St Joseph Chateau
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Joseph, Missouri.
- Location
- 811 North 9th Street, Saint Joseph, Missouri 64501
- CMS Provider Number
- 265852
- Inspections on file
- 29
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Joseph Chateau during CMS and state inspections, most recent first.
A resident with complex psychiatric and medical needs was not allowed to return to the facility after a hospital stay, despite no documented evidence that the facility could not meet their needs. The facility initiated transfer to another SNF without providing a 30-day notice, discharge instructions, or information about appeal rights, and did not document a valid reason for the non-readmission. The guardian was not in agreement with the permanent transfer and reported feeling pressured due to the facility's refusal to readmit the resident.
A resident with complex psychiatric and medical needs was discharged without the facility providing the required 30-day written notice, bed hold policy, discharge summary, or reason for discharge to the court-appointed guardian. The facility also failed to provide a statement of appeal rights, Ombudsman contact information, and did not notify the Ombudsman of the discharge. Documentation and communication gaps were identified throughout the discharge process.
The facility failed to maintain a clean and safe environment, with observations of mold, damaged areas, and pest infestations. Staff and residents reported frequent sightings of mice, and the pest control company's recommendations were not implemented. The lack of adherence to maintenance and cleaning policies contributed to the ongoing issues.
The facility failed to ensure residents were cared for in a dignified manner, with two residents having their skin exposed in common areas and one resident avoiding the dining room due to excessive noise. Staff did not assist in covering exposed skin or addressing noise complaints, impacting the residents' quality of life.
The facility failed to maintain an accurate accounting of resident trust fund accounts by not performing monthly reconciliations. Bank statements from March 2023 through February 2024 showed no documentation of reconciliations, and attempted reconciliations did not match residents' current balances. The Business Office Manager confirmed the discrepancies, affecting funds for 56 residents.
The facility failed to maintain a clean and safe environment, with observations of sticky floors, chipped door frames, mold-like substances, and broken fixtures. Persistent urine odors and gnats were reported, particularly in the 200 hall. Staff and residents confirmed these issues, which had been ongoing for months.
The facility failed to provide written notices of transfer or discharge to residents or their responsible parties, including necessary details and appeal rights. This affected three residents, who were transferred to the emergency room without proper documentation. Interviews revealed a lack of a formal process to notify the Ombudsman of such transfers.
The facility failed to follow professional standards in medication administration and blood sugar monitoring. Staff did not check blood sugars prior to meals for two residents and failed to clarify a Vitamin D3 supplement order before administration. Interviews confirmed that orders must be followed precisely.
The facility failed to assess and maintain bed rails for two residents, leading to potential safety risks. One resident with severe cognitive impairment and hemiplegia, and another with moderate cognitive impairment and a seizure disorder, were observed with bed rails in the up position without proper assessments or physician's orders. Staff were unclear about responsibilities for entrapment assessments and bed measurements.
The facility failed to monitor monthly Medication Regimen Review (MRR) reports and did not ensure timely communication of pharmacist recommendations to physicians, affecting three residents. Delays in addressing recommendations for lab tests and medication changes were noted, with the Director of Nursing acknowledging the need for a faster process.
The facility failed to serve palatable, attractive, and safe food to three residents, with issues including cold temperatures and insufficient portions. Observations and staff interviews confirmed that food temperatures were below the required 135 degrees Fahrenheit, and complaints about cold food and small portions were common.
The facility failed to ensure that pureed foods were prepared in the correct consistency, affecting three residents with dysphagia. The pureed food was too thin and runny, posing a choking hazard. Dietary staff and the registered dietitian confirmed that the food consistency did not meet the required smooth, pudding-like texture.
The facility failed to maintain the kitchen in a sanitary manner, with dirt and debris observed in various areas, undated open food in freezers, and a lack of communication and responsibility for repairs and cleaning. Interviews revealed that staff were unaware of the needed repairs and cleaning, and the maintenance book did not show any requests for the kitchen.
The facility failed to maintain quarterly QAA committee meetings with the required members. The QAA committee met in April, June, October, January, and March, but the Medical Director only attended two of these meetings. The DON was unaware of the QAA and QAPI coordinator, and the Corporate Compliance Nurse indicated that the Administrator was responsible but was unaware of the Medical Director's attendance issues. The facility was in transition to a new Administrator.
The facility failed to follow infection control standards for medication administration when staff touched medications with ungloved hands for two residents. Additionally, the facility did not provide annual Tb testing for three residents, with staff showing a lack of clarity and responsibility regarding the administration and documentation of Tb tests.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and mice droppings in various areas, including resident rooms and common areas. Staff and residents reported persistent issues, and structural problems were identified but not adequately addressed.
The facility failed to ensure dependent residents received necessary services for personal hygiene. Staff did not provide complete perineal and urinary catheter care to two residents, failing to clean all perineal folds and using the same area of wipes for different parts of the body. The DON confirmed the staff did not follow proper procedures.
The facility failed to supervise a resident with severe cognitive impairment and a history of choking during meals, as required by the care plan. Despite documented needs and staff acknowledgment, the resident was observed eating alone on multiple occasions, leading to a deficiency.
A resident experienced significant weight loss of over 10% in 3 months due to dissatisfaction with cold food and renal diet restrictions. Despite various nutritional interventions and recommendations from the RD, the weight loss continued. Staff and the resident reported issues with small portions and food quality, but these concerns were not effectively addressed by the facility.
Failure to Allow Resident Return and Inadequate Discharge Process
Penalty
Summary
A deficiency occurred when the facility failed to allow a resident to return after a hospital stay, without providing documented evidence that the resident's needs could not be met. The resident, who had a court-appointed guardian, had multiple diagnoses including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of attention-seeking behaviors and statements of self-harm, which were being managed through monitoring, therapy, and medication adjustments. Despite these interventions, the facility decided not to readmit the resident after a psychiatric hospital stay, citing concerns about ongoing suicidal ideation (SI) and the belief that the resident required a higher level of care. The facility initiated referrals to other skilled nursing facilities (SNFs) while the resident was still at the mental health hospital, and ultimately transferred the resident to another SNF without providing a documented reason that the resident's needs could not be met at the original facility. Communication records show that the guardian did not agree to a permanent transfer and expected the resident to return if no alternative placement was found. The facility did not provide a 30-day discharge notice, discharge instructions, or information about the right to appeal or contact the Ombudsman, as required by regulations. The guardian reported feeling pressured to accept the new placement due to the facility's refusal to readmit the resident. Interviews with facility staff, the guardian, and hospital staff confirmed that the facility had previously managed the resident's SI and behaviors with interventions such as one-on-one monitoring and medication adjustments. Staff acknowledged that there was no emergency requiring immediate transfer and that the facility could have continued to care for the resident. The decision to transfer was made without proper discharge planning, documentation, or regulatory notifications, and the accepting SNF was not screened to ensure it could meet the resident's needs. The lack of a documented reason for non-readmission and failure to follow required discharge procedures led to the deficiency.
Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide the required written 30-day notice of discharge, bed hold policy, discharge summary, and the reason for discharge to the resident's court-appointed guardian. Additionally, the facility did not provide a statement of appeal rights, nor did it include the name, address, or telephone number of the Office of the State Long Term Care Ombudsman. The Ombudsman was also not notified of the resident's discharge. The facility was unable to provide its Discharge Policy upon request. The resident involved had multiple diagnoses, including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of psychiatric hospitalizations. On one occasion, the resident was transferred to an emergency room following a suicide hotline call, but there was no documentation of a bed hold notice, appeal rights, or Ombudsman contact information related to this transfer. The guardian did not receive discharge instructions, a recapitulation of the resident's stay, a final summary status, or a reconciliation of medications. Communication records show that the facility decided not to allow the resident to return after a psychiatric hospitalization, citing an inability to provide the necessary level of safety. The guardian was informed of this decision and agreed to a transfer to another skilled nursing facility only after being told the resident could not return. Interviews with facility staff and the guardian revealed conflicting accounts regarding the resident's wishes and the discharge process, but it was confirmed that the required written notifications and documentation were not provided to the guardian, and the Ombudsman was not notified.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of unclean and damaged areas within the facility. Observations included a cracked ceiling with a dark substance at the nurses' station, mold-like substances in various locations such as the activity office and laundry room, and damaged sheetrock in the closet containing the ice machine. Additionally, the kitchen was found to have a sticky floor with food debris, and a mouse was observed stuck to a glue trap under the sink. The facility's pest control program was not effectively implemented, as evidenced by the presence of mice and other pests throughout the facility. Interviews with staff and residents revealed frequent sightings of mice in various areas, including resident rooms, the therapy office, and the activity office. The pest control company had made several recommendations to address structural concerns and sanitation issues, such as sealing holes and cleaning mouse droppings, but these recommendations were not acted upon. The facility's maintenance and cleaning policies were not adequately followed, contributing to the pest control issues. The Director of Maintenance acknowledged the lack of a maintenance person and the ongoing pest control problem. The Administrator was aware of the pest control issue and expected the facility to be clean and comfortable, with staff following the cleaning schedule and reporting cleanliness issues. However, the observations and interviews indicated that these expectations were not met, leading to the deficiency.
Failure to Maintain Resident Dignity and Dining Experience
Penalty
Summary
The facility failed to ensure residents were cared for in a dignified manner, as evidenced by two residents having their skin exposed in common areas. Resident #47, who has severe cognitive impairment and requires substantial assistance with dressing, was observed walking down the hall with exposed skin on the left chest. Despite passing multiple staff members, including CNAs, no one assisted in covering the resident's exposed skin. Similarly, Resident #32, who has a history of mental health diagnoses and requires supervision for dressing, was observed multiple times with their abdomen exposed while in common areas and in bed, without staff offering assistance to cover them up or pulling the privacy curtain in their room. Staff interviews confirmed that residents should not have exposed skin and that they should assist in covering them when noticed, but this was not done in these instances. Additionally, the facility failed to provide a dignified dining experience for Resident #14, who stopped eating in the dining room due to excessive noise from other residents playing music and using cell phones. The resident, who has minimal cognitive loss and requires supervision for ADLs, reported that the noise and occasional bad odors in the facility made it difficult to eat. Staff interviews corroborated the resident's complaints about the noise and odor, with the Housekeeping Supervisor and DON acknowledging persistent odors in certain hallways and the need for tile replacement. These deficiencies highlight the facility's failure to maintain a dignified environment for its residents, as required by their policy on promoting and maintaining resident dignity. The staff's inaction in addressing exposed skin and excessive noise in the dining room directly impacted the residents' quality of life and comfort within the facility.
Failure to Properly Reconcile Resident Trust Fund Accounts
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. Record reviews of the facility-maintained bank statements for account ending in #8793 from March 2023 through February 2024 showed no documentation of reconciliations. Additionally, the attempted reconciliations did not match the residents' current balances at the time of reconciliation. Email correspondence and an interview with the Business Office Manager confirmed that the reconciliations were not performed properly, affecting the funds managed for 56 residents out of a facility census of 62.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of unclean and unsafe conditions. Specific issues included sticky floors, chipped and peeling door frames, dirty and debris-laden floors, and broken fixtures in resident rooms and common areas. Additionally, there were significant cleanliness issues in the dining rooms, hallways, and shower rooms, including mold-like substances, broken tiles, and malfunctioning equipment. These conditions were observed over several days and were corroborated by staff and resident interviews. Residents and staff reported persistent and strong urine odors, particularly in the 200 hall, which were attributed to residents urinating on the floors, mattresses, and in shared bathrooms. The facility's housekeeping and maintenance staff acknowledged these issues but failed to adequately address them. The Housekeeping Director admitted to not tracking or inspecting the completion of deep cleaning tasks, and the Maintenance Director was unaware of several maintenance issues, including loose handrails and broken fixtures. Interviews with residents and staff revealed that the urine odors and cleanliness issues had been ongoing for several months, with some staff resorting to wearing masks due to the strong odors. The facility's Director of Nursing (DON) and Administrator were aware of the problems but had not implemented effective solutions. The presence of gnats in resident rooms further indicated a lack of proper sanitation and pest control measures. Overall, the facility's failure to maintain a clean and safe environment compromised the residents' quality of life and well-being.
Failure to Provide Proper Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. The notice should have included the effective date of discharge or transfer, the location to which the resident was transferred or discharged, a statement of the resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. This deficiency affected one of 16 sampled residents, Resident #5, and the facility also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, affecting three residents in total (Residents #5, #13, and #32). The facility census was 62 at the time of the survey. Resident #32, who had cognitive skills intact but required supervision for certain activities, was transferred to the emergency room for a psychiatric evaluation after exhibiting aggressive behavior. The facility did not have a copy of any discharge letter or documentation of the bed-hold letter sent with the resident. Similarly, Resident #5, who had severe cognitive impairment and multiple diagnoses including schizophrenia and hemiplegia, was transferred to the emergency room for evaluation after showing signs of a stroke. The record did not contain a copy of any discharge letter or bed-hold letter documentation. Resident #13, who had no cognitive impairment but had a history of psychotic disorder, anxiety, and depression, was transferred to the emergency room after exhibiting aggressive behavior and refusing redirection. The facility did not have a copy of the notice provided to a representative of the Office of the State Long-Term Care Ombudsman. Interviews with the Social Services Designee and the Director of Nursing revealed that there was no formal process in place to notify the Ombudsman of transfers and discharges, and the Director of Nursing believed that Social Services was handling these notifications as a group.
Failure to Follow Professional Standards in Medication Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure staff followed professional standards of quality in the administration of medications and monitoring of blood sugars for residents. Specifically, staff did not check blood sugars prior to meals for two residents, Resident #32 and Resident #53, and failed to obtain blood sugars on the day ordered by the physician for Resident #53. Additionally, there was no physician's order to check blood sugars for Resident #32, and a Vitamin D3 supplement order for Resident #41 was not clarified before administration. These deficiencies were observed during a survey where staff did not adhere to the facility's medication administration policy, which mandates that medications be administered as ordered by the physician and in accordance with professional standards of practice. For Resident #53, the physician's order required weekly blood sugar checks on Saturdays, but the resident's blood sugar was checked on a different day, and insulin was administered post-breakfast. For Resident #32, there was no physician's order for blood sugar checks, yet the resident's blood sugar was checked after breakfast, and insulin was administered. The resident refused the fast-acting insulin. For Resident #41, a Certified Medication Technician administered Vitamin D3 without clarifying the dosage, despite recognizing the discrepancy in the order. Interviews with staff, including an LPN and the Director of Nursing, confirmed that blood sugars should be obtained before meals and that orders must be followed precisely.
Failure to Assess and Maintain Bed Rails
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the resident's size and weight. Additionally, the facility did not perform scheduled maintenance of the bed rails for two of the 16 sampled residents. Resident #5, who had severe cognitive impairment, hemiplegia, and a history of falls, was observed with a bed rail in the up position without a physician's order or an entrapment assessment. The resident's care plan and MDS did not indicate the use of bed rails, and staff were unsure of the reasons for the bed rail's presence or who was responsible for the entrapment assessments and measurements. The maintenance supervisor also confirmed the lack of documentation for entrapment assessments and measurements since their tenure began three months prior. Resident #19, who had moderate cognitive impairment, heart failure, dementia, and a seizure disorder, was also observed with bed rails in the up position on both sides of the bed without a physician's order or an entrapment assessment. The resident's care plan indicated the use of bed rails for bed mobility, but there was no documentation of an entrapment assessment. Interviews with staff, including the physical therapy assistant, registered nurse, and maintenance supervisor, revealed confusion and lack of clarity regarding the responsibility for conducting entrapment assessments and measuring bed dimensions. The Director of Nursing was also unsure of the policy and where maintenance documented the measurements. The facility's undated Side Rails Policy required an assessment for risk of entrapment, obtaining a physician's order, ensuring correct installation and maintenance, and inspecting the mattress and bed rails for gaps and areas of possible entrapment. However, the facility did not adhere to these procedures, resulting in the deficiency. The lack of proper assessments, documentation, and maintenance of bed rails posed a potential risk to the residents' safety.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to monitor the monthly Medication Regimen Review (MRR) reports for November 2023 and January 2024, completed by the pharmacist, and did not ensure that recommendations were addressed with Resident #5's physician by midnight of the next calendar day. This affected three residents. For Resident #5, the pharmacist recommended a monthly complete blood count (CBC) due to the resident's Clozapine medication, but the facility did not address this recommendation with the physician until March 2024. Resident #5 had moderate cognitive impairment and required substantial assistance with daily activities, and was on multiple medications including antipsychotics and antidepressants. Similarly, for Resident #19, the pharmacist noted the absence of a Valproic Acid level lab result, which was due in December 2023. The facility did not address this with the physician until March 2024. Resident #19 also had moderate cognitive impairment and required substantial assistance with daily activities, and was on multiple medications including antipsychotics and diuretics. For Resident #39, the pharmacist recommended discontinuing Hydroxyzine for anxiety, but the facility did not address this with the physician until March 2024. Resident #39 had no cognitive impairment but required moderate to substantial assistance with daily activities and was on multiple medications including antidepressants and opioids. During an interview, the Director of Nursing (DON) acknowledged that the process for addressing pharmacist recommendations was slow, taking 7 to 10 days for the physician to review and act on them. The DON mentioned that the pharmacist emails the recommendations, which are then placed in a folder for the physician to review during their weekly visits on Fridays. This delay in addressing the recommendations led to the deficiencies noted in the report. The DON has been working on improving the time frame since May 2023 but acknowledged that the process still needs to be faster.
Failure to Serve Palatable and Safe Food
Penalty
Summary
The facility failed to serve food to the residents that was palatable, attractive, and served at a safe and appetizing temperature. This deficiency affected three residents. Resident #34, who had no cognitive impairment and was independent with activities of daily living (ADLs), was served a bowl of dumplings that was only a quarter full and cold. Resident #47, who had severe cognitive impairment and required extensive assistance, was not offered a meal tray and ended up eating cold food from an uncovered plate in their room. Resident #33, who had intact cognitive skills but required extensive assistance with ADLs, reported that the food received in their room was usually cold. Observations of meal preparation and test trays revealed that the temperatures of the food were below the required 135 degrees Fahrenheit. The pureed green beans were 97 degrees Fahrenheit, the regular hamburger was 98 degrees Fahrenheit, and the pureed chicken was 105 degrees Fahrenheit. Additionally, the pureed green beans were very thin and ran off the spoon like water. Interviews with the dietary staff confirmed that the residents should receive full servings of food and that hot food should be served at temperatures above 135 degrees Fahrenheit. Interviews with various staff members, including a Licensed Practical Nurse (LPN), a Certified Medication Technician (CMT), and a Certified Nurse Aide (CNA), indicated that complaints about cold food and small portion sizes were common among the residents. The Registered Dietitian also confirmed that residents should receive full servings and that pureed food should not be runny. Despite these guidelines, the facility failed to meet the standards for food service, resulting in dissatisfaction and potential health risks for the residents.
Failure to Ensure Proper Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a consistency designed to meet the needs of individual residents. Specifically, the pureed food provided to three residents (Residents #5, #19, and #47) was observed to be too thin and runny, posing a choking hazard. The dietary manager and Cook A were responsible for preparing the pureed meals, but the food consistency did not meet the required smooth, pudding-like texture. This inconsistency was confirmed through observations and interviews with the dietary staff and the registered dietitian, who all acknowledged that the pureed food should not be runny like liquid. Resident #5, who had a history of dysphagia and was on a pureed diet, was served food that was not properly prepared, increasing the risk of choking. Similarly, Resident #19, who also had swallowing difficulties and required a pureed diet, received improperly prepared food. Resident #47, with severe cognitive impairment and a need for a pureed diet due to dysphagia, was also affected. The facility's failure to provide the requested policy on pureed food preparation further highlights the deficiency in ensuring the safety and dietary needs of these residents.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and the kitchen was maintained in a sanitary manner. Observations revealed that the floor under the three-compartment sink, the ceiling above it, and the top of the dishwasher were covered with dirt and debris. Additionally, baseboards and tiles were missing under the dishwasher, and vents in the ceiling above the coolers were dirty. The wheels of the meal carts were also covered with dirt and debris. Further observations showed that the vent and window by the handwashing sink were dirty, the plate warmer had food spatters, and the kitchen ceiling had peeling paint. The dry storage area had bugs in the light and debris on the floor. The chest freezer contained undated open bags of food and was dirty inside, while the upright freezer had dirt and debris on the sides and bottom, and its drawers were cracked and chipped with dirt inside them. Interviews with the Dietary Manager, Maintenance Director, Registered Dietitian, and Administrator revealed a lack of communication and responsibility for maintaining the kitchen's cleanliness and repair. The Dietary Manager acknowledged that the kitchen should be clean and in good repair, with food labeled and dated, and no open containers in the refrigerator or freezer. The Maintenance Director, who had only been at the facility for three weeks, was unaware of the needed repairs and cleaning in the kitchen. The Registered Dietitian and Administrator both expected the kitchen to be clean, sanitary, and in good repair, with proper food storage. However, the maintenance book at the nurse's desk did not show any repair or cleaning requests for the kitchen, indicating a breakdown in the reporting and addressing of maintenance issues.
Failure to Maintain Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members. The facility's policy mandates that the QAA committee be interdisciplinary, including the Director of Nursing (DON), the Medical Director or designee, the infection preventionist, and at least three other staff members, and that it meets at least quarterly. Review of sign-in sheets from April 2023 to March 2024 revealed that the committee met in April 2023, June 2023, October 2023, January 2024, and March 2024. However, the Medical Director only attended the meetings in June 2023 and March 2024, and there was no sign-in sheet for the quarter between June 2023 and October 2023. During interviews, the DON was unaware of who was responsible for QAA and QAPI coordination, while the Corporate Compliance Nurse indicated that the Administrator was in charge but was unaware of the Medical Director's attendance issues. The facility was in a state of flux due to the transition to a new Administrator.
Infection Control and Tb Testing Deficiencies
Penalty
Summary
The facility failed to follow infection control standards and guidelines for medication administration when staff touched medications with ungloved hands for two residents. One resident, who had diagnoses including OCD, stroke, and paranoid schizophrenia, was observed receiving Vitamin D and Cranberry tablets that were handled by a Certified Medication Technician (CMT) with bare hands. Another resident, with diagnoses including stroke, aphasia, and Parkinson's disease, was given Depakote Sprinkles that were placed directly on the medication cart surface and handled without gloves by a CMT. Additionally, the facility failed to provide annual tuberculosis (Tb) testing for three residents. These residents had various diagnoses such as dementia, stroke, and coronary artery disease, and their medical records showed that their last Tb tests were administered over a year ago. The Infection Preventionist (IP) and the Assistant Director of Nursing were interviewed, revealing a lack of clarity and responsibility regarding the administration and documentation of Tb tests. The Director of Nursing (DON) confirmed that staff should not handle medications with bare hands or place pills directly on the medication cart without a barrier. The DON also indicated uncertainty about the timing and responsibility for annual Tb testing, highlighting a gap in the facility's infection prevention and control program.
Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and mice droppings in various areas, including resident rooms, the dining room, and common areas. Observations on multiple dates revealed gnats in residents' rooms, the dining room, the hall, the beauty shop, and the front office area. Interviews with staff confirmed the persistent presence of gnats, with one Certified Nurse Aide noting that gnats were always in the building. The Administrator acknowledged delays in addressing the issue and mentioned that pest control had treated a drain where gnats were nesting. However, the problem persisted despite these efforts. Additionally, mice droppings were observed in two residents' rooms, on bedside tables, dressers, floors, and refrigerators. A mouse was also seen running down the hall and through a hole under the exit doors. Interviews with residents and staff indicated that complaints about mice had been made but not adequately addressed. The maintenance supervisor and pest control company manager both noted structural issues, such as gaps in doors and holes in walls, that facilitated the pest problem. Despite recommendations to fix these issues, the facility had not taken the necessary actions, leading to ongoing pest control deficiencies.
Failure to Provide Complete Perineal and Catheter Care
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, staff did not provide complete perineal and urinary catheter care to two residents. For Resident #20, who had long and short-term memory problems, hemiplegia, and was always incontinent of bowel and bladder, the CNA did not properly clean all perineal folds and used the same area of the wipe for different parts of the body. Additionally, the mattress was not cleaned after the resident urinated on it. The care plan indicated that the resident required extensive assistance for toileting due to dementia and hemiplegia. For Resident #33, who had cognitive skills intact but was dependent on staff for toilet use and transfers, the CNA did not anchor the catheter tubing and failed to clean all perineal folds properly. The resident had a urinary catheter and was always incontinent of bowel. The CNA used the same area of a wipe for different parts of the body and did not separate and clean all areas of the skin where urine had touched. The Director of Nursing confirmed that the staff did not follow proper procedures for perineal and catheter care, including not using the same area of the wipe and not anchoring the catheter tubing.
Failure to Supervise Choking Risk Resident During Meals
Penalty
Summary
The facility failed to provide supervision while eating for a resident who is a choking risk, as outlined in the resident's care plan. The resident, who has severe cognitive impairment, dysphagia, and a history of choking episodes, was observed eating alone in their room on multiple occasions without staff supervision. Despite the care plan and staff acknowledgment that the resident requires supervision during meals, the resident was left unsupervised while eating on at least three separate occasions. Interviews with staff revealed inconsistencies in their understanding and execution of the supervision requirement, with some staff unaware of the need for supervision and others failing to follow through on the care plan directives. The resident's care plan, dated 10/23/23, indicated the need for supervision due to right-sided hemiplegia, cognitive deficits, and a history of choking episodes. The resident's Quarterly Minimum Data Set (MDS) dated 2/9/24, confirmed severe cognitive impairment and the need for substantial assistance with ADLs, including eating. Despite these documented needs, observations on 3/26/24, 3/27/24, and 3/28/24 showed the resident eating alone in their room. Interviews with the RN, CNA, and DON confirmed that the resident should not eat without supervision, yet this protocol was not consistently followed, leading to the deficiency noted in the report.
Failure to Prevent Significant Weight Loss in Dialysis Resident
Penalty
Summary
The facility failed to prevent significant weight loss of more than 10% of a resident's body weight in a 3-month period. The resident, who was at nutritional risk and received dialysis, experienced a total weight loss of 23.1 lbs or 15.38% over 90 days. Despite being on a therapeutic diet and receiving various nutritional interventions, the resident continued to lose weight. The resident expressed dissatisfaction with the food, stating it was always cold and that they did not like the renal diet restrictions. Multiple complaints about small portions and the inability to get desired food were also noted by staff and the resident. The facility's policy on weight monitoring required that significant weight changes be reported to the physician, and appropriate interventions be implemented. However, the primary care physician and the Advanced Practice Registered Nurse (APRN) were not aware of the resident's significant weight loss. The Registered Dietician (RD) had made several recommendations to liberalize the resident's diet and provide supplements, but these were not effectively communicated or implemented. The resident's weight continued to decline despite these efforts. Interviews with staff revealed that multiple residents had complained about small portion sizes and cold food, which contributed to weight loss. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged the resident's significant weight loss and the issues with the renal diet but did not take effective action to address these concerns. The Administrator was also unaware of any complaints about portion sizes or food quality, indicating a lack of communication and follow-up on these issues within the facility.
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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