Ssm Health Depaul Hospital - Anna House
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeton, Missouri.
- Location
- 12284 Depaul Drive, Bridgeton, Missouri 63044
- CMS Provider Number
- 265842
- Inspections on file
- 11
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ssm Health Depaul Hospital - Anna House during CMS and state inspections, most recent first.
A CNA transferred a resident alone using a sit-to-stand lift, contrary to facility policy requiring two staff for mechanical lift transfers. The resident, who had multiple medical conditions and required substantial assistance, resisted during the transfer and slid out of the sling, resulting in a fractured femur. Staff found the resident hanging from the lift and later confirmed the injury by x-ray before sending the resident to the hospital.
The facility failed to maintain cleanliness in the main kitchen and ensure operational dishwashers on the A2 unit, affecting two residents. Observations showed food debris, grease, and dust accumulation in the kitchen, while dishwashers were non-functional, leading to inadequate handwashing of dishes. Residents reported receiving meals with dirty utensils, highlighting the facility's failure to adhere to cleaning protocols and maintain proper sanitation.
The facility failed to conduct weekly skin assessments for residents at risk of skin breakdown, did not complete necessary admission procedures for a newly admitted resident, and neglected to implement physician orders for a resident with a history of edema and blood clots. Staffing issues and inadequate documentation practices contributed to these deficiencies.
The facility experienced a 35.71% medication error rate due to unavailable medications for several residents. Medications for a resident were not in the cart, leading to delayed administration. Another resident's medication was left at the bedside, and eye drops were missing. A third resident's supplement was unavailable. Staff interviews revealed non-compliance with policies for using emergency kits and ensuring medication availability.
The facility failed to serve food at safe and appetizing temperatures, as observed with food items like buttered potatoes and cornbread casserole being below the required temperature. Residents reported that food was often cold, and staff interviews confirmed the expectation for food to be served at appropriate temperatures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and catheters, as staff did not wear isolation gowns during high-contact care activities. Additionally, hand sanitizer dispensers were found empty, compromising hand hygiene. Staff interviews revealed a lack of understanding regarding EBP, and the facility's leadership acknowledged deficiencies due to inadequate education and oversight.
A facility failed to assess residents for self-administration of medications and did not supervise them during medication administration. Observations showed a CMT leaving residents unsupervised while they took their medications, contrary to facility policy. Interviews confirmed that staff should supervise medication administration, but the CMT believed residents were capable of self-administration despite their medical conditions.
A resident admitted to hospice care with neurocognitive disorder and dementia did not receive a significant change MDS assessment within the required 14 days. The MDS Coordinator was unaware of the hospice admission due to a missing physician order in the EMR, leading to the oversight.
The facility failed to meet the ADL care needs for two residents who required assistance. One resident, with hemiplegia and other conditions, reported no assistance with oral hygiene, resulting in poor oral care and unshaved facial hair. Another resident with Alzheimer's disease was observed with poor oral hygiene and unshaved facial hair, despite being independent after setup. Interviews with staff and the DON confirmed the lack of consistent assistance with oral care and personal hygiene.
A resident with a left hand contracture did not receive a palm protector as recommended by occupational therapy, due to a lack of communication and documentation within the facility. Observations showed the resident without the device, and staff interviews revealed unawareness of the requirement. The Therapy Director admitted to not obtaining a physician order, and the DON and Administrator acknowledged the need for better communication and procedure adherence.
A resident with multiple sclerosis and bladder dysfunction did not receive proper catheter care, as the facility failed to change the catheter tubing and bag every 30 days, leading to cloudy tubing with green residue. The catheter bag was left on the floor after becoming unhooked during care, and staff did not perform necessary catheter care after a bowel movement. Interviews revealed a lack of awareness and adherence to catheter care protocols among staff.
The facility failed to obtain necessary physician orders for respiratory care, affecting three residents. Two residents used CPAP machines without orders, and one had an outdated oxygen order. Another resident received oxygen therapy without a required order. Facility policies were inadequate, and staff interviews confirmed the lack of proper documentation.
A resident with severe cognitive impairment and limited mobility was found without a call light at the bedside, despite the ability to use the right hand. Observations confirmed the absence of a call light over several days. Staff interviews revealed a lack of awareness about the missing call light, although it was acknowledged that all residents should have one within reach.
The facility did not post nurse staffing information daily for two days during the survey. The Staffing Coordinator, responsible for this task, was out sick, and no one else was assigned to update the information. The DON acknowledged the requirement and the lack of a protocol for covering this duty in the Coordinator's absence.
The facility failed to ensure that a resident with a pressure ulcer received appropriate wound care due to the staff not entering physician orders into the medical record. The resident had a Stage 2 pressure ulcer, but the necessary treatment orders were not documented, leading to a lapse in care. Interviews with staff revealed that the facility's policies and procedures were not followed, resulting in the deficiency.
The facility failed to ensure complete and accurate medical record documentation for a resident with multiple diagnoses and pressure injuries. Inconsistent entries in the Medication Administration Record (MAR) and confusion among staff about who performed and documented treatments led to this deficiency.
Failure to Provide Adequate Supervision and Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) used a Sara lift (sit-to-stand lift) alone to transfer a resident who required substantial assistance, despite facility policy requiring two trained staff for all mechanical lift transfers. The CNA did not wait for assistance, even though another CNA was present in the facility and had previously been asked to help. During the transfer, the resident began to resist, moved around, and attempted to remove their arms from the sling, resulting in the resident sliding out of the sling and ending up hanging from the lift with their legs twisted underneath them. The resident involved had a history of dementia, stroke, osteoporosis, an artificial knee joint, spondylosis, and muscle weakness. The resident's care plan indicated a need for one-person assistance for transfers, but interviews and staff statements revealed that the resident was actually a two-person assist and required a Hoyer lift for transfers. There was no documented update in the care plan to reflect this change in transfer status, and staff used both the Sara and Hoyer lifts interchangeably. The resident was cognitively intact but had a history of rejecting care and required substantial to maximal assistance for transfers and bathing. Following the incident, staff responded to the CNA's call for help and found the resident hanging from the lift with a twisted leg. The resident was assessed and later found to have an acute impacted fracture of the left distal femur, confirmed by x-ray. The resident was subsequently sent to the hospital, where they later passed away. Staff interviews confirmed that the CNA was aware of the two-person requirement and the resident's transfer status but did not follow protocol, and there was a lack of clear signage or consistent communication regarding the resident's transfer needs.
Sanitation and Equipment Deficiencies in Kitchen and A2 Unit
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in the main kitchen and the A2 unit, leading to significant deficiencies. Observations over several days revealed that the main kitchen had food debris, grease, and dust accumulation in various areas, including the walk-in refrigerator and freezer, bulk bins, deep fryer, and ceiling tiles. The facility's cleaning rotation policy was not adhered to, as evidenced by the unclean conditions of the kitchen floors, appliances, and storage areas. Interviews with dining service staff and management indicated a lack of clarity and consistency in cleaning responsibilities, contributing to the unsanitary conditions. Additionally, the facility failed to ensure that dishwashers on the A2 unit were operational, affecting the cleanliness of utensils and dishes used by residents. Two residents reported receiving meals with dirty utensils, and observations confirmed that the dishwashers were not functioning, leading staff to wash dishes by hand. However, the handwashing process was inadequate for proper sanitation, as the water temperature in the dishwashers did not reach the necessary level for effective cleaning. The deficiency impacted residents, including one with severe cognitive impairment and another who was cognitively intact, both of whom expressed concerns about the cleanliness of their dining utensils. The facility's failure to maintain operational dishwashers and adhere to cleaning protocols compromised the sanitation of the dining services, posing a potential risk to resident health and safety.
Deficiencies in Skin Assessments and Admission Procedures
Penalty
Summary
The facility failed to ensure that weekly skin assessments were completed for residents at risk for skin breakdown or with impaired skin integrity. Specifically, three residents did not receive the required weekly skin assessments, despite being identified as at risk for developing pressure ulcers. The facility's policy mandates weekly skin inspections, but due to staffing issues, these assessments were not conducted. The usual floor nurse for the A2 unit was moved to a supervisory position, leaving the unit without a dedicated nurse to perform these assessments. Additionally, the facility did not complete necessary admission procedures for a newly admitted resident, including an admission skin assessment, obtaining an admission weight, and securing treatment orders for a skin tear. The resident reported not being weighed or assessed upon arrival, and a skin tear was not properly documented or treated according to protocol. The facility's lack of an admission checklist contributed to these oversights, as the required assessments did not auto-populate in the system. The facility also failed to implement physician orders for a resident with a history of edema and blood clots, specifically the use of thromboembolic deterrent (TED) hose. Despite a physician's order, the TED hose was not documented in the resident's records, and the resident was observed without them. Furthermore, the facility did not address the resident's weight gain, as required by their policy, and failed to document the resident's refusal of care in the medical record. These deficiencies highlight a lack of adherence to established protocols and inadequate documentation practices.
High Medication Error Rate Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 35.71% error rate during the survey. This deficiency was observed through multiple instances where medications were not administered as prescribed. For Resident #161, several medications, including metoprolol, amiodarone, Symbicort, bupropion, furosemide, gabapentin, and nitrofurantoin, were unavailable in the medication cart, and the resident was informed they would have to wait until the evening shift for the pharmacy delivery. This indicates a failure to ensure timely administration of prescribed medications. Resident #163 experienced a similar issue where the docusate sodium was left at the bedside and not administered, and the Systane eye drops were not found in the medication cart. The medication technician left the resident's room without ensuring the medication was ingested, which is against the facility's policy of observing residents after medication administration. This oversight contributed to the high medication error rate observed during the survey. For Resident #162, the Omega 3 fatty acids supplement was not available, and the staff indicated they might need to purchase it from an external source. Interviews with staff revealed that there was a lack of adherence to the facility's policy of using the emergency kit for new admissions and ensuring medications are available and administered as prescribed. The facility's administration acknowledged the expectation for staff to follow physician orders accurately and utilize available resources to prevent medication errors.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature for three residents, as observed during a survey. The facility's policy required that hot foods maintain a temperature of 140 degrees Fahrenheit or greater, and cold foods maintain a temperature of less than 40 degrees Fahrenheit. However, observations revealed that food served to residents on the first floor was below the required temperature, with buttered potatoes measuring at 114.2 degrees Fahrenheit and cornbread casserole at 112 degrees Fahrenheit. Further observations showed baked ham at 118 degrees Fahrenheit and Brussels sprouts at 136 degrees Fahrenheit, indicating a consistent issue with maintaining appropriate food temperatures. Interviews with residents confirmed that food was often served cold, which was corroborated by the resident council meeting where six alert and oriented residents reported similar concerns. Staff interviews, including those with the Dining Service Associate, Dining Service Manager, and Director of Dining Services, acknowledged the expectation that food should be served at a safe and palatable temperature. The Administrator and Director of Nursing also expressed the same expectation, highlighting a disconnect between policy and practice in ensuring food safety and quality.
Failure to Implement Enhanced Barrier Precautions and Maintain Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS for residents with central lines, catheters, and wounds requiring treatments. Observations revealed that staff did not wear isolation gowns during high-contact care activities for residents with wounds and catheters. For instance, staff members were seen handling residents' wounds and catheters without the necessary protective equipment, such as gowns, which are crucial for preventing the transmission of multidrug-resistant organisms (MDROs). Additionally, the facility did not maintain functional hand sanitizer dispensers on one unit, which is essential for proper hand hygiene. Several dispensers were found empty, and staff reported that they had been empty for months, forcing them to rely on sinks for handwashing. This lack of readily available hand sanitizer compromised the ability of staff to perform hand hygiene between resident interactions, increasing the risk of infection transmission. Interviews with staff revealed a lack of understanding and awareness regarding EBP and the necessary precautions for residents with wounds and catheters. Some staff members were unaware of the meaning of EBP or the requirement to use additional PPE. The facility's Infection Preventionist and Director of Nursing acknowledged the deficiencies, attributing them to a lack of education and oversight, and noted that the correct signage and PPE were not consistently available outside residents' rooms.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to self-administer medications and that staff adequately supervised residents during medication administration. This deficiency was observed in the cases of three residents, all of whom had various medical conditions including dementia, anxiety, and depression. Despite the facility's policy requiring an interdisciplinary team assessment and a prescriber's order for self-administration, none of the residents had been assessed or authorized to self-administer their medications. Observations revealed that staff, specifically a Certified Medication Technician (CMT), did not supervise the residents while they took their medications. For instance, one resident was observed taking medications unsupervised in the dining room, with the CMT's back turned towards them. This lack of supervision was consistent across multiple observations and interviews, where residents reported that staff sometimes left them alone to take their medications. Interviews with staff, including a Nurse Supervisor and the Director of Nursing, confirmed that the facility's protocol required staff to supervise residents during medication administration to ensure safety and accuracy. However, the CMT involved believed that the residents were cognitively intact enough to take their medications without supervision, despite their diagnoses. This misunderstanding and deviation from protocol contributed to the deficiency identified during the survey.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in status assessment within 14 days for a resident who was admitted to hospice care. The resident, who had been diagnosed with neurocognitive disorder with Lewy bodies and dementia, was admitted to hospice with a diagnosis of failure to thrive. Despite the requirement for a significant change Minimum Data Set (MDS) assessment to be completed within 14 days of such a change, the facility did not complete this assessment in the required timeframe. The MDS Coordinator acknowledged that a resident's admission to hospice is considered a significant change, necessitating a timely MDS assessment. However, the coordinator was not informed of the resident's hospice admission due to the absence of a physician order in the resident's electronic medical record (EMR). The Director of Nurses and the Administrator confirmed that the MDS Coordinator is responsible for completing all MDS assessments and that the expectation is for these assessments to be completed within the specified period following a significant change.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to meet the Activities of Daily Living (ADL) care needs for two residents, Resident #13 and Resident #35, who were dependent on staff assistance. Resident #13, who is cognitively intact and diagnosed with hemiplegia, hemiparesis, major depressive disorder, anxiety, and morbid obesity, reported that staff never assisted with brushing his/her teeth, resulting in a white thick matter on the teeth and unshaved facial hair. Observations confirmed the resident's poor oral hygiene and facial hair growth. Interviews with the resident and staff, including a CNA and the Director of Nursing (DON), revealed that the expected assistance with oral hygiene and shaving was not provided. Resident #35, with moderately impaired cognition and diagnosed with Alzheimer's disease and muscle weakness, was observed to have a strong odor emitting from his/her mouth and unshaved facial hair. The resident's care plan indicated independence in personal hygiene after setup, but observations and interviews with CNA G and the DON indicated that consistent assistance with oral hygiene was lacking. CNA G admitted to using mouth swabs for oral care but did not inquire about the resident's preference for facial hair shaving. The DON confirmed the expectation for staff to assist with oral care and personal hygiene.
Failure to Ensure Use of Palm Protector for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited mobility, specifically in ensuring the use of a palm protector for a left hand contracture. The resident, who had a history of stroke, contracture to the left elbow, generalized muscle weakness, dementia, and cognitive communication deficit, was observed multiple times without the recommended palm protector. The resident's care plan did not include documentation regarding the application of a palm protector, despite recommendations from occupational therapy. Observations over several days showed the resident without a palm protector, and staff interviews revealed a lack of awareness and communication regarding the resident's need for the device. Certified Nurse Aides (CNAs) and a Restorative Aide (RA) were unaware of the requirement for the resident to wear a palm protector, and there was no physician order for the device in the resident's electronic medical record. The resident's left hand was noted to be contracted and slightly swollen, with indentations from the fingers, indicating a lack of appropriate intervention. Interviews with facility staff, including a Licensed Practical Nurse (LPN), Nurse Supervisor, Therapy Director, and the Director of Nurses (DON), highlighted a breakdown in communication and procedure. The Therapy Director acknowledged the oversight in obtaining a physician order for the palm protector, and the DON and Administrator confirmed that therapy should have educated nursing staff and ensured the order was entered into the electronic medical record. This deficiency in care coordination and communication led to the resident not receiving the necessary equipment to maintain or improve their range of motion.
Failure in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide proper urinary catheter care for a resident, leading to a deficiency. The resident, who had multiple sclerosis, hemiplegia, and neuromuscular dysfunction of the bladder, was observed with a Foley catheter that had not been changed in a long time. The catheter tubing and bag appeared cloudy with green residue, indicating a lack of adherence to the facility's policy of changing the catheter tubing and bag every 30 days. Additionally, the resident's care plan did not address the frequency of catheter changes, and there was no recent lab work or urinalysis to monitor the resident's condition. During an observation, the resident's catheter bag was found on the floor after being unhooked from the bedframe during a care procedure. The staff failed to pick up the catheter bag from the floor and did not provide catheter care after the resident had a bowel movement. The catheter bag remained on the floor for an extended period, and the staff did not follow the facility's policy of keeping the catheter bag off the floor and securing it below the level of the bladder. Interviews with staff revealed a lack of awareness and adherence to catheter care protocols. The Nurse Supervisor and CNA were not aware of the green residue in the catheter tubing and bag, and the Director of Nursing stated that catheter tubing should only be changed if there is dysfunction or discomfort. The facility's failure to follow its own catheter care policies and lack of proper documentation and monitoring contributed to the deficiency.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents by not obtaining necessary physician orders for the use of CPAP machines and oxygen therapy. Two residents were using CPAP machines without physician orders, and one of these residents also had an outdated order for continuous oxygen use that was no longer needed. Another resident was receiving continuous oxygen therapy without a physician order, despite the facility's policy requiring such orders for oxygen use above 2 liters per minute. The facility's policies on CPAP and oxygen administration were inadequate, as the CPAP policy did not address the need for physician orders, and the oxygen policy required orders for specific flow rates. Observations and interviews with staff and residents confirmed the lack of appropriate orders and documentation in the residents' care plans and medical records. The facility's Administrator and DON acknowledged the need for physician orders for CPAP machines and oxygen therapy, highlighting a gap in compliance with professional standards of practice.
Resident Lacks Call Light Access
Penalty
Summary
The facility failed to ensure that a resident's room was adequately equipped with a call light at the bedside. The resident, who had a history of stroke, contracture in the left elbow, dementia, and cognitive communication deficit, was observed multiple times without a call light connected to the port in the wall next to the bed. The resident's care plan indicated a need for a safe environment with a call light within reach, yet this was not provided. Observations over several days confirmed the absence of a call light, despite the resident's ability to use the right hand. Interviews with staff, including CNAs and the Nurse Supervisor, revealed that the resident could understand commands and respond verbally at times, and had the ability to use a call light with the right hand. However, the staff were unaware of the missing call light and acknowledged that all residents should have one within reach. The Director of Nurses and Administrator also confirmed the expectation for all residents to have accessible call lights and noted that staff should report missing call lights to maintenance, although some staff struggled with entering repair requests into the system.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis for two out of four days during the survey. On 9/24/24 and 9/25/24, the direct care staff daily report was dated 9/23/24, indicating that the staffing information was not updated as required. The Staffing Coordinator, who is responsible for posting this information, was out sick for the past two days, and no one else was assigned to fulfill this duty in her absence. During interviews, both the Staffing Coordinator and the Director of Nurses (DON) acknowledged the requirement to post staffing hours daily and admitted that there was no current protocol for covering this task when the Staffing Coordinator is unavailable.
Failure to Document and Provide Wound Care for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received services consistent with professional standards of practice. Specifically, the staff did not enter physician orders for wound care into the medical record for a resident with a pressure ulcer on the left ischial tuberosity. This oversight could have resulted in the wound care not being provided. The resident had moderately impaired cognition, limited range of motion, and was at risk for developing pressure ulcers due to a progressive neurological condition and other diagnoses. The resident's care plan indicated a need for treatment and observation of pressure injuries, but the necessary treatment orders were not documented in the medical record. The deficiency was identified during an observation and interview with the resident, who confirmed having a sore on the buttocks. The wound nurse's evaluation showed a Stage 2 pressure ulcer with slough present, but no treatment order was found in the physician's order summary report or the Treatment Administration Record. Despite the wound nurse obtaining an order for Santyl, it was not entered into the computer. Interviews with various staff members, including a Certified Medication Technician, Care Partner, Registered Nurse, and the Assistant Director of Nursing, revealed that the wound was not properly documented or communicated, and the treatment orders were not entered as required. The facility's policies and procedures were not followed, as confirmed by the Assistant Director of Nursing and the Administrator. They expected staff to notify the doctor, obtain treatment orders, and document wounds in the progress notes and medical record. The failure to enter the treatment orders into the medical record within the expected timeframe of 24 to 72 hours led to the deficiency. The lack of proper documentation and communication regarding the wound care for the resident highlights a significant lapse in the facility's adherence to its own policies and procedures.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one resident. The resident had moderately impaired cognition and multiple diagnoses, including a progressive neurological condition and pressure injuries. The care plan required specific treatments for pressure injuries on the coccyx and left buttock, including the application of wound gel and collagenase ointment. However, the Medication Administration Record (MAR) showed inconsistent documentation, with some entries marked with a '9' indicating 'other/see progress notes,' and others showing only the initials of a Certified Medication Technician (CMT). Progress notes indicated that all medications were given, but there was confusion about who actually performed the treatments and documented them. Interviews with staff revealed discrepancies in the documentation process. The CMT stated that they felt comfortable performing treatments, but the Wound Nurse and Assistant Director of Nursing (ADON) indicated that nurses were responsible for wound care. The Director of Nursing (DON) acknowledged that sometimes the computer system would not accept documentation, leading staff to use a '9' or have nurses document treatments under the CMT's login. The Administrator expected the person who completed the task to document it accurately, but this was not consistently followed, leading to incomplete and inaccurate medical records for the resident.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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