St Joe Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bonne Terre, Missouri.
- Location
- 10 Lake Drive, Bonne Terre, Missouri 63628
- CMS Provider Number
- 265701
- Inspections on file
- 20
- Latest survey
- February 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Joe Manor during CMS and state inspections, most recent first.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, as required by policy. This deficiency affected multiple residents, with no documentation of written notifications at the time of transfer. Interviews with staff revealed that the responsibility for sending transfer forms lies with floor nurses, but the expected notifications were not documented.
The facility failed to provide written information about the bed hold policy to residents and/or their representatives at the time of hospital transfer. This deficiency was noted for four residents, despite the facility's policy requiring such information to be given in writing. Interviews indicated that floor nurses were responsible for this task, but documentation was lacking.
The facility failed to accurately document MDS assessments for four residents, leading to discrepancies in recorded medical information. A resident's MDS inaccurately recorded insulin injections, while another's did not reflect hospice status. The facility lacked a policy on MDS accuracy, contributing to these errors, despite expectations from the MDS Coordinator and administration for accurate assessments.
The facility failed to implement comprehensive care plans for four residents, resulting in deficiencies in addressing their individual needs. A resident with paraplegia used side rails not included in their care plan. Another resident with sleep apnea used oxygen and a BIPAP machine, which were not documented. A third resident with COPD used oxygen therapy not reflected in their care plan. Lastly, a resident with chronic UTIs was on antibiotics, but their care plan did not address UTI management. The facility's policy requires care plans to be updated, but this was not followed.
The facility failed to update and revise care plans for several residents, leading to deficiencies in addressing individual needs. A resident's care plan did not address vape use, another was inaccurately listed as full code despite hospice care, and a third was not informed about care plan meetings. Additionally, a resident with multiple falls had outdated fall risk interventions, and another's care plan lacked bleeding precautions for an anticoagulant. The administration acknowledged the expectation for care plans to reflect current conditions.
Two residents in the facility did not receive consistent showers as per their scheduled ADLs, leading to extended periods without proper hygiene. One resident, with multiple health conditions, reported receiving showers only once every two weeks, while another resident with Parkinson's disease reported having only one shower a month. Staff interviews confirmed that residents should receive two showers per week, but records showed multiple missed opportunities.
A facility failed to obtain a physician's order for oxygen administration and did not ensure a BIPAP order included settings for a resident with multiple respiratory and cardiac conditions. The resident was observed using oxygen and a BIPAP machine without documented orders, and staff interviews confirmed the lack of necessary orders.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate due to improper insulin administration. Three residents were affected as insulin pens were not primed before use, contrary to manufacturer instructions. CMTs misunderstood the priming process, believing it was only necessary when the pen was first used. The ADON and DON confirmed the expectation to follow manufacturer's guidelines.
A facility failed to maintain proper infection control practices during foley catheter care for a resident. A CNA did not adhere to the facility's Handwashing/Hand Hygiene Policy and EBP policy, failing to perform hand hygiene between tasks and not wearing a gown as required. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
A facility failed to follow infection control practices during perineal care for a resident with a PICC line. Staff did not adhere to the Enhanced Barrier Precaution (EBP) policy, which required wearing gowns, gloves, and masks. Observations showed that CNAs did not wash hands before donning gloves or after removing them, and did not clean the area before placing a brief. Interviews revealed a lack of understanding of EBP requirements, and the administration acknowledged the failure to follow policy.
Facility staff failed to report a resident-to-resident abuse incident to the state licensing agency. A resident pushed another, causing a fall and head injury requiring staples. The DON did not report the incident, believing it unnecessary unless harm occurred, despite the facility's policy requiring such reports. The Administrator expected the incident to be reported, highlighting a protocol discrepancy.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfers or discharges to a hospital, including the reasons for such transfers, for eleven residents out of 28 sampled and one additional resident outside the sample. This deficiency was identified through interviews and record reviews, revealing a lack of documentation that the residents' representatives were informed in writing at the time of transfer. The facility's policy, revised in October 2022, mandates written notification to residents and their representatives, including specific details about the transfer or discharge, the effective date, and the new location. The policy also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. However, the review showed that for multiple residents, including those who were transferred to the hospital on various dates, there was no documentation of written notification to the residents' representatives. The facility's policy considers transfers to acute care settings as facility-initiated transfers, not discharges, and expects residents to return to the facility. Despite this, the required notifications were not documented. Interviews with facility staff, including the Social Services Designee and Registered Nurse, indicated that the responsibility for sending out transfer forms lies with the floor nurses. The Administrator, Director of Nursing, and Assistant Director of Nursing acknowledged the expectation that residents and their representatives should be notified in writing of transfers. The lack of documentation for these notifications constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to the hospital. This deficiency was identified for four residents out of a sample of 28, despite the facility's policy requiring that such information be provided in writing at least twice: in advance of any transfer and at the time of transfer. The policy, revised in October 2022, mandates that residents and their representatives be informed of the bed hold policies, which address holding or reserving a resident's bed during periods of absence, such as hospitalization or therapeutic leave. Interviews with facility staff revealed that the responsibility for sending out the bed hold policies lies with the floor nurses at the time of resident discharge. However, there was no documentation in the medical records of the four residents indicating that they or their representatives were informed in writing of the bed hold policy at the time of their transfers to the hospital. The facility's administration, including the Administrator, Director of Nursing, and Assistant Director of Nursing, collectively acknowledged the expectation that residents and/or their representatives should be made aware of bed holds in writing.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the recorded medical information. Resident #40's medical record indicated that they received an injection of Ozempic but did not receive insulin during the seven-day look-back period. However, the MDS assessment inaccurately recorded that the resident received one insulin injection. Similarly, Resident #41's record showed an injection of Ozempic without any insulin received, yet the MDS assessment incorrectly noted one insulin injection. Resident #131's medical record documented two Haldol injections, but the MDS assessment marked zero injections received in the look-back period. Lastly, Resident #138, who was admitted to hospice, had an MDS assessment that inaccurately marked 'no' for a condition that may result in a life expectancy of less than six months. The facility did not provide a policy regarding MDS accuracy, which may have contributed to these inaccuracies. Interviews with the MDS Coordinator and the facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed an expectation for MDS assessments to accurately reflect the residents' conditions at the time of assessment. Despite this expectation, the discrepancies in the MDS documentation for these residents indicate a failure to meet this standard, as evidenced by the inaccurate coding of injections and hospice status.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans with specific interventions for four residents, leading to deficiencies in meeting their individual needs. Resident #31, who has diagnoses including paraplegia and rheumatoid arthritis, was observed using side rails for mobility, yet their care plan did not address the use of side rails. This oversight indicates a lack of alignment between the resident's needs and the documented care plan. Resident #41, diagnosed with obstructive sleep apnea and other respiratory conditions, was observed using oxygen and a BIPAP machine, but their care plan did not include these critical interventions. Similarly, Resident #55, with COPD and atrial fibrillation, was using oxygen therapy, which was not reflected in their care plan. These omissions suggest a failure to update care plans to reflect the residents' current medical needs and prescribed treatments. Resident #111, who has a history of chronic UTIs and other health issues, was taking antibiotics for a UTI, yet their care plan did not address the management of chronic UTIs. The facility's policy requires care plans to be updated with measurable objectives and time frames, but these were not adhered to, as evidenced by the lack of updates in response to significant changes in the residents' conditions. The facility's administration acknowledged the expectation for care plans to be current and reflective of residents' conditions.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of five residents. Resident #1's care plan did not address the use of vapes, despite observations of the resident having a vape in their room and on their lap. Additionally, the resident reported not taking any medications, yet the care plan included several medication-related interventions. Resident #6's care plan inaccurately listed the resident as a full code, despite an order for hospice care and a DNR status. Resident #18 was not informed about upcoming care plan meetings, and there was no documentation to indicate that the resident was notified, despite expressing a desire to attend these meetings. Resident #34 experienced twelve unwitnessed falls, including falls with injuries, but the care plan's fall risk interventions had not been updated since August 2023. This lack of updated interventions occurred despite a significant change in the resident's condition, as indicated by a recent MDS assessment. Resident #126's care plan failed to address bleeding precautions and interactions related to the prescribed anticoagulant, Apixaban. Additionally, the care plan did not address the resident's use of marijuana, despite noting the resident's unsupervised smoking and vaping habits. The facility's administration acknowledged the expectation for care plans to reflect the current condition of residents, which was not met in these cases.
Inconsistent Shower Schedule for Residents
Penalty
Summary
The facility failed to provide consistent care for activities of daily living (ADLs) for two residents, resulting in extended periods without showers. Resident #24, who has multiple health conditions including arthritis, spinal stenosis, COPD, diabetes, heart failure, morbid obesity, and severe chronic kidney disease, reported receiving showers only once every two weeks despite being scheduled for twice a week. The resident expressed feeling dirty and uncomfortable with facial hair due to the infrequent showers. Records showed that in December 2024, the resident missed six out of nine scheduled showers, and in January 2025, missed another six out of nine. Similarly, Resident #55, diagnosed with Parkinson's disease, COPD, heart failure, and other conditions, reported having only one shower a month, despite being scheduled for two per week. The resident expressed concern about personal hygiene and odor. Records indicated that in December 2024, the resident missed seven out of nine scheduled showers, and in January 2025, missed eight out of nine. Interviews with staff, including a CNA, RN, ADON, and DON, confirmed that residents should receive two showers per week, but the facility failed to adhere to this schedule consistently.
Failure to Obtain Orders for Oxygen and BIPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration and did not ensure that a physician's order for bilevel positive airway pressure (BIPAP) included the necessary settings for a resident. This deficiency affected one resident who had multiple diagnoses, including obstructive sleep apnea, shortness of breath, respiratory failure, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. The resident was observed using oxygen via nasal cannula at 3.5 liters per minute and had a BIPAP machine at bedside, but there were no documented orders for the oxygen or the BIPAP settings. Interviews with the resident and facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed the lack of necessary orders. The resident reported regular use of oxygen and BIPAP at bedtime, while the staff acknowledged that orders for oxygen and BIPAP settings should be in place. The facility's policy required a review of the physician's order for BIPAP settings, but this was not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency affected three residents out of seven sampled. The errors were related to the improper administration of insulin using pen-type devices, specifically the failure to prime the insulin pens before administration, as required by the manufacturer's instructions. This oversight was observed in the administration of both NovoLog and Insulin Lispro to the residents. Resident #32 received three units of NovoLog without the pen being primed, despite a blood sugar level of 204. Similarly, Resident #102 was administered six units of Insulin Lispro without priming the pen for a blood sugar level of 236. Resident #133 also received three units of Insulin Lispro without the pen being primed. Interviews with the Certified Medication Technicians (CMTs) involved revealed a misunderstanding of the priming process, as they believed priming was only necessary when the pen was first used. The Assistant Director of Nursing and the Director of Nursing confirmed that staff are expected to follow the manufacturer's guidelines for insulin administration.
Infection Control Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter care for a resident. The facility's Handwashing/Hand Hygiene Policy and EBP policy were not adhered to by a Certified Nursing Aide (CNA) during the care of a resident with a foley catheter. The CNA did not wash or sanitize hands before donning gloves, did not wear a gown as required by EBP, and failed to perform hand hygiene between dirty and clean tasks and before leaving the resident's room. During the observation, the CNA was seen entering the resident's room, donning gloves without prior hand hygiene, and not wearing a gown despite EBP signage and supplies being accessible. The CNA performed catheter care and peri care without proper hand hygiene between tasks and left the room with trash without sanitizing hands. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene between tasks and before leaving the room. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
Infection Control Deficiency During Perineal Care
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal care for a resident with a Peripherally Inserted Central Catheter (PICC). The facility's Perineal Care Policy and Enhanced Barrier Precaution (EBP) Policy were not followed. During an observation, it was noted that a Certified Nursing Aide (CNA) donned gloves without washing hands and performed perineal care without cleaning the area first. Additionally, the CNA did not wash hands after removing gloves and before leaving the room. The EBP signage on the resident's door indicated the need for protective gear, but the staff did not adhere to these guidelines. Interviews with the staff revealed a lack of understanding and adherence to the EBP policy. CNA A and CNA B did not wear the required gown, gloves, and mask during care for the resident with a PICC line, despite the policy indicating that EBP should be used for residents with such devices. The Licensed Practical Nurse (LPN) confirmed that EBP should be worn for residents with medical devices like a PICC line. The resident also reported that staff had not been wearing gowns during care, only masks and gloves during PICC line care. The facility's administration acknowledged that the staff should have followed the policy and washed hands between dirty and clean tasks.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility staff failed to report an incident of resident-to-resident abuse to the state licensing agency as required. The incident involved two residents, where one resident pushed another, resulting in a fall that caused a head injury requiring two staples and a skin tear on the elbow. The facility's policy mandates reporting such incidents to the state agency, but this was not done. The Director of Nursing (DON) was informed by the state licensing agency that reporting was not necessary unless harm occurred, which led to the decision not to report the incident. The incident occurred when one resident accused another of stealing food and pushed them, causing the fall. The facility's investigation noted the fall was unwitnessed and did not initially observe injuries on the resident who fell. However, the resident was later transferred to the hospital due to the injuries sustained. The Administrator expressed that such incidents should be reported to the state licensing agency, indicating a discrepancy between the facility's actions and the expected protocol.
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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