toilet for three hours, resulting in stiffness and pain.
Insufficient Nursing Staff Resulting in Delayed and Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delayed and inadequate care. Four residents who were incontinent of bowel and/or bladder did not receive timely incontinence care. Three other residents reported that staff did not check on them every two hours, leaving them wet for extended periods, and that call lights often went unanswered for hours. One resident with a history of bypass surgeries experienced chest pain, used the call light, and did not receive a response from staff for 10 minutes, prompting the resident to contact EMS. When EMS arrived, they could not locate facility staff until they found one staff member asleep on a couch. Another resident returned from the hospital with EMS at the same time and that EMS crew also could not find staff readily available. Additionally, a hospital emergency department report indicated that a resident called 911 after being left on the toilet for three hours, resulting in stiffness and pain. The facility census was 118 residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During observation, interview, and record review, eight medication errors were identified out of 30 opportunities, resulting in a 26.66% error rate. These errors involved two residents while the facility census was 118. The deficiency was identified through direct observation and review of medication administration practices, which revealed multiple errors affecting the residents involved.
Neglect in Incontinence Care and Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure residents were free from neglect, as evidenced by inadequate incontinence care and delayed response to call lights. Four residents were observed wearing two saturated incontinence briefs, emitting strong odors of urine and feces, indicating they had not been changed for extended periods. Interviews with residents and staff revealed that residents were not checked every two hours as required, and staff shortages were cited as a reason for the neglect. Additionally, residents reported that call lights were not answered promptly, sometimes taking hours for a response. One resident with a history of bypass surgeries experienced chest pains and activated their call light, but when staff did not respond within 10 minutes, the resident called 911. Emergency Medical Services (EMS) arrived but could not locate facility staff immediately, eventually finding one staff member asleep on a couch. Another resident returned from the hospital with EMS at the same time, and the EMS crew again struggled to find staff readily available. Another resident's hospital Emergency Department report indicated they called 911 after being left on the toilet for three hours, resulting in stiffness and pain. The facility's staffing issues were further highlighted by interviews with staff, who admitted to being unable to perform regular checks due to insufficient personnel. The Assistant Director of Nursing (ADON) acknowledged that it was inappropriate to check residents' briefs through their clothing and that staff should provide privacy and visually check for soiling. The report also noted that residents were not offered fresh ice water regularly, and some residents had to rely on family members to provide it. These deficiencies had the potential to affect all residents, with a census of 118.
Inadequate Incontinence Care and Hygiene Maintenance
Penalty
Summary
The facility failed to provide timely incontinence care and maintain personal hygiene for residents who were unable to perform activities of daily living independently. This deficiency affected several residents who were incontinent of bowel and/or bladder. Observations revealed that residents were left in soiled briefs for extended periods, sometimes wearing two briefs, which made it difficult to determine if the inner brief was wet. This practice led to residents lying in urine-soaked sheets and experiencing discomfort and potential skin integrity issues. Interviews with staff and residents highlighted that the facility did not adhere to its policy of checking residents every two hours for incontinence. Staff admitted to not changing residents during the night shift and acknowledged the inappropriate practice of placing two briefs on residents. Residents reported that call lights were not answered promptly, often taking over an hour, and that they were not provided with fresh ice water regularly. The lack of adequate staffing was cited as a reason for the delay in providing care, with only two CNAs available for 58 residents during the night shift. The facility's failure to provide necessary care and services resulted in residents being left in unsanitary conditions, with some experiencing redness and potential moisture-associated skin damage. The administration and DON acknowledged the issues with call light response times and the inappropriate practice of checking briefs through clothing. However, the report does not mention any corrective actions or plans to address these deficiencies.
Failure to Follow Physician Orders and Perform Wound Treatments
Penalty
Summary
The facility failed to provide care consistent with professional standards by not following physician orders and performing wound treatments for three residents. Resident #10, who was cognitively intact and had multiple diagnoses including peripheral vascular disease and diabetes, did not receive wound dressing changes as ordered. The resident's dressings were not changed according to the schedule, and the care plan did not address the treatment for the resident's lower extremities. Observations confirmed that the dressings were not dated correctly, and interviews with staff revealed a lack of adherence to the physician's orders. Resident #8, admitted with cellulitis and malignant melanoma, experienced a skin tear after a fall. The skin tear was not documented in the resident's medical record, and no physician's order was obtained for the treatment. The dressing applied to the skin tear was not changed as it should have been, and the resident was later admitted to the hospital. Interviews with staff indicated that the necessary steps to document and treat the skin tear were not followed, leading to a lapse in care. Resident #1, with severe cognitive impairment and diagnoses including Alzheimer's Disease, had undated dressings on the right lower and upper extremities. The treatments were documented as completed, but observations showed that the dressings were not dated. Additionally, Resident #18, who was cognitively intact and admitted with a hip fracture, did not receive a proper assessment of a surgical wound upon admission. The dressing on the surgical incision was not changed, and there was no physician's order for the dressing. Interviews with staff highlighted the failure to perform a complete skin assessment and obtain necessary treatment orders for surgical wounds.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care, affecting multiple residents. Several residents reported that staff did not check on them every two hours, leaving them wet for extended periods, and it often took hours for staff to answer call lights. One resident with a history of bypass surgeries experienced chest pains and contacted EMS after staff did not respond to his call light for 10 minutes. When EMS arrived, they found a staff member asleep on the couch, and another EMS crew could not find staff readily available when another resident returned from the hospital. The facility's staffing levels were inadequate, particularly during the night shift, as observed during the initial tour. There were only two nurses and five CNAs on duty for 118 residents, with one nurse and two CNAs assigned to each floor. Interviews with staff revealed that this staffing level was insufficient to provide timely care, with some residents not being checked or changed for incontinence throughout the night. The facility's assessment indicated a need for more staff, but the facility failed to meet these staffing expectations on multiple occasions. Specific residents were observed to be wearing two briefs, both soaked with urine, and lying in urine-soaked bedding. These residents had not been changed for several hours, leading to potential skin integrity issues. Staff interviews confirmed that the lack of adequate staffing made it difficult to provide necessary care, and some staff were unaware of the facility's policies regarding resident care. The facility's failure to provide adequate staffing and timely care had the potential to affect all residents.
False Documentation and Lack of Nursing Coverage
Penalty
Summary
The facility failed to provide services that meet professional standards of clinical practice on the day shift of 12/15/24 on [NAME] Hall. There was no Licensed Practical Nurse (LPN) or Registered Nurse (RN) available to administer medications, perform gastrostomy (g-tube) flushes, provide treatments, complete assessments, or monitor residents as ordered. The Director of Nursing (DON) falsely documented that they administered medications and g-tube flushes, completed treatments, and assessments for residents from 7:00 A.M. through 3:00 P.M. This affected 41 residents on the hall, with specific issues identified in 15 sampled residents. Additionally, LPN FF and/or Certified Medication Technician (CMT) GG obtained resident blood glucose levels and administered insulin but were unable to record these in the Medication Administration Record (MAR). The DON entered these blood glucose levels and insulin administration into the MAR using their electronic signature, falsely indicating they had performed these tasks. This affected 17 residents who received blood glucose monitoring and/or insulin, with problems identified in 10 sampled residents. Interviews with staff and the facility's Medical Director revealed that the DON was not present during the day shift and did not perform the documented tasks. The DON admitted to initialing several day shift medications, treatments, assessments, and monitoring as completed, despite not performing them. The facility's policies require that medications, treatments, and assessments be documented accurately and completed at the time they are done. The DON's actions were not in line with these policies, leading to a significant deficiency in the facility's care standards.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to adhere to its change of condition policy for a resident who experienced a significant decline in health. The resident, who had severe cognitive impairment and a history of dysphagia, was found unresponsive with slow, shallow breaths. Despite the speech therapist's observations of the resident's deteriorating swallowing abilities and increased confusion, the physician was not notified in a timely manner. The resident was eventually transported to the hospital after being found in a critical state, but this was only after a significant delay in communication and action by the facility staff. The facility's policy required that any change in a resident's condition be promptly communicated to the attending physician and the resident's representative. However, the staff failed to notify the physician about the resident's worsening condition, as reported by the speech therapist. The speech therapist had noted the resident's increased risk of aspiration and had communicated these concerns to the nursing staff, who were supposed to inform the physician. Despite multiple attempts by the LPN to contact the physician, no message was left, and the information was inadequately passed on to subsequent shifts. Interviews with the facility staff revealed a breakdown in communication and adherence to protocol. The primary care physician and medical director were not informed of the resident's condition change, which they expected to be notified about. The administrator and director of operations also confirmed that staff were expected to follow the facility's policies and procedures, which included documenting changes in condition and notifying the appropriate parties. This failure to follow established protocols resulted in a delay in the resident receiving necessary medical evaluation and treatment.
Failure to Maintain Comfortable Room Temperature for Residents
Penalty
Summary
The facility failed to maintain a comfortable room temperature for Resident #6, who reported that the cold temperature in his/her room was causing discomfort and affecting his/her sleep. Despite the resident's repeated complaints to the maintenance staff, nurses, and the Administrator, the issue persisted for nine weeks without resolution. The Maintenance Supervisor acknowledged the problem but cited delays due to other tasks, such as moving furniture, and the need for a replacement part, which was only purchased the day before the surveyor's observation. Resident #6's medical history includes moderate cognitive impairment and chronic lung conditions, which could be exacerbated by the cold environment. The resident's temperature readings consistently showed low body temperatures, indicating the room's coldness was affecting his/her physical state. The Maintenance Supervisor was unaware of the thermostat's malfunction, which was set to 78 degrees but only reached 71 degrees, and had not taken timely action to address the issue. Similarly, Resident #19 also experienced discomfort due to the cold air blowing continuously in his/her room, despite the air conditioner being turned off. The resident, who is on blood thinners, expressed frustration and concern about the cold environment. The Maintenance Supervisor and Assistant were aware of the issue but had not communicated any updates or resolved the problem, leaving the resident to cope with the cold by using extra blankets and wearing a sweater to bed.
Facility Fails to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its written policy by not permitting a resident to return after hospitalization, despite the absence of a proper discharge order or documentation. The resident, who was admitted for skilled services, was transported to the hospital without a documented physician's order for transfer. Upon the resident's return, the facility staff refused to accept the resident back, citing a lack of information and system issues, despite the hospital's insistence on the facility's legal obligation to do so. The Emergency Medical Service (EMS) report indicated that the facility's nurse refused to sign a transfer of care for the resident, who was medically cleared to return. The nurse claimed the resident did not want to be there and that it was not their problem, further stating that the facility's system was down, and they had no information on the resident. The EMS had to return the resident to the hospital after the facility's refusal to accept them back. There was no documentation in the resident's progress notes regarding the transfer to the hospital, updates on the resident's status, or the refusal to readmit the resident. Additionally, there was no record of a bed-hold, a 30-day discharge notice, or any physician order to discharge the resident. The facility's Administrator and Director of Nursing were unaware of the resident's status and expected the nursing staff to have documented the necessary information and updates.
Failure to Develop Timely and Individualized Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive, accurate, and individualized care plan was developed for a resident, identified as Resident #10, within the required timeframe. The facility's policy mandates that a comprehensive care plan should be developed within seven days after the completion of the Admission Minimum Data Set (MDS). However, the MDS/Care Plan Coordinator acknowledged that a comprehensive care plan was not present in the resident's chart, despite the expectation that it should be completed within 14 days of admission. The Director of Nursing and Administrator confirmed this expectation during an interview. Resident #10, who was cognitively intact, had a history of high blood pressure, peripheral vascular disease, diabetes, high cholesterol, and stroke, and was admitted with wounds. The care plan in use at the time of the survey included outdated information from a previous admission and did not reflect the resident's current needs. The MDS/Care Plan Coordinator admitted to making changes to the care plan at a later time, indicating a delay in updating the care plan to address the resident's specific needs and conditions.
Failure to Update Care Plans for Aspiration Precautions and Fall Interventions
Penalty
Summary
The facility failed to ensure timely revisions to resident care plans, resulting in deficiencies in care for two residents. One resident returned from the hospital with a diagnosis of aspiration pneumonia and required aspiration precautions during meals. However, these precautions were not added to the resident's care plan. Observations revealed that the resident was left unsupervised during meals, and staff were unaware of the aspiration precautions, leading to the resident being served food and drink inappropriately. Another resident, who had a history of falls, was found under the bed during routine rounds and was subsequently hospitalized. Upon readmission, new orders for bilateral fall mats were received, but these interventions were not added to the resident's care plan. Observations showed inconsistencies in the placement of fall mats and the height of the bed, which was not always in the lowest position as required. Interviews with the MDS/Care Plan Coordinator and facility administration confirmed that the necessary updates to the care plans were not made. The facility's policies and procedures for fall management and care plan updates were not followed, leading to these deficiencies in resident care.
Failure to Follow Aspiration Precautions and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure staff followed aspiration precautions for a resident with a recent diagnosis of aspiration pneumonia. The resident, who had unclear speech, severely impaired cognition, and required partial assistance with eating, was observed without supervision during meals. The resident's care plan was not updated to include the aspiration precautions ordered upon discharge from the hospital, which included sitting at a 90-degree angle, alternating liquids and solids, and requiring 100% supervision. Staff, including CNAs and LPNs, were unaware of these precautions and left the resident unsupervised, contrary to the hospital's discharge instructions. Another deficiency involved a resident with a history of falls who did not have a mat on both sides of the bed and whose bed was not kept in the lowest possible position when unattended. The resident, who had no speech and was dependent on others for mobility, was found under the bed during routine rounds. Although new orders were received for bilateral fall mats, observations showed that the resident's bed was not consistently equipped with mats on both sides, and the bed height was not maintained at the lowest position when staff were not present. The facility's policies on fall management and staff responsibilities were not adhered to, as evidenced by the lack of updated care plans and failure to implement necessary safety measures. The Administrator and DON acknowledged that the policies provided were current and expected to be followed, yet the deficiencies in supervision and safety precautions for both residents were evident during the survey observations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 26.66% error rate during the survey. This was observed through multiple medication administration errors involving two residents. For Resident #41, the Certified Medication Technician (CMT) prepared medications by crushing them and mixing them with pudding, despite some medications being on the facility's 'Do Not Crush' list. The medications were then stored improperly in the medication cart for over an hour before administration, which posed an infection risk and could affect the efficacy of the medications. Additionally, there was no documented order allowing for the crushing of medications, and the resident's preference for receiving medications in pudding was not properly documented or communicated. For Resident #42, the CMT administered a new inhaler without priming it first, as required by the manufacturer's instructions, and failed to provide the correct dosage of two puffs. The resident was also not instructed to rinse their mouth after using the inhaler, which is necessary to prevent fungal infections. Furthermore, the CMT administered a chewable aspirin instead of the prescribed delayed-release form, indicating a lack of awareness of the differences between medication forms. Interviews with facility staff, including the Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON), revealed expectations for proper medication administration practices that were not followed. These included ensuring medications are administered as ordered, documenting resident preferences and refusals, and adhering to facility policies and guidelines. The failure to follow these protocols contributed to the high medication error rate and the deficiencies observed during the survey.
Medication Error: Simultaneous Administration of Blood Thinners
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident received two different blood thinner medications simultaneously. The resident, who was cognitively intact and had diagnoses including anemia, heart failure, low blood pressure, kidney disease, and high cholesterol, was admitted with physician discharge orders for apixaban and heparin. However, the orders were not correctly transcribed, leading to the resident receiving apixaban earlier than intended and Lovenox instead of heparin due to pharmacy issues. The Director of Nursing was unaware of the discrepancy in the orders until after the error occurred, and the Medical Director expected the nurses to have clarified the orders. The Licensed Practical Nurse involved stated that medication orders should be written as per the admission orders. The error was discovered when it was noted that the apixaban was not to be started until a specific date, and the Lovenox was only to be administered for four days, which was not followed as per the orders.
Failure to Adhere to Dietary Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to ensure that residents receiving dialysis were provided with diets as ordered by their physicians. Two residents, both receiving in-house dialysis, were served meals that included restricted food items such as potatoes, despite clear dietary orders to avoid them. The dietary restrictions were not reflected in the residents' care plans, and the dietary aides and CNAs did not adhere to the menu slips that specified the necessary dietary substitutions. Resident #5, who had severe cognitive impairment and required partial assistance with eating, was served breakfast and lunch that included potatoes, a restricted item. The CNAs responsible for serving and feeding the resident did not read the menu slip, which clearly stated the dietary restrictions. The LPN and CNA involved acknowledged the oversight but did not take immediate corrective action to replace the restricted food items. Resident #17, who was cognitively intact and aware of their dietary restrictions, also received meals containing potatoes. Despite knowing the restrictions, the resident consumed the potatoes due to the lack of available substitutes. The Dietary Manager confirmed that the dietary aides should have followed the menu slips and provided appropriate substitutions. The facility's Administrator and DON expected staff to follow physician orders and ensure dietary compliance, but this was not consistently practiced, leading to the deficiency.
Failure to Maintain Accurate Medical Records for Hospitalized Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a change in condition and was admitted to the hospital. The resident, who had been admitted to skilled services, showed signs of confusion and dependency in self-care and mobility. On the day following their admission, the resident experienced chest pain and was advised by their primary care provider to be sent to the emergency room. However, there was no documentation of a hospital transfer order, physician notification, or updates on the resident's status in the facility's records. During an interview, both the Administrator and the Director of Nursing (DON) were unaware of the resident's whereabouts and lacked documentation regarding the resident's hospital transfer. The DON did not recall completing the necessary hospital transfer form, and the Administrator discovered only during the interview that the resident had been transferred to another facility. The absence of documentation, including admission notes and progress notes, led to the inability of the facility staff to provide information about the resident's status, highlighting a significant lapse in maintaining medical records according to professional standards.
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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