River Crossing Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 11278 Schuetz Road, Saint Louis, Missouri 63146
- CMS Provider Number
- 265457
- Inspections on file
- 24
- Latest survey
- January 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at River Crossing Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain professional standards for food service safety, with multiple instances of improperly stored and unlabeled food items in the kitchen. Observations revealed unsanitary conditions, including caked-on stains on kitchen equipment and debris on the floor. Staff did not follow proper sanitary practices during food preparation, using bare hands and inadequately cleaning equipment between uses. The Dietary Manager acknowledged these issues, highlighting a need for improved cleanliness and food labeling.
The facility did not maintain RN coverage for at least eight consecutive hours daily, as required. On several days, there was no RN present, and on others, the only RN was the DON, who was also acting as the DON due to a nursing shortage. The ADON, an LPN, often took on DON responsibilities. This deficiency had the potential to affect all 87 residents.
The facility failed to ensure proper communication with dialysis centers for residents receiving dialysis services. Three residents reported no paperwork or communication forms were used, and the facility did not check vital signs. Interviews with the DON and Administrator confirmed the lack of communication and documentation, contrary to the facility's policy.
The facility failed to follow standardized recipes for pureed meals, leading to inconsistent textures and potential safety risks for residents on pureed diets. Additionally, the facility did not maintain proper food temperatures during service, with hot foods not reaching the required 120 degrees Fahrenheit and cold foods exceeding 41 degrees Fahrenheit. Residents reported dissatisfaction with the quality and temperature of meals, particularly those served in their rooms.
A resident with communication difficulties due to a stroke was dismissed by a housekeeper who did not speak the resident's language, compromising the resident's dignity. The facility lacked a consistent communication strategy, relying on family visits for translation. Staff interviews revealed gaps in communication support, with the ADON acknowledging the lack of a communication board and attributing the incident to the housekeeper's inexperience.
A facility failed to document a resident's change in condition according to its policy. The resident, with a history of acute respiratory failure and other health issues, showed signs of facial drooping and drowsiness. An LPN contacted the physician and family, who decided to keep the resident in the facility. However, there was no follow-up documentation, and the resident passed away without further intervention. Interviews revealed an expectation for proper documentation, which was not met, leading to a deficiency.
A long-term care facility failed to maintain an effective infection prevention and control program. An LPN did not change gloves or perform hand hygiene after wound care, and catheter tubing was reconnected without disinfection. Additionally, staff did not wear appropriate PPE during high-contact activities with a resident on enhanced barrier precautions. These actions were contrary to the facility's policies, which emphasize hand hygiene, aseptic technique, and PPE use to prevent infection spread.
The facility failed to protect residents from physical abuse by not adequately educating staff on the risk of resident-to-resident physical assault and immediate interventions. This led to a resident physically assaulting another resident after a verbal altercation escalated. The staff was unaware of the resident's history of verbal aggression and potential for physical violence, contributing to the severity of the incident.
The facility failed to maintain complete and accurate medical records, including documentation of verbal and physical aggressive incidents, encounters with the SSD, and timely uploading of neurological checks. A resident with a history of aggression had significant gaps in their progress notes, and another resident's neurological checks were not uploaded promptly.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed over several days. Food items in the dry storage room and freezers were found improperly stored, with many items not labeled, dated, or covered. Specific items included bags of chocolate chips, tortilla chips, crispy onions, powdered sugar, bow noodles, croutons, chicken patties, and chicken nuggets, all lacking proper labeling and dating. Additionally, a bag of biscuit dough was found open and exposed to air. These practices were observed on multiple occasions, indicating a systemic issue with food storage and labeling. The kitchen environment was also found to be unsanitary, with heavy caked-on stains on the stove burners, the front of the stove, and the deep fryer, which also contained old grease. The kitchen floor was dirty, with debris and food particles present. Furthermore, staff failed to follow sanitary practices during food preparation. On one occasion, a dietary staff member rinsed a blending bowl with plain water, leaving chicken puree residue before preparing a carrot puree. Another staff member used bare hands to clean a blending bowl, leaving soup puree residue before preparing cornbread puree. The Dietary Manager acknowledged these issues, noting that deep fryers were cleaned monthly and that there was an expectation for all equipment and floors to be clean, with food properly labeled and stored.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. The nursing schedules from 12/30/24 through 1/23/25 revealed multiple days without RN coverage, specifically on 1/3, 1/4, 1/5, 1/6, 1/8, 1/12, 1/13, 1/20, and 1/22. On other days, the only RN scheduled was the Director of Nursing (DON), who was also serving as the acting DON due to a shortage of nurses. The Assistant Director of Nursing (ADON), an LPN, often assumed DON responsibilities, as the DON preferred to work on the floor. The facility acknowledged the shortage and had posted an ad for an RN, but the deficiency persisted, potentially affecting all 87 residents.
Lack of Communication Between Facility and Dialysis Centers
Penalty
Summary
The facility failed to ensure proper communication between the nursing home and the dialysis centers for residents receiving dialysis services. The facility's policy required written communication with the dialysis center, including pertinent information such as medication changes, recent changes in condition, and the resident's tolerance of dialysis procedures. However, the facility did not adhere to this policy, as evidenced by the lack of written communication for three sampled residents who received dialysis services. Resident #32, who was cognitively intact and diagnosed with end-stage kidney disease, reported that no paperwork was provided by the facility for the dialysis center, and there was no communication form used. Similarly, Resident #58, also cognitively intact and diagnosed with end-stage renal disease, had no documentation of being assessed before or after dialysis, and the care plan did not align with the physician's order for dialysis days. Resident #60, who was cognitively intact and received dialysis, also reported that neither the resident nor the driver took any paperwork to the dialysis appointments, and the facility did not check vital signs. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not use the dialysis communication forms, and there was a lack of documentation regarding the residents' dialysis treatments. The DON acknowledged the need for in-service training to implement the communication form, but it was not in use at the time of the survey. The Administrator confirmed that there should be communication between the facility and the dialysis centers, but this was not occurring as required by the facility's policy.
Inconsistent Food Preparation and Temperature Control
Penalty
Summary
The facility failed to adhere to standardized recipes for pureed meals, resulting in inconsistencies in food texture and potential safety risks for residents on pureed diets. Observations revealed that dietary staff did not measure ingredients accurately, leading to variations in the consistency of pureed chicken, bean soup, and cornbread. The dietary manager acknowledged that the cornbread should not have been thick and pasty, emphasizing the importance of following recipes to ensure nutritional value and safety for residents with swallowing difficulties. Additionally, the facility did not maintain proper food temperatures during service, with hot foods not reaching the required 120 degrees Fahrenheit and cold foods exceeding 41 degrees Fahrenheit. Observations showed that food temperatures were not checked before serving, and test trays revealed that meals were served at inadequate temperatures. Residents reported that meals served in their rooms were often cold, while those in the dining room were served promptly and warm. The facility's policy required food to be served at proper temperatures to ensure safety, but this was not consistently followed. Resident feedback from council meetings indicated ongoing issues with cold meals, particularly for those receiving trays in their rooms. Residents expressed dissatisfaction with the quality and temperature of the food, with some relying on family members to bring meals from outside. Interviews with residents confirmed that meals were often unappetizing and cold, regardless of where they were consumed. The administrator acknowledged the expectation for hot foods to be served hot and cold foods to be served cold, highlighting a gap between policy and practice.
Failure to Ensure Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident who was dismissed by a housekeeper when attempting to communicate. The resident, who primarily speaks Cantonese and has a communication problem due to a stroke, attempted to engage with Housekeeper E, who shrugged and stated they did not speak the resident's language before walking away. This interaction was observed by two CNAs who giggled at the situation, highlighting a lack of sensitivity and understanding of the resident's needs. The resident's medical history includes atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's Disease, and a stroke, which has resulted in aphasia. The resident's care plan indicates a need for an interpreter and anticipates communication challenges. Despite this, the facility did not have a communication board in place, and staff relied on the resident's family for translation, who visited three times a day. The CNAs admitted they were unsure how the resident would communicate pain, indicating a gap in the facility's ability to meet the resident's communication needs. Interviews with various staff members, including an LPN, CMT, and the ADON, revealed that while some staff attempted to use translators or simple questions, there was no consistent approach to ensuring the resident's communication needs were met. The ADON acknowledged the lack of a communication board and attributed the incident to the housekeeper's inexperience in long-term care. The facility's failure to provide adequate communication support and training for staff resulted in a situation where the resident's dignity and respect were compromised.
Failure to Document Change in Resident's Condition
Penalty
Summary
The facility failed to adhere to its policy and accepted professional standards for documentation when a resident experienced a change in condition. The policy required licensed nurses to document the date, time, and details of the incident, contact the attending physician and family, update the care plan, and maintain records in the resident's medical record and 24-hour report. However, the facility did not follow these procedures when a resident showed signs of a change in condition, including facial drooping and increased drowsiness. The resident, who had a history of acute respiratory failure with hypoxia, generalized muscle weakness, and other health issues, was observed by an LPN to have a disfigured mouth and facial drooping. The LPN contacted the physician and the resident's family, who decided to keep the resident in the facility as long as they remained responsive. Despite this, there was no follow-up documentation regarding the resident's condition change, and the resident passed away in their bed without further intervention or documentation of the change in condition. Interviews with facility staff, including the acting DON, ADON, and the physician, revealed that there was an expectation for staff to notify the physician and family of any changes in condition and to document these changes properly. However, the documentation was incomplete, and there were no follow-up notes, nurses' notes, or SBAR sheets regarding the resident's change of condition. The lack of documentation and follow-up actions led to a deficiency in the facility's adherence to its policies and professional standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. During wound care for a resident, an LPN did not change gloves or perform hand hygiene after completing the procedure. Instead, the LPN continued to handle the resident's personal items and bed controls with the same gloves used during wound care, which is against the facility's hand hygiene policy. This policy emphasizes that hand hygiene is the primary means to prevent the spread of infections and should always be performed after removing gloves. In another instance, a resident with a suprapubic catheter had their catheter tubing disconnected and reconnected without disinfecting the junction, contrary to the facility's catheter care policy. This policy requires aseptic technique and disinfection of the catheter tubing junction with alcohol or a chlorhexidine sponge before reconnection. The resident had a history of urinary tract infections and was receiving catheter care every shift, highlighting the importance of adhering to infection control protocols. Additionally, staff failed to wear appropriate personal protective equipment (PPE) during high-contact activities with a resident on enhanced barrier precautions (EBP) due to an MDRO. Despite the presence of PPE supplies and signage indicating EBP, CNAs did not wear gowns while transferring the resident from bed to wheelchair and during morning care. The facility's policy mandates the use of gowns and gloves during high-contact care for residents on EBP to minimize the risk of infection transmission.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by not adequately educating nursing staff on the risk of resident-to-resident physical assault and immediate interventions to deescalate verbal altercations. This deficiency was highlighted when Resident #1, who was cognitively intact, willfully physically assaulted Resident #2. The nursing staff was unaware of Resident #1's potential for physical aggression and did not intervene promptly when a verbal altercation between the two residents escalated to physical violence. Resident #1 had a history of verbal aggression, which was not adequately documented or communicated to the staff, leading to a lack of appropriate interventions to prevent the escalation. Resident #1's care plan indicated a history of verbal aggression and poor impulse control, with interventions to monitor behavior and intervene before agitation escalates. However, the staff was not informed of these risks or the necessary interventions. On the day of the incident, Resident #1 had a distressing phone conversation and attempted to go outside to smoke, leading to a confrontation with Resident #2, who was blocking the hallway. The situation escalated quickly, resulting in Resident #1 physically assaulting Resident #2 by pulling their hair and hitting them repeatedly. The staff's delayed response and lack of awareness of Resident #1's potential for physical aggression contributed to the severity of the incident. Interviews with staff members revealed that they were not aware of Resident #1's history of verbal aggression or the risk of physical violence. The facility's documentation practices were also found to be lacking, as behavior incidents were kept in soft files and not included in the resident's medical record. This lack of documentation and communication prevented the staff from being fully informed about Resident #1's behavior and the necessary interventions to prevent such incidents. The facility's failure to educate and inform staff about the risks and appropriate interventions for resident-to-resident altercations directly led to the physical assault on Resident #2.
Failure to Maintain Accurate Medical Records and Document Behavioral Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for its residents, specifically failing to document verbal and physical aggressive incidents, encounters with the Social Services Director (SSD) discussing behaviors, and when psychiatric services or counseling were offered to a resident. For Resident #1, there were significant gaps in the progress notes, missing documentation of verbal and physical altercations, and no records of psychiatric services or counseling being offered. The facility kept behavior investigations in soft files that were not uploaded into the resident's medical records, making it difficult to track and manage the resident's behavioral issues effectively. Resident #1 had a history of verbal aggression towards staff and other residents, including using racial slurs and cursing when denied pain medication or smoking outside of scheduled breaks. Despite these behaviors, there was no documentation of the SSD's counseling sessions or the resident's refusal of psychiatric services. The facility's practice of keeping behavior incidents in soft files and not expecting nurses or the SSD to document these incidents in the medical record contributed to the incomplete documentation. For Resident #2, the facility failed to upload neurological checks into the resident's medical record in a timely manner. After an altercation with another resident, Resident #2 sustained injuries and required neurological checks, which were documented on a paper flow sheet. However, there was no established timeframe for uploading these flow sheets into the medical record, and the facility kept them in soft files instead. This practice resulted in incomplete medical records and hindered the ability to provide comprehensive care to the resident.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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