St Andrew's At Francis Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, Missouri.
- Location
- 400 Summerville Blvd, Eureka, Missouri 63025
- CMS Provider Number
- 265195
- Inspections on file
- 22
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Andrew's At Francis Place during CMS and state inspections, most recent first.
A CNA failed to honor a resident's right to refuse getting out of bed for a shower, proceeding with a transfer despite the resident's objections. The resident, who was able to communicate their wishes, sustained a significant skin tear during the transfer, requiring hospital treatment. The incident revealed that staff did not consistently respect or understand resident rights, and the facility's investigation focused on transfer technique rather than the violation of self-determination.
A resident did not receive appropriate care or services to maintain or improve range of motion (ROM) and mobility, and the facility did not ensure interventions were in place to prevent decline unless medically unavoidable.
The facility failed to accommodate resident preferences and needs, leading to deficiencies in care. Two residents faced issues with room arrangements that hindered access to personal belongings and wheelchair maneuverability. Additionally, the facility removed siderails from beds without providing alternatives or conducting proper assessments, affecting four residents who relied on them for mobility and repositioning. The facility's policies on adaptive devices were not followed, and there was confusion among staff about assessment responsibilities.
The facility failed to maintain consistent and updated code status documentation for four residents, leading to discrepancies between their wishes and recorded medical directives. The policy requires residents to complete a therapeutic support level/resuscitation plan upon admission, but inconsistencies were found in the EMR and nurse's report sheets. Interviews with staff revealed lapses in verifying and updating code status information, contributing to the deficiency.
The facility failed to maintain cleanliness and food safety standards in the kitchen, with equipment like the stove and fryer found with heavy stains and old grease. Expired milk was also not discarded, as observed over several days. The Dietary and Kitchen Managers acknowledged the lapses in cleaning and food disposal protocols, affecting the facility's 73 residents.
The facility failed to track the required 12 hours of annual education for CNAs and CMTs, as documentation did not include the length of time for completed in-services. The Administrator acknowledged the lack of tracking and inability to confirm if staff received the mandated education.
The facility failed to follow up on TPL forms for a deceased resident, resulting in a deficiency. A resident's account remained open with a balance of $481.39 beyond the 30-day period after death. The Corporate Business Office Manager admitted to not following up with the TPL unit in a timely manner, contrary to the Administrator's expectations.
The facility failed to update care plans for two residents, one with a fall risk and another with a hospice diagnosis. A resident with impaired cognition and multiple diagnoses experienced an unwitnessed fall, but their care plan did not reflect fall risk or interventions. Another resident receiving hospice care had no updates in their care plan to reflect hospice status, despite a physician's order. Interviews confirmed that care plans should be updated following changes in condition.
The facility did not follow physician orders for two residents. One resident, with multiple health issues, had orders for daily and weekly weights, but only one weight was recorded. Another resident, on hospice care, lacked a documented physician's order for hospice, despite it being noted in their care plan. The DON confirmed the need for a physician's order for hospice care.
The facility failed to implement a 14-day stop date for PRN psychotropic medications for two residents with severe cognitive impairments. One resident had an order for Lorazepam without a stop date, while another had an order for Quetiapine for agitation, also lacking a stop date. Staff interviews confirmed the expectation for a 14-day stop date on such medications.
The facility failed to document treatments for a resident's stage four pressure ulcer consistently, with multiple instances of blank entries in the TAR. Additionally, another resident receiving hospice care lacked the required certification of terminal illness form in their records. These deficiencies indicate lapses in documentation practices, which are essential for ensuring proper care and oversight.
The facility failed to follow infection control standards by not ensuring staff wore appropriate PPE for two residents and did not post necessary signage for another resident requiring Enhanced Barrier Precautions (EBP). Staff did not wear gowns while repositioning a resident with an indwelling catheter, and the catheter drain was observed touching the floor without being sanitized. Another resident with a G-tube on EBP was assisted without PPE due to flipped signage. Additionally, a resident with a suprapubic catheter and MDRO lacked visible signage and accessible PPE supplies.
The facility failed to ensure residents received treatment and care according to professional standards, with significant documentation gaps for ordered treatments. A resident with a g-tube and another with a suprapubic catheter did not receive documented care, and similar issues were noted for other residents. Interviews confirmed expectations for staff to follow orders and document treatments, but consistent failures were observed, particularly with evening and agency staff.
A resident, who is cognitively intact and has multiple health conditions, experienced a deficiency in dignity and respect when their preference for female caregivers was not honored. Despite expressing this preference during a care plan meeting, a male CNA assisted the resident with toileting and bedtime routines, leading to distress. The CNA did not respect the resident's wishes regarding personal care routines, resulting in a deficiency finding.
The facility failed to follow its fall policy by not conducting necessary assessments and neurological checks for three residents after falls. A resident returned from the hospital without documented neuro-checks, another had a head injury without consistent documentation, and a third had multiple falls without completed assessments. This led to a deficiency in care.
An LPN at a facility was found to have misappropriated controlled substances, including oxycodone and Ativan, from multiple residents. The facility's policies on controlled substance management and reporting were not effectively enforced, allowing the LPN to remove medications unauthorizedly over several days. The LPN was observed on video taking narcotics and discrepancies were noted in narcotic sign-out sheets.
The facility failed to report the misappropriation of controlled substances by an LPN within the required timeframe, affecting multiple residents. The LPN was found to have diverted medications such as oxycodone and Ativan, with discrepancies noted in narcotic sign-out sheets and video evidence showing the LPN placing narcotics in their pocket. This delay in reporting compromised resident safety.
A facility failed to suspend an LPN during an investigation into alleged misappropriation of controlled substances, allowing the LPN to continue working and misappropriate medications from multiple residents. The facility did not follow its policy of suspending staff pending investigation, resulting in continued medication discrepancies. Additionally, the facility failed to conduct thorough investigations into other incidents, such as missing resident property, and did not report findings to the DHSS within the required timeframe.
A resident with severe cognitive impairment fell while using a walker, and the facility failed to follow a stat x-ray order for the resident's right shoulder and humerus. The incident was not documented, and no investigation was conducted. The RN did not document the fall or follow up on the x-ray order, and the resident was monitored overnight without complaints of pain. The next day, severe pain and swelling were noted, and the x-ray revealed a complex fracture, leading to hospital treatment.
A resident with moderate cognitive impairment and multiple sclerosis fell out of bed during perineal care due to a CNA's lack of awareness of the two-person assistance requirement. The facility's system for accessing care plans via iPhone was not effectively utilized by all staff, resulting in inadequate supervision and care.
Resident's Right to Refuse Care Not Honored, Resulting in Injury
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA), who was an agency staff member, failed to respect a resident's right to self-determination by transferring the resident out of bed for a shower despite the resident's explicit refusal. The resident, who had diagnoses including high blood pressure, arthritis, weakness, and chronic pain, was assessed as having moderate cognitive impairment but was able to make their needs known and communicate effectively. The resident verbally communicated to the CNA that they did not want to get out of bed, but the CNA proceeded with the transfer after being told by a nurse that the resident would be fine once up. During the transfer, the resident resisted, and the CNA used a bear hug technique to move the resident from the bed to the wheelchair. As a result of the transfer, the resident sustained a significant skin tear, approximately ten centimeters long, to the left lower leg, which required hospital treatment and sutures. The incident was witnessed by other staff who noted the CNA appeared verbally agitated, and the resident later described the transfer as rough and feeling like a tussle. The resident expressed being upset about being made to get up and reported pain and ongoing discomfort from the injury. The care plan and medical records confirmed the resident's ability to make choices and the expectation that staff would respect those choices, including the right to refuse care. The facility's investigation into the incident focused primarily on the mechanics of the transfer rather than the violation of the resident's rights. Interviews with staff revealed inconsistent understanding and application of resident rights, with some staff indicating they would follow a nurse's directive even if it contradicted a resident's expressed wishes. The facility's policies and resident handbook emphasized the importance of resident choice and self-determination, but these were not followed in this instance, leading to the resident's rights being disregarded during the event.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve ROM and mobility were not implemented as required.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents, leading to deficiencies in their care. Two residents experienced issues with room arrangements that hindered their ability to access personal belongings and maneuver their wheelchairs. Despite expressing their preferences for bed placement against the wall, the facility staff rearranged the rooms, citing state regulations, which resulted in one resident being unable to reach their nightstand and another struggling to move around due to limited space. The facility did not address these concerns adequately, as staff members were either unaware of the issues or did not take action to resolve them. Additionally, the facility removed all siderails from residents' beds without providing alternative options or conducting proper assessments. Four residents who relied on siderails for mobility and repositioning were affected by this decision. These residents expressed that the siderails helped them feel safer and more independent, yet the facility removed them, citing regulations and corporate decisions. The lack of siderail assessments and the absence of alternative solutions left these residents without necessary support for their mobility needs. The facility's policies and procedures regarding adaptive and assistive devices were not followed, as evidenced by the lack of evaluations and consent for the removal of siderails. The therapy department was not involved in assessing the need for adaptive equipment, and there was confusion among staff about who was responsible for conducting these assessments. The facility's administrator acknowledged the removal of siderails and the ongoing evaluation of their usage, but the residents' care plans were not updated to reflect their needs without siderails, leading to deficiencies in their care.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to maintain consistent and updated code status documentation for four out of 18 sampled residents, leading to discrepancies between the residents' wishes and the recorded medical directives. The facility's policy requires that upon admission, residents or their representatives complete a therapeutic support level/resuscitation plan to ensure timely intervention in emergencies. However, the survey revealed inconsistencies in the documentation of code statuses in the electronic medical records (EMR) and the nurse's report sheets. For Resident #18, there was a conflict between the scanned DNR form and the TSL/Resuscitation Plan, which indicated a full code status. Similarly, Resident #14's records showed a discrepancy between the TSL form indicating full code and the advanced directive tab showing a DNR. Resident #17 and Resident #62 had outdated TSL/resuscitation plans, which had not been updated as required by the facility's policy. These inconsistencies suggest a failure in the process of verifying and updating code status information during admission and annually thereafter. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, highlighted that the responsibility for obtaining and updating code status information lies with the nurses and clinical support staff. The DON acknowledged the need for immediate updates to Resident #18's code status, while the Administrator emphasized the expectation for staff to update code statuses annually and upon any changes requested by residents or their representatives. These lapses in documentation and adherence to policy contributed to the deficiency identified by the surveyors.
Deficiencies in Kitchen Cleanliness and Food Safety
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen, as observed over a period of five out of six days. The kitchen equipment, including the stove, steamer, flat grill, and deep fryer, were found with heavy caked-on stains and old grease, indicating a lack of regular cleaning. The cleaning schedules reviewed showed inconsistencies, with some equipment not listed or not initialed as cleaned on certain days. This lack of adherence to cleaning protocols was confirmed during interviews with the Dietary Manager and Kitchen Manager, who acknowledged the expectation for daily general cleaning and a rotational cleaning schedule for certain items. Additionally, the facility failed to discard expired thickened milk, which was observed in the cooler on multiple occasions. The expired milk cartons were not properly labeled or removed, as confirmed by the Dietary Manager, who stated that all items should be labeled, dated, and expired items discarded. The Kitchen Manager also noted that everyone is responsible for ensuring proper labeling and disposal of expired food. These deficiencies in food safety and cleanliness had the potential to affect all residents consuming food from the facility kitchen, given the facility's census of 73 residents.
Deficiency in Tracking CNA and CMT Education Hours
Penalty
Summary
The facility failed to ensure a system was in place to track the required 12 hours of annual education for Certified Nurse Aides (CNAs) and Certified Medication Technicians (CMTs). The review of employee files for six CNAs and four CMTs revealed that while in-services were completed, the documentation did not include the length of time the training was provided. This lack of documentation made it impossible to verify if the staff received the mandated 12 hours of education. During an interview, the Administrator acknowledged that the facility did not track the time for the in-services and could not confirm whether the CNAs or CMTs had received the required education. The Administrator expressed an expectation that staff should have the required education and that the hours should be tracked, indicating a gap between the facility's expectations and its practices.
Failure to Follow Up on TPL Forms for Deceased Resident
Penalty
Summary
The facility failed to ensure timely follow-up on third party liability (TPL) forms for the final accounting of a resident who expired, resulting in a deficiency. This issue affected one of five residents who had money in their resident trust account at the time of death. Specifically, the resident had a balance of $481.39 in their account, and although the TPL form was completed, the account remained open with the same balance beyond the 30-day period. The Corporate Business Office Manager acknowledged the delay in following up with the TPL unit to close the account and admitted that she should have acted sooner. The Administrator expected the TPL form to be submitted within 30 days and follow-up to ensure a zero balance in the resident's account, which was not met in this case.
Failure to Update Care Plans for Fall Risk and Hospice Status
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in addressing their current health needs. Resident #26, who has moderately impaired cognition and multiple diagnoses including cancer and paraplegia, experienced an unwitnessed fall in their room. Despite the facility's policy requiring immediate updates to care plans following a fall, the care plan for Resident #26 did not reflect their fall risk or include interventions to prevent future falls. This oversight indicates a failure to adhere to the facility's Fall Risk Reduction policy, which mandates updating the care plan and implementing interventions after a fall. Resident #56, who was admitted to the facility with moderate cognitive impairment and a prognosis indicating a life expectancy of less than six months, was receiving hospice care. However, the care plan was not updated to reflect the resident's hospice status, goals, or interventions, despite a physician's order for a hospice consult. Interviews with the MDS Coordinator and the Administrator confirmed that care plans should be updated following changes in a resident's condition, such as a fall or a new hospice diagnosis, to ensure CNAs have accurate information to provide appropriate care.
Failure to Follow Physician Orders for Weights and Hospice Care
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following physician orders for two residents. For one resident, the facility did not record daily and weekly weights as ordered by the physician. The resident, who had diagnoses including anemia, malnutrition, hypertension, heart disease, and heart failure, had a physician order for daily weights every Tuesday and weekly weights, but only one weight was recorded. This oversight was acknowledged by the Administrator and Director of Nursing during an interview. For another resident, the facility did not obtain a physician's order for hospice care, despite the resident being on hospice care as indicated in their care plan. The resident had severe cognitive impairment and multiple diagnoses, including anemia, heart failure, and Alzheimer's disease. The care plan noted the resident was receiving palliative care directed by a hospice interdisciplinary team, but the medical records lacked a documented physician's order for hospice care. The Director of Nursing confirmed that there should have been a physician's order for hospice care.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to implement a 14-day stop date for the PRN use of psychotropic medications or provide a rationale for the continued use of the medication for two residents. Resident #18, who was readmitted with severe cognitive impairment and diagnoses including Alzheimer's disease, stroke, anxiety, and depression, had a physician order for Lorazepam Intensol Oral Concentrate without a documented stop date. The resident's care plan included the use of antidepressant and anti-anxiety medications, with interventions to monitor and document side effects and effectiveness every shift. Resident #15, admitted with severe cognitive impairment and diagnoses of dementia and depression, had a physician order for Quetiapine Fumarate Tablet for agitation, also without a documented stop date. The resident's care plan focused on meeting emotional, intellectual, physical, and social needs related to cognitive deficits, but did not mention the use of psychotropic medication. Interviews with facility staff, including an LPN and the Administrator and DON, confirmed that all PRN psychotropic medications should have a 14-day stop date, and a new order should be obtained if needed.
Incomplete Documentation of Treatments and Hospice Certification
Penalty
Summary
The facility failed to ensure complete and accurate documentation of resident records, specifically for two residents. For one resident, the facility did not document the treatments for a stage four pressure ulcer consistently. The Treatment Administration Record (TAR) showed multiple instances where documentation was left blank, indicating that treatments may not have been completed as ordered. There was no documentation of treatment refusals or notifications to the physician, which is required when treatments are not administered as prescribed. Interviews with staff revealed that treatments should be documented after completion, and if not documented, it is assumed they were not done. Another resident receiving hospice services did not have the required certification of terminal illness form in their medical records or hospice binder. The resident had been admitted to hospice care recently, but the necessary documentation was not available in the facility at the time of the survey. The facility administrator acknowledged the absence of the form and mentioned that the hospice provider was in the process of sending it over. These deficiencies highlight lapses in the facility's documentation practices, which are crucial for ensuring that residents receive appropriate care and that their medical records are maintained according to professional standards. The lack of documentation for treatments and hospice certification could lead to inadequate care and oversight of residents' medical needs.
Infection Control Deficiencies in PPE Use and Signage
Penalty
Summary
The facility failed to adhere to infection control standards by not ensuring staff wore appropriate Personal Protective Equipment (PPE) for two residents and did not post necessary signage for another resident requiring Enhanced Barrier Precautions (EBP). Specifically, staff did not wear gowns while repositioning a resident with an indwelling catheter and stage four pressure ulcers, and the catheter drain was observed touching the floor without being sanitized before being placed back in the holder. This oversight was confirmed through interviews with various staff members who acknowledged the need for sanitation if the catheter drain touched the floor. Another incident involved a resident with a G-tube who was on EBP, yet staff failed to wear gloves or gowns while assisting the resident in the bathroom. The EBP signage on the resident's door was not visible, leading to staff being unaware of the need for PPE. Interviews with the staff involved revealed a lack of awareness about the resident's EBP status, which was attributed to the signage being flipped over and not visible. Additionally, a resident with a suprapubic urinary catheter and MDRO was on EBP, but there was no signage on the door, and PPE supplies were not readily available near the resident's room. Interviews with staff indicated that they relied on door signage and verbal reports to identify residents on EBP, but the absence of visible signage and accessible PPE supplies contributed to the failure to follow proper infection control protocols.
Failure to Document and Administer Ordered Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for residents with specific medical needs. Resident #3, who has a gastronomy tube and is at risk for pressure ulcers, did not receive documented skin observations, Calmoseptine applications, g-tube site care, and wound care as ordered. Observations revealed the g-tube site was not properly dressed, and interviews indicated that the dressing was often missing, suggesting a lack of adherence to care protocols. Resident #1, who had a suprapubic catheter and was at risk for pressure ulcers, also did not receive documented treatments as ordered, including zinc oxide applications, catheter flushes, and wound care. The resident was hospitalized and later expired, but during their stay, there were significant gaps in the documentation of care provided. This lack of documentation implies that the treatments were not administered as required. Additional residents, including Residents #2, #4, #5, and #6, also experienced similar issues with missing documentation for ordered skin treatments and observations. Interviews with the Director of Nursing and the Administrator confirmed that staff are expected to follow orders and document treatments, and any failure to do so should be reported. However, the report highlights consistent failures in documentation and treatment administration across multiple shifts, particularly the evening and agency staff.
Failure to Honor Resident's Caregiver Preferences
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, leading to a deficiency in treating the resident with respect and dignity. The resident, who is cognitively intact and has multiple diagnoses including heart failure and renal failure, expressed a clear preference for female staff during a care plan meeting. Despite this, a male CNA assisted the resident with toileting and bedtime routines, which the resident found distressing. The resident reported that the male CNA was rough and did not respect their wishes regarding personal care routines, such as wearing panties to bed and the placement of their wheelchair and bedside table. The incident occurred when the resident needed assistance to use the restroom and go to bed. The male CNA, identified as CNA A, did not follow the resident's instructions and became frustrated, handling the resident roughly and disregarding their preferences for personal items' placement. The resident had previously communicated their caregiver preferences, which included a list of acceptable staff members, to the staffing coordinator. However, this preference was not honored, leading to the incident and subsequent deficiency finding.
Failure to Follow Fall Policy and Conduct Neurological Checks
Penalty
Summary
The facility failed to adhere to its fall policy by not conducting necessary assessments and neurological checks following falls for three residents. Resident #2 experienced an unwitnessed fall and was sent to the hospital with a head laceration. Upon return, the facility did not document the required neurological checks every four hours for 72 hours, as per policy. Additionally, there was no completed neuro-check form to show the results of assessments, including motor function and pupil response. Resident #9 had an unwitnessed fall resulting in a head injury, but the facility did not complete a fall assessment or document all required neurological checks. The resident was found with a bump on the forehead and skin tears, yet the neuro-checks were not consistently documented, and no neuro-check form was completed to show the results of assessments. Resident #8 had multiple unwitnessed falls, but the facility failed to complete fall assessments for each incident. After a fall on 10/6/24, there were no documented neuro-checks or completed neuro-check forms to show the results of assessments. The facility's failure to follow its fall policy and document necessary assessments and interventions contributed to the deficiency.
Misappropriation of Controlled Substances by LPN
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of controlled substances for 11 residents. This deficiency was identified through interviews and record reviews, revealing that controlled substances were unauthorizedly removed by an LPN. The facility's policy on Resident Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property was not effectively implemented, as evidenced by the unauthorized removal of medications such as oxycodone, Norco, Percocet, and Ativan. The facility's investigation showed that the LPN was observed on video taking narcotics and placing them in their pocket, and discrepancies were noted in narcotic sign-out sheets and Medication Administration Records. The investigation revealed that the LPN had signed out narcotics multiple times without proper documentation and had signed out medication for a resident without an active order. The facility's Controlled Substance policy, which requires accurate accountability and documentation of controlled substances, was not adhered to, leading to the unauthorized removal of medications. The LPN was identified as the individual responsible for the discrepancies, and it was discovered that their nursing license had been previously placed on probation for a similar offense. The deficiency was further compounded by the facility's failure to recognize and investigate the involvement of an additional resident in the misappropriation. The facility's policies on discrepancies, loss, and diversion of medications, as well as controlled substance audits, were not effectively enforced, allowing the LPN to continue unauthorized activities over several days. The facility's lack of timely reporting and investigation of the incidents contributed to the deficiency, resulting in the unauthorized removal of controlled substances from the residents.
Failure to Report Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to report alleged violations involving the misappropriation of controlled substances within the required 24-hour timeframe to the Department of Health and Senior Services (DHSS), law enforcement, and the Board of Nursing. This failure involved two nurses, LPN C and LPN D, and affected 11 residents. The facility's policy mandates immediate investigation and reporting of any suspected abuse, neglect, or misappropriation of resident property, but these procedures were not followed in this instance. The investigation revealed that LPN B was involved in the unauthorized removal of controlled substances, including oxycodone, Norco, Percocet, and Ativan, from the facility. The facility's records showed discrepancies in narcotic sign-out sheets and Medication Administration Records, with LPN B's signature appearing multiple times for medications not documented as administered. Video evidence suggested that LPN B was placing narcotics in their pocket, and LPN B admitted to taking medication not prescribed to them. Despite these findings, the facility delayed reporting the incident to the appropriate authorities. The affected residents, including those with no active orders for pain medication, were subjected to potential harm due to the diversion of their prescribed medications. Resident #11, for example, was cognitively intact and had a history of hip fracture and pain but was not on a scheduled pain medication regimen. The facility's failure to promptly report and address the diversion of medications compromised the safety and well-being of the residents involved.
Failure to Suspend LPN During Investigation Leads to Continued Misappropriation
Penalty
Summary
The facility failed to prevent further misappropriation and diversion of controlled substances by not adhering to its policy of suspending staff during an investigation. LPN C and LPN D reported alleged violations by LPN B, who was accused of misappropriating and diverting medications. Despite these allegations, LPN B was allowed to continue working for three days, during which time the misappropriation continued, affecting nine residents. The facility's policy clearly states that employees alleged to have committed abuse or neglect should be suspended pending investigation, which was not followed in this case. The report highlights specific instances of medication misappropriation involving several residents. For example, Resident #11, who was cognitively intact and had a history of hip fracture and pain, had Norco signed out by LPN B without documentation of administration. Similarly, Resident #15, with severe cognitive impairment and chronic pain, had Percocet signed out more frequently than prescribed, and there was no documentation of administration for MS Contin. These discrepancies indicate a failure to maintain accurate medication records and ensure proper administration. Additionally, the facility failed to conduct thorough investigations into other incidents, such as a resident's missing device and another resident's missing wallet and money. The facility did not submit a completed investigation to the Department of Health and Senior Services within the required timeframe. The lack of comprehensive investigations and timely reporting further demonstrates the facility's failure to adhere to its policies and regulatory requirements, contributing to the overall deficiency.
Failure to Follow Stat X-ray Order and Document Fall Incident
Penalty
Summary
The facility failed to follow a Nurse Practitioner's (NP) order for a stat x-ray of a resident's right shoulder and humerus after the resident experienced a fall while using a rollator walker. The incident was not documented in the resident's medical record, and no investigation into the fall was conducted. The resident, who had severe cognitive impairment and a history of falls, was observed on video footage falling to the floor, after which a dietary aide sought help. A Registered Nurse (RN) assessed the resident and moved them to a wheelchair without documenting the incident or following up on the stat x-ray order. The RN contacted the NP, who ordered a stat x-ray, but the RN was unable to reach the x-ray company and did not document the order or inform the oncoming Charge Nurse. The RN claimed to have been unfamiliar with the facility's electronic health record system, which contributed to the lack of documentation. The resident was monitored overnight without complaints of pain, likely due to their dementia, and the stat x-ray order was not communicated to the next shift. The following day, a Licensed Practical Nurse (LPN) noted the resident's severe pain and swelling in the right arm and contacted the NP, who reiterated the stat x-ray order. The x-ray revealed a complex fracture, and the resident was sent to the hospital for treatment. The Director of Nursing (DON) and Nurse Manager were unaware of the fall and the x-ray order until informed by the LPN. The NP stated that if informed of the inability to contact the x-ray company, they would have ordered the resident to be sent to the hospital immediately.
Failure to Provide Two-Person Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and care as per the care plan for a resident with moderate cognitive impairment and multiple sclerosis, resulting in the resident falling out of bed. The resident's care plan required two staff members to assist with bed mobility and repositioning. However, during perineal care, a CNA attempted to provide care alone, leading to the resident rolling out of bed and sustaining minor abrasions. The CNA was unaware of the two-person assistance requirement, as this information was not readily accessible in the resident's medical record or known to the CNA at the time. Interviews revealed that the facility had a system in place for CNAs to access resident care information via a designated iPhone, but not all staff were familiar with its use. The Director of Nursing and the Administrator acknowledged that CNAs were expected to check the facility's iPhone for care instructions before providing care. However, it was discovered that some CNAs were not aware of this resource or how to use it, leading to a lack of proper communication and understanding of the resident's care needs.
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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