St Peters Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Peters, Missouri.
- Location
- 5400 Executive Centre Parkway, Saint Peters, Missouri 63376
- CMS Provider Number
- 265824
- Inspections on file
- 28
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at St Peters Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its own policy and federal resident rights requirements when moving several residents from long‑standing private rooms to semi‑private or LTC rooms. Cognitively intact and cognitively impaired residents with significant medical conditions, including quadriplegia, dementia, heart failure, and prior stroke, were told by an ADON, SW, or an individual identifying as the Administrator that they would be moved to accommodate isolation, COVID, rehab, or acuity‑based staffing needs. Families reported being informed by phone that moves would occur within a short timeframe, with notes documenting only vague "consent" and no written notices explaining the reasons for the moves. Residents and families were not offered choices of rooms or roommates, were not introduced to new roommates in advance, and were not informed they could refuse the moves, despite facility policy stating residents have the right to written notice, to share a room with a roommate of choice, and to refuse room changes unless necessary for health or safety.
The facility failed to provide required written discharge notices, including appeal rights and bed-hold information, to three residents who were dependent on staff for ADLs and were cognitively intact or impaired. As part of a unit reconfiguration to free up rehab beds, residents were told by phone they had to move within a short timeframe and were discharged to other SNFs without documented 30‑day or emergency discharge notices. Families reported they were not offered in‑house room alternatives, felt they had no choice, were not informed of appeal rights, and did not receive written discharge notices. Social workers reported they were directed by an administrator to move residents to open rehab beds and believed written notices were unnecessary for SNF‑to‑SNF transfers, resulting in discharges that did not comply with required notification standards.
Staff improperly used a mechanical lift’s emergency release button to rapidly lower a dependent resident with Parkinson’s disease, Alzheimer’s disease, dementia, and severe cognitive impairment onto a bed, contrary to facility policy requiring slow, controlled lowering. Video showed two CNAs transferring the resident from wheelchair to bed, with one CNA asking about dropping the resident and then pressing the emergency release, causing a quick drop that startled the resident and moved the bed. The DON confirmed there was no equipment malfunction and that the emergency release should only be used in true emergencies, while the CNA who operated the lift stated they used the button because the lift lowered residents very slowly and believed they had not been instructed not to use it during transfers.
Two residents with dementia and Alzheimer's disease were not treated with dignity and respect by CNAs, who failed to greet or explain care, used forceful and disrespectful language, left residents exposed, and engaged in argumentative and mocking exchanges during ADL assistance, as documented by video footage and family reports.
Two residents who required two-person assistance for mechanical lift transfers due to conditions such as dementia and Parkinson's disease were transferred by staff without consistent two-person support, contrary to facility policy. Video evidence and staff interviews confirmed that only one CNA operated the lift while the other was not assisting, resulting in residents being left unsupported and swinging in the lift during transfers.
Staff did not adhere to infection control protocols during personal care for two residents who were dependent for ADLs and incontinent. CNAs failed to perform hand hygiene before care, used the same gloves for both clean and dirty tasks, and handled clean supplies, bedding, and room equipment without changing gloves or washing hands, despite being aware of facility policy.
Several residents were awakened, dressed, and brought to common areas earlier than their stated preferences, despite care plans and facility policy supporting resident choice. Staff followed a predetermined list for morning routines, resulting in residents with cognitive and physical impairments being up before their desired times and expressing dissatisfaction. This practice did not align with the documented directives for resident self-determination and dignity.
Staff failed to consistently use Enhanced Barrier Precautions and proper hand hygiene during high-contact care for two residents with indwelling medical devices. Observations showed that required PPE, such as gowns and face shields, was not used, and hand hygiene protocols were not followed between tasks. Interviews revealed staff confusion about EBP requirements, leading to lapses in infection control practices.
The facility failed to maintain the dish machine at the required temperature and ensure kitchen cleanliness, affecting all residents receiving meals. The dish machine's wash and rinse cycles only reached 100°F, below the required 120°F, with no temperature documentation. The kitchen had grease and debris build-up, and the RD was unaware of these issues.
The facility failed to provide a dignified dining experience for several residents. Staff were observed standing while assisting severely cognitively impaired residents with meals, contrary to policy. One resident waited 48 minutes for an alternative meal after refusing the initial offering. Another resident, with intact cognition, felt unloved due to being served last at a table where others had already started eating. These actions indicate a failure to adhere to the facility's dining assistance policy.
A resident with severe cognitive impairment and malnutrition experienced significant weight loss due to the facility's failure to implement prescribed nutritional interventions. Observations revealed that the resident was not consistently provided with the fortified diet and chocolate milk as ordered, and staff did not encourage meal consumption. Interviews with staff indicated a lack of awareness and adherence to dietary interventions, contributing to the resident's poor nutritional intake.
The facility failed to ensure proper garbage disposal practices, as observed with open dumpster lids and food debris spillage. Despite the policy requiring closed lids, staff did not consistently comply, posing a risk of attracting pests.
A facility failed to submit a discharge return anticipated (DCRA) MDS assessment for a resident within the required timeframe. The assessment, with an ARD of 09/15/24, was completed but not submitted, as confirmed by the MDS Coordinator. This oversight could potentially affect care planning and provision or payment to other facilities.
The facility failed to create comprehensive care plans with measurable goals for two residents prescribed psychoactive medications. One resident's care plan lacked goals for antipsychotic medication, while the other had unmeasurable goals due to missing baseline data. The DON confirmed the absence of necessary documentation to track medication effects.
A resident with severe cognitive impairment experienced distress due to delayed toileting assistance, while another resident with a catheter lacked necessary orders for its management. The facility's limited CNA availability contributed to the toileting delay, and an oversight in transferring urology orders led to missing catheter care documentation.
The facility failed to document indications for psychotropic medication use and monitor their efficacy for two residents. One resident was prescribed quetiapine without documented justification, and another was on multiple psychoactive medications without monitoring target behaviors. This lack of documentation and monitoring could affect the ability to prescribe the lowest effective dose.
A resident with a history of heart failure and other conditions was not asked about her food preferences, leading to repeated servings of disliked items such as scrambled eggs. Despite being cognitively intact and having a care plan that required catering to her preferences, the dietary interview sections were left blank, and the dietary manager and registered dietitian were unaware of her dislikes.
The facility failed to provide proper written transfer notices to three residents transferred to the hospital, lacking details such as the reason, location, and appeals process. Interviews revealed staff did not adhere to the facility's policy, leading to deficiencies in communication and documentation.
A facility failed to provide a complete bed hold notice to a resident or their representative during an emergent transfer to the hospital. The notice lacked financial information, such as the daily cost, required by facility policy. The resident, with multiple medical diagnoses, was transferred due to a change in a feeding tube's position. Staff interviews confirmed the omission, and there was no documentation of the notice being mailed promptly.
The facility did not serve meals at an appetizing temperature, as residents who ate in their rooms reported that the food was often cold. This issue was identified through observations, interviews, and record reviews, with the facility having a census of 115 residents.
The facility did not inform five residents or their representatives about potential charges for respiratory therapy services not covered by Medicare/Medicaid or the facility's per diem rate. These residents were charged without prior notification, as identified during interviews and record reviews.
A resident with Alzheimer's and other medical conditions did not receive prescribed medications for a UTI due to a failure in entering verbal orders into the medication administration record. The ADON received orders for a probiotic and to switch antibiotics, but these were not documented, leading to the resident's hospitalization with pyelonephritis. Interviews revealed communication lapses and expectations for immediate reporting of lab results.
The facility failed to maintain a licensed nursing home administrator, as required by state law, affecting all residents. The administrator's temporary license expired, yet he continued to perform duties, including issuing a discharge notice. An interim administrator was delayed in starting, and the Regional President acknowledged the lapse in compliance.
The facility did not have a qualified Infection Preventionist (IP) for some time, leading to a lack of infection tracking and control. The Director of Nursing (DON) recently obtained her IP certification, but during the absence of a designated IP, there was no monitoring of infections or antibiotics. The DON noticed a trend in urinary tract infections but was unaware of the affected residents or the actions being taken. The Administrator expected infection tracking to be in place.
The facility failed to follow the planned menu reviewed by the RD, resulting in discrepancies between the menu and meals served. Meals often did not match the menu, and correct serving sizes were not provided. For example, chicken rice soup was not prepared, and no substitute was available. A resident expressed dissatisfaction with receiving only half a BLT sandwich, and the RD was unaware that the facility was not following the approved spreadsheets for meal preparation.
A facility failed to provide an appropriate discharge notice for a resident with severe cognitive impairment, lacking a proper discharge location and necessary appeal information. The resident's physician did not document unmet needs, and the facility did not assist the DPOA in finding alternative care. The administrator was unaware of documentation requirements.
The facility failed to maintain a kitchen faucet, resulting in continuous water flow. Despite multiple work orders submitted by the Dietary Manager, the Maintenance Director marked the issues as resolved, but the problem persisted. The Administrator was unaware of the issue, indicating a communication breakdown in the maintenance process.
A resident who fell and was in pain did not receive a timely x-ray or pain management. A STAT mobile x-ray was ordered but delayed, and results were not promptly communicated to the physician. The resident was later diagnosed with a fractured shoulder. Pain medication orders from the emergency room were not followed until 12 days after the injury.
The facility failed to address significant weight loss in three residents, with one resident losing 5.9% of their weight over five months, another losing 9.3% in three months, and a third losing 17% in seven months. The facility did not notify the physician or RD about these losses, nor did it implement or evaluate interventions. Specifically, interventions for one resident were not communicated or implemented as recommended by the RD.
The facility was found to have unsanitary kitchen conditions, including unclean floors with food, debris, and rodent feces, and equipment surfaces with rodent feces. Staff failed to label and date opened food, improperly stored food, and did not discard compromised items like ice cream and apples. The facility had 117 residents during the survey.
The facility failed to maintain an effective pest control program, leading to the presence of rodents in the kitchen. This issue was identified through observation and interview during a survey, with the facility having a census of 117 residents.
A facility failed to provide appropriate care for a resident with dementia, who exhibited behaviors affecting themselves and others. Despite recognizing these behaviors, the facility did not evaluate or implement further care approaches. The resident's increased behaviors led to the use of anti-anxiety IM and psychotropic medications without trying alternative interventions. Although a psychiatric consultation was ordered, it was not scheduled, leading to continued behavior issues and increased medication use.
A resident with severe cognitive impairment fell and sustained a shoulder fracture. The facility delayed obtaining a STAT x-ray and failed to administer pain medication or alternative interventions. The x-ray results were not communicated to the physician promptly, delaying the resident's transfer to the ER. Additionally, the facility did not follow the hospital's discharge orders for pain management, resulting in the resident experiencing prolonged pain.
The facility failed to monitor and address significant weight loss in three residents, leading to a deficiency in providing adequate nutrition. One resident with severe cognitive impairment was not assisted with meals, resulting in a 5.9% weight loss over five months. Another resident experienced a 9.3% weight loss in three months without proper documentation or physician notification. A third resident, at risk for malnutrition, was not provided with fortified foods, leading to a 17% weight loss in seven months. The facility did not notify the physician or implement interventions to address these issues.
The facility failed to maintain sanitary conditions in the kitchen and kitchenette, leading to a health deficiency. Observations showed contamination with rodent feces and improper food storage, labeling, and dating. Staff interviews confirmed awareness of the rodent problem and unsanitary conditions, with reports shared among administration. Despite this, facility policies on sanitization and pest control were not effectively implemented.
The facility failed to inform several residents or their representatives about respiratory therapy services not covered by Medicare/Medicaid before providing these services. Residents were charged without prior notification, and the facility lacked a policy for the respiratory therapy department. Interviews revealed that residents and their representatives were unaware of the services and associated costs, leading to confusion and billing issues.
The facility failed to provide necessary oral hygiene care for five residents unable to perform their own ADLs. Observations showed food particles and white substances on their teeth, and interviews revealed missing or unused oral care supplies. Staff interviews indicated challenges with agency staff compliance, and the DON acknowledged difficulties in ensuring oral hygiene tasks were completed.
The facility failed to follow the planned menu and serve correct portion sizes, leading to inconsistencies in meal service. Observations showed random meal serving order, missing menu items, and improper portioning. Interviews revealed a lack of recipes and oversight in the kitchen, with the Administrator assuming responsibility due to the absence of a dietary manager.
The facility failed to serve food at appetizing temperatures, with residents reporting cold meals in their rooms. Records showed no food temperatures were taken for several meals, and a test tray revealed food served below required temperatures. The dietary manager had recently quit, leaving the administrator to oversee the kitchen.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions like indwelling catheters and pressure ulcers, lacking a specific policy and staff awareness. Observations showed inadequate signage and PPE availability, with staff interviews revealing a lack of understanding of EBP. The Director of Nursing admitted reliance on a general contact isolation policy, which did not cover EBP requirements.
The facility's kitchen was found to have a significant rodent infestation, with numerous instances of rodent feces observed on various surfaces and food particles scattered throughout. The Dietary Manager, Maintenance Director, and Registered Dietician were aware of the issue, which had persisted despite pest control efforts. The problem was exacerbated by a shortage of staff and nearby construction, as noted by the Administrator.
The facility failed to ensure medications were not left in resident rooms without proper orders, affecting three residents. Medications, including Nystatin Powder, artificial tears, Clear Eyes eye drops, Mineral Cream, and triple antibiotic ointment, were found improperly labeled or without orders. Staff and residents were unable to identify the owners of these medications, and the DON confirmed that medications should not be left in rooms without self-administration orders.
A resident with dementia exhibited increased behavioral issues, but the facility failed to evaluate and implement appropriate interventions, relying instead on medications without attempting alternatives. Despite an order for psychiatric consultation, it was not scheduled, leading to continued behavioral problems and increased medication use. Interviews revealed a lack of communication and follow-through regarding psychiatric care.
The facility failed to comply with state laws by appointing an acting administrator who was not licensed in the state as a nursing home administrator. The acting administrator, in the role for about a week, admitted to not holding a state license and not contacting the state licensing board for a temporary license. This oversight had the potential to affect all 118 residents.
Failure to Provide Written Notice and Honor Resident Choice in Room and Roommate Changes
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights related to room changes, including the right to receive written notice of a room or roommate change, the right to share a room with a roommate of choice, and the right to refuse a room move unless necessary for health or safety reasons. The facility’s own undated policy stated that room or roommate changes may occur when the facility deems it necessary or when requested by the resident, that resident preferences are to be considered, and that residents have the right to share a room with a spouse, domestic partner, or friend. The policy also required that all parties receive verbal or written notice prior to a room or roommate change, that written notice include the reason for the change and information to help the new roommates become acquainted, and that residents have the right to refuse a room move without affecting Medicare or Medicaid eligibility. Despite this, multiple residents were moved without written notice, without being offered choices of rooms or roommates, and without being informed they could refuse the move. One cognitively intact resident with quadriplegia, anxiety, and depression had been in a private room for over two years and was moved to a semi‑private room. A progress note documented that the ADON and social worker (SW) called the resident’s POA about the move and that the POA was agreeable, and that the resident was told he/she would be moving the next day. The note did not document any written notice or explanation of the reason for the move. The resident later reported being very upset about losing the long‑standing private room, stated that he/she was not given an option and was simply told by the SW and ADON that the move would occur the next day, and described staff coming in the next morning and moving him/her. The resident and family reported that many decorations and belongings had to be taken home due to lack of space, and that staff “shoved” belongings into boxes and did not offer to put them away. The POA stated that the SW had emailed that the resident was being moved to make room for potential isolation patients, that no choice of rooms was given, and that neither the POA nor the resident were told they could refuse the move. Another resident with cognitive impairment, heart disease, hypertension, diabetes, and a history of stroke was also moved from a private room. A progress note by the SW documented a call to two family members about a room change and that “consent” was obtained, but did not specify what the consent covered or provide any written notice. The family members reported being told by the SW that the resident would be moved to another room to create a quarantine room for potential hospital admissions and that the move had been approved by the Administrator. They stated they were told they had three days to move the resident, were not offered any alternative rooms, and were not introduced to the new roommate until after the move into a semi‑private room. There was no documentation that the resident or family were informed of a right to refuse the move or that written notice explaining the reason for the move was provided. A third resident with cognitive impairment, heart failure, hypertension, heart disease, a fractured hip, and dementia was moved from a rehab hall room to a LTC room. The SW’s progress notes documented a phone call to the resident’s family member with “verbal consent” and a late entry stating that consent was obtained from the spouse to move from the rehab hall to a LTC room that became available, but did not specify the content of the consent or any written notice. The family member reported being told by the SW that the resident was being moved because a new administrator was changing things and moving residents, and that when the family member asked if the move could wait, the SW said no. The family member also reported speaking with a person identifying himself as the Administrator, who stated the current room was meant for rehab and that the resident was moving to the LTC section that day, and that the resident was not the only one being moved. The family member stated the resident was not given a choice of room or roommate, and that staff moved the resident the next day. A fourth resident, cognitively able to make decisions and dependent on staff for ADLs, was admitted to a private room and later moved. The resident’s family member reported receiving a phone call from a person identifying himself as the Administrator, who said the resident was being moved to another room to create an isolation room for potential COVID patients. The family member stated that the SW later said the move had to occur and that the new roommate did not want a camera in the room. The family member reported that the resident was not offered a choice of rooms and was not introduced to the new roommate before the move. There was no documentation of written notice explaining the reason for the move or of any opportunity for the resident to see the new location, meet the new roommate, or ask questions prior to the move. Interviews with staff further clarified the circumstances leading to these deficiencies. The SW stated she had been told by a person identifying himself as the Administrator that residents needed to be moved off the rehab unit to free up rooms for potential rehab residents, and that she was to find rooms on the LTC side or discharge the residents. She reported she was not aware that residents had a choice to move or not, or that they had a choice of roommates, and that she was following instructions. The Administrator interviewed stated he had recently come to the facility, that his temporary license had not yet been approved, and that he needed to move residents to better align acuity for staffing and to keep rehab and LTC residents grouped together. He stated they had obtained permission for the residents to move and that he was not aware residents had the right to decline a room move, although he would expect staff to give residents a choice when able. Across these cases, there was no evidence that residents received written notice of room or roommate changes, were informed of their right to refuse, or were given the opportunity to see the new room, meet the new roommate, and ask questions as required by facility policy and resident rights. The facility also failed to ensure residents’ right to share a room with a roommate of choice. The policy stated that residents have the right to share a room with a spouse, domestic partner, or friend, and that resident preferences are considered when room or roommate changes are proposed. In the described room moves, residents and families reported that no choices of rooms or roommates were offered, and there was no documentation that roommate preferences were solicited or honored. The moves were driven by facility needs such as creating isolation or rehab rooms and redistributing residents by acuity, rather than by resident choice or preference, and were implemented without the written notices and pre‑move opportunities outlined in the facility’s own policy.
Failure to Provide Required Written Discharge Notices and Appeal Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written discharge notices, including information on appeal rights and bed-hold policies, to three cognitively intact or partially impaired residents who were dependent on staff for ADLs. Facility policy and resident rights documents required that, once admitted, residents have the right to remain in the facility and that any transfer or discharge must meet specific criteria, include proper documentation in the medical record, and be accompanied by written notice detailing the basis for discharge, effective date, new location, appeal rights, and bed-hold policy. Despite these requirements, the facility moved residents off a rehab unit as part of a reconfiguration to group rehab residents together and free up rooms, without issuing the mandated 30‑day or emergency discharge notices. For one resident, progress notes showed the resident and POA were offered placement in a semi‑private LTC room but expressed concerns about room size and setup, and an option to transfer to another facility was offered and accepted. The family member later reported receiving a phone call stating the resident needed to be out within a few days due to reconstruction of the rehab unit and the need to have only rehab residents on that unit, and stated they were not offered a different room in the same facility, did not have a chance to see the new facility, were unaware of resident rights, and did not receive a written discharge notice. The medical record documented a SNF‑to‑SNF transfer and discharge to another facility, but there was no documentation of a written discharge notice or provision of appeal rights and bed‑hold information. For two additional residents, records showed SNF‑to‑SNF transfers and discharges to other facilities, with notes indicating consent obtained and referrals sent, but again without documentation of written discharge notices. Family members reported being told by phone that the residents had to be moved within two days because the rooms were being converted back to rehab use or to make room for an emergency admission, that they felt they had no choice, and that they were not informed of appeal rights. One family member reported the resident’s belongings were hastily packed into boxes, and another reported there was no communication from the discharging facility to the receiving facility regarding medications and pain management. The social workers stated they were instructed by an individual they understood to be the administrator to move residents to free up rooms for rehab residents and believed that written discharge notices were not required for SNF‑to‑SNF transfers, and acknowledged that no 30‑day or emergency discharge notices were issued to these residents.
Improper Use of Mechanical Lift Emergency Release During Resident Transfer
Penalty
Summary
Staff failed to safely transfer a dependent resident using a mechanical lift by inappropriately using the lift’s emergency release button to lower the resident rapidly onto the bed. Facility policy for mechanical lift use required at least two CNAs, selection of an appropriate sling, ensuring the lift was stable and locked, checking attachments and sling fit, and slowly lifting and lowering the resident only as high and as fast as necessary to complete the transfer. The policy specified that residents should be gently supported and slowly lowered to the receiving surface. The resident involved had Parkinson’s disease, Alzheimer’s disease, dementia, anxiety, severe cognitive impairment, and was dependent on staff for transfers per the most recent MDS. Ring camera footage from the resident’s room showed two CNAs placing the resident in a mechanical lift sling to transfer from wheelchair to bed, with one CNA operating the controls and keeping hands on the resident. While the resident was suspended over the bed, the CNA at the controls placed a hand on the red emergency release button, verbally said “Drop him/her?” and then pressed the button, causing the resident to quickly drop onto the bed, which moved on impact, and the resident exclaimed “Oh!” The resident verbally questioned why “drop it” was said. The family member later showed the video to the DON and ADON and stated the method of lowering was unacceptable. The DON confirmed there was no reason to use the emergency release button because the lift battery was charged and there were no reports of malfunction. One CNA reported not hearing the “drop” comment, while the CNA who operated the lift admitted using the emergency release button because the lift lowered residents very slowly and stated they had never been told not to use it for transfers. The ADON and Administrator both stated the emergency release button should only be used in a real emergency when a resident needs to be removed from the lift quickly.
Failure to Treat Residents with Dignity and Respect During Care
Penalty
Summary
Staff failed to treat two residents with dementia and Alzheimer's disease with dignity and respect during the provision of care. In both cases, certified nurse aides (CNAs) did not greet or explain care to the residents, who had significant cognitive impairments and were dependent on staff for activities of daily living. The CNAs used forceful and disrespectful language, exposed the residents unnecessarily, and did not follow the care plans that required clear communication and anticipation of the residents' needs. For one resident, video footage showed a CNA using a mechanical lift to transfer the resident to bed without any greeting or explanation. The CNA removed the resident's clothing, left the resident exposed, and used a scolding tone, repeatedly telling the resident to comply and threatening to call a doctor for a sedative. The CNA also made inappropriate comments about sending the resident out if they did not cooperate. The resident, who was unable to make decisions and had impaired communication, showed resistance, which was misinterpreted by the staff as defiance rather than a lack of understanding. In the second case, another CNA entered a resident's room, turned on the light, and began providing care without speaking to or explaining actions to the resident. The CNA pushed the resident, removed blankets despite the resident's protests, and engaged in an argumentative and mocking exchange. The resident became visibly upset, used foul language, and attempted to defend themselves physically. The CNA continued to provide care in a hostile manner, laughed at the resident, and made dismissive comments, further escalating the resident's distress. Both incidents were captured on video and reported by family members.
Failure to Use Two-Person Assist During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the safety of two residents who were dependent on staff for transfers and at risk for falls by not following its own policy requiring two staff members to assist with mechanical lift transfers. The facility's policy, revised in July 2017, clearly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift. Both residents involved had care plans and Minimum Data Set (MDS) assessments indicating they required two-person assistance for transfers due to conditions such as dementia, Parkinson's disease, and cognitive impairment, and were dependent on staff for activities of daily living. Direct observations and review of video footage provided by family members showed that staff did not consistently use two-person assistance during mechanical lift transfers. In one instance, after both CNAs initially prepared the resident for transfer, only one CNA operated the lift and moved the resident from the wheelchair to the bed, while the other CNA was not assisting and was instead gathering supplies. The resident was left unsupported and swung while suspended in the lift. A similar pattern was observed with another resident, where one CNA operated the lift and moved the resident while the other CNA sat in a chair and did not participate until the resident was being lowered into the wheelchair. Interviews with the involved CNAs and the Director of Nursing confirmed that facility policy requires two staff members for all mechanical lift transfers, with one person operating the controls and the other guiding the resident. The staff acknowledged that they did not follow this protocol during the observed transfers. These actions directly led to the deficiency, as the facility did not provide adequate supervision or follow established procedures to prevent accidents for residents at risk of falls.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow established infection control protocols during personal care for two residents who were dependent on staff for activities of daily living and incontinent of bowel and bladder. In both cases, certified nurse aides (CNAs) did not perform hand hygiene before beginning care, donned gloves taken from their pockets, and proceeded to provide care without changing gloves or washing hands between clean and dirty tasks. During care, CNAs handled soiled briefs, performed peri care, and then touched clean supplies, resident bedding, and room equipment without removing soiled gloves or performing hand hygiene. In one instance, a CNA also used a cell phone and handled other items in the resident's environment while wearing the same gloves used for personal care. Interviews with staff confirmed knowledge of the facility's hand hygiene policy, which requires handwashing before and after resident care and glove changes between clean and dirty tasks. However, observations and video evidence showed repeated failures to adhere to these protocols, including not removing gloves or washing hands after providing peri care and before touching other surfaces or equipment. The facility's policy emphasized the importance of hand hygiene to prevent the spread of healthcare-associated infections, but these procedures were not followed during the observed care episodes.
Failure to Honor Resident Choice in Morning Routines
Penalty
Summary
The facility failed to honor the rights of several residents to make choices about their daily routines, specifically regarding their preferred wake-up and get-up times. Observations and interviews revealed that multiple residents were awakened, dressed, and brought to common areas significantly earlier than their stated preferences, with some residents expressing distress or dissatisfaction about being up too early. Staff interviews confirmed the existence of a 'get-up list' or 'early riser list' that directed CNAs to get specific residents up in the early morning hours, regardless of individual preferences, unless a resident was adamant in refusing. Resident records and care plans indicated that residents should be offered the choice to get up in the morning and allowed to refuse, with encouragement for out-of-bed activities aligned with their preferences. Despite these documented directives, residents with varying levels of cognitive impairment and physical assistance needs were observed awake, dressed, and in wheelchairs or specialized chairs in their rooms or dining areas before their preferred times. Several residents directly stated they were not asked about their preferences or were upset about being awakened early, and staff acknowledged following a list rather than individualized routines. The facility's policy on resident rights emphasizes dignity, respect, and self-determination, including support for residents' choices regarding their daily routines. However, the practice of using a predetermined list to manage morning routines resulted in residents being awakened and dressed earlier than they desired, contrary to their care plans and stated preferences. This practice was confirmed through staff interviews and documentation, demonstrating a failure to fully support residents' rights to self-determination and a dignified existence.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The facility failed to ensure that direct care staff consistently utilized Enhanced Barrier Precautions (EBP) and adhered to proper hand hygiene and glove use during high-contact care activities for residents with indwelling medical devices, such as urinary catheters and gastrostomy tubes. Observations revealed that staff did not don required personal protective equipment (PPE), including gowns and face shields, when providing care to residents with these devices, despite clear signage and facility policy indicating the necessity of EBP for such situations. For example, staff were observed assisting a resident with a urinary catheter without wearing gowns or face shields, and performed multiple care tasks, including perineal and catheter care, with soiled gloves and without appropriate hand hygiene between tasks. Additionally, staff demonstrated a lack of understanding regarding the purpose and application of EBP. Interviews with CNAs indicated confusion about when and why EBP bins and PPE were to be used, with some staff believing the precautions were only necessary when residents were acutely ill or "had something going on." This misunderstanding led to inconsistent use of PPE and lapses in infection control practices, such as failing to wash hands after glove removal and before donning new gloves, and not changing gloves between dirty and clean tasks. The residents involved had significant care needs and indwelling devices that required strict adherence to infection prevention protocols. One resident had a suprapubic catheter and required EBP during high-contact care, while another had a gastrostomy tube and was dependent on staff for all activities of daily living. Despite these needs, staff did not follow established protocols for EBP and hand hygiene, as evidenced by multiple observed care episodes and staff interviews. The Director of Nursing confirmed that staff were expected to use EBP for residents with relevant signage and devices, but observations and interviews showed this was not consistently practiced.
Dish Machine Temperature and Kitchen Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure that the dish machine in the kitchen operated at the correct temperature and that equipment and surfaces were kept clean, potentially affecting all 113 residents who received meals prepared in the facility. Observations revealed that the dish machine's wash and rinse cycles only reached 100 degrees Fahrenheit, below the manufacturer's requirement of 120 degrees Fahrenheit. The Dietary Manager (DM) did not document the wash and rinse temperatures, only the results of the sanitation test strips, and was unaware of how long the machine had been operating at the incorrect temperature. The Administrator and DM confirmed the lack of temperature documentation, which could have identified the issue sooner. Additionally, the kitchen was found to have several cleanliness issues. The ventilation filters and exterior hood had a thick layer of grease, the fryer contained food particles, and the oven and grill had a build-up of grease and debris. The dish machine area had dried splatters, a black substance, and a warped surface, while the floors had dried spills, food, trash debris, and a dark build-up. The Registered Dietitian (RD) was unaware of the dish machine's temperature issue and the unclean conditions, having only conducted one kitchen sanitation inspection since starting at the facility.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, as observed during multiple instances. For Resident 68, who was severely cognitively impaired and required assistance with eating, staff members were observed standing while assisting with meals, contrary to the facility's policy that emphasizes sitting to ensure dignity. This occurred on multiple occasions with different staff members, including a CNA, MDS Coordinator, and a CMT, who all stood while feeding the resident, citing reasons such as readiness to assist others or simply not knowing the policy. Resident 98, also severely cognitively impaired, experienced a similar issue where a CMT stood while offering food, then moved to assist another resident without sitting. Additionally, Resident 88, who refused the meal served, was not promptly offered an alternative. It took 48 minutes for the resident to receive a grilled cheese sandwich after initially refusing the fish fillet, potatoes, and bread. During this time, the resident was observed looking around at others eating, indicating a lack of timely response to her needs. Furthermore, Resident 102, who had intact cognition, was the last to be served at a table where others had already started eating. This delay made the resident feel unloved, highlighting the lack of continuous dining service. The facility's Director of Nurses acknowledged the expectation for all residents at a table to be served simultaneously, although there was no specific policy addressing this. These observations indicate a failure to adhere to the facility's dining assistance policy, affecting the dignity and dining experience of the residents involved.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to implement weight loss interventions and provide meal encouragement for a resident identified as R95, who was reviewed for nutrition among 30 sample residents. R95, who was severely cognitively impaired with diagnoses of malnutrition, Alzheimer's disease, and primary open-angle glaucoma, experienced significant weight loss. The facility's policy on nutrition and unplanned weight loss required staff and physicians to identify and monitor interventions based on the resident's condition. However, R95's care plan did not include a specific plan for diet or nutrition, despite the resident's significant weight loss and malnutrition diagnosis. Observations revealed that R95 was not consistently provided with the prescribed fortified diet and chocolate milk, which were part of the interventions to address the resident's nutritional needs. During multiple meal observations, R95 did not receive chocolate milk or fortified items, and there was a lack of encouragement from staff to consume meals. For instance, during breakfast and lunch observations, R95 was served meals without the prescribed chocolate milk, and staff failed to encourage or assist the resident in eating, resulting in poor intake. Interviews with staff, including the Director of Nursing (DON), Certified Nurse Aides (CNAs), and the Registered Dietitian (RD), highlighted a lack of awareness and adherence to the prescribed dietary interventions for R95. The DON acknowledged the resident's significant weight loss and the need for chocolate milk at meals, yet it was not consistently provided. The RD, who was new to the facility, was aware of the weight loss but not of the lapses in providing the prescribed diet. The facility's failure to implement and monitor the necessary nutritional interventions for R95 had the potential to cause further weight loss.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain the cleanliness and proper closure of dumpster lids in the dumpster area adjacent to the kitchen's rear exit hall, which serves 115 census residents. The facility's policy, revised in April 2006, mandates that all garbage and rubbish containing food waste be kept in containers with tight-fitting lids, which must be closed when not in continuous use. During an observation with the Dietary Manager, it was noted that the lids of two garbage dumpsters were open, exposing numerous plastic garbage bags. Additionally, two plastic garbage bags were found on the concrete next to the dumpsters, which the Maintenance Assistant placed inside the dumpsters without closing the lids. Further observations revealed that the lids remained open on subsequent days, and food debris spillage was noted on the outside of the recycling dumpster. The Administrator acknowledged that the lids should be closed each time trash is placed inside but mentioned the difficulty in ensuring compliance across all departments. This failure to adhere to the facility's policy on garbage disposal has the potential to attract rodents and other pests, posing a risk to the facility's environment.
Failure to Submit DCRA MDS Assessment Timely
Penalty
Summary
The facility failed to ensure timely submission of a discharge return anticipated (DCRA) Minimum Data Set (MDS) assessment for one resident, identified as Resident 6, out of a sample of 30 residents. According to the facility's policy, resident assessments must be submitted in accordance with federal and state submission timeframes. The October 2023 Resident Assessment Instrument (RAI) Manual specifies that the DCRA assessment should be transmitted within 14 calendar days of the MDS Completion Date. However, a review of Resident 6's electronic medical record revealed that the DCRA MDS assessment, with an Assessment Reference Date of 09/15/24, was in a completed status but not in an accepted status, indicating it was never submitted for processing. During an interview, the MDS Coordinator acknowledged the oversight, confirming that the assessment was not added to a batch for submission. This failure to submit the assessment in a timely manner had the potential to adversely affect care planning and care provision or payment to other facilities for any resident lacking a transmitted discharge assessment. The facility's policy, last reviewed in July 2017, assigns the responsibility of ensuring timely submission of assessments to the assessment coordinator or designee, but this protocol was not followed in this instance.
Deficiency in Developing Comprehensive Care Plans for Psychoactive Medications
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan with measurable goals and plans for two residents who were prescribed psychoactive medications. For one resident, the care plan did not include goals or interventions for the antipsychotic medication, and there was no identification of the target behavior being monitored for the psychoactive medications. The resident had been admitted with diagnoses including dementia, insomnia, and depression, and was prescribed multiple psychoactive medications without a clear care plan to monitor their effects. For the second resident, the care plan included a goal for improved sleep but lacked baseline data to measure the effectiveness of the hypnotic medication. Additionally, the care plan for antipsychotic medication did not establish a baseline for therapeutic effects, making the goal unmeasurable. The resident was admitted with similar diagnoses and was prescribed several psychoactive medications. The Director of Nursing acknowledged the absence of shift documentation to establish baselines or measure decreases in symptoms.
Deficiencies in Toileting Assistance and Catheter Order Management
Penalty
Summary
The facility failed to provide timely toileting assistance to a resident with severe cognitive impairment, leading to discomfort and distress. The resident, who required maximum assistance with toileting, was observed requesting to use the bathroom multiple times over a 19-minute period without receiving assistance. During this time, the resident was visibly distressed and crying, indicating significant discomfort. The delay in assistance was attributed to the limited availability of CNAs, as they were occupied with other residents. Additionally, the facility did not have an order in place for the use of an indwelling catheter for another resident with moderately impaired cognition and a history of prostate cancer. This resident was observed with a catheter bag, but the necessary orders for catheter care were missing from the electronic medical record. The absence of these orders meant that catheter care was not documented, and the staff was unaware of the specific requirements for the catheter, such as size and care instructions. Interviews with staff, including an LPN and the DON, revealed that the lack of catheter orders was due to an oversight in transferring orders from the urology department into the facility's system. This oversight resulted in a lack of documentation for catheter care, which is essential for preventing complications such as urinary tract infections. The DON acknowledged the need for proper orders to ensure appropriate catheter management.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure documented indications for the use of psychotropic medications and to monitor their efficacy for two residents. Resident 61 was admitted with diagnoses including dementia, hypertension, and insomnia. The resident was prescribed quetiapine, an atypical antipsychotic, without a documented diagnosis or behaviors justifying its use. Additionally, there was no monitoring of the medication's efficacy or target symptoms in the resident's medical records. Interviews with the Assistant Director of Nursing revealed that the medication was prescribed due to nighttime yelling, but this behavior was not documented. Resident 94, admitted with dementia, insomnia, and depression, was prescribed multiple psychoactive medications, including Ambien, Lorazepam, Mirtazapine, Modafinil, Prozac, Trazodone, and Vraylar. Despite having orders for behavior monitoring and non-pharmacological interventions, there was no documentation of monitoring target behaviors for medication efficacy in the resident's records. The Director of Nursing confirmed that behaviors should be monitored each shift, but this was not reflected in the documentation. The lack of documentation and monitoring for both residents indicates a failure to adhere to the facility's policy on psychotropic medication use. This oversight could potentially affect the ability of physicians to prescribe the lowest effective dose of medication, as there is no recorded evidence of the medications' necessity or effectiveness.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences were obtained and honored, which had the potential to affect the resident's nutritional status. The resident, who was cognitively intact and had a history of heart failure, atrial fibrillation, and coronary artery disease, was on a mechanically altered diet. Despite the care plan indicating that food preferences should be catered to, the dietary interview sections for beverage preferences, snacks, and food likes/dislikes were left blank. This oversight led to the resident being served meals that included items she disliked, such as scrambled eggs, which she received repeatedly for breakfast. Observations and interviews revealed that the resident expressed dissatisfaction with the repetitive nature of her meals and the inclusion of disliked items. The dietary manager, responsible for the initial assessment of food preferences, was unaware of the resident's dislikes and had not communicated with her regarding her preferences. The registered dietitian also confirmed that she was not informed about the resident's food preferences not being obtained. The administrator acknowledged the oversight when informed that the resident's dislikes were not listed on the meal ticket, leading to the repeated serving of scrambled eggs, which the resident did not like.
Failure to Provide Proper Transfer Notices
Penalty
Summary
The facility failed to provide proper written transfer or discharge notices to three residents who were transferred to the hospital. The facility's policy requires that residents and their representatives receive a written notice that includes the reason for transfer, the place of transfer, and information about the appeals process. However, this policy was not followed for three residents, leading to deficiencies in communication and documentation. Resident 6 was transferred to the hospital due to a change in the position of a feeding tube and associated vomiting. Although a transfer notice was created, it lacked specific details such as the recipient of the document, the destination of the transfer, and the specific reason for the transfer. Interviews with staff revealed that the notice was not provided to the resident or their representative, and there was no documentation of the notice being mailed. Resident 16, who was severely cognitively impaired, was transferred to the hospital with a urinary tract infection and sepsis. The transfer notice did not include the date of transfer, the reason for transfer, the location, or an explanation of the appeals process. Similarly, Resident 54, who was cognitively intact, was transferred due to cardiac issues. The transfer notice for this resident also lacked essential information. Interviews with staff indicated a lack of understanding and adherence to the facility's policy on providing written notices, contributing to the deficiency.
Failure to Provide Complete Bed Hold Notice During Emergent Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice with all required information to a resident or their representative during an emergent transfer to the hospital. The facility's policy mandates that residents or their representatives receive written information about bed-hold policies at least twice: in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is an emergency. However, in the case of one resident, the facility did not include information regarding the financial commitment, such as the daily cost, in the bed hold notice provided during an emergency transfer. The resident in question was admitted with multiple medical diagnoses, including cerebral infarction and acute respiratory failure, and was transferred to the hospital due to a change in a feeding tube's position with associated vomiting. The facility's documentation showed that the social services department attempted to contact the resident's representative to discuss the transfer form, which included the bed hold notice, but there was no documentation of the form being mailed or received. Interviews with facility staff, including an LPN and the DON, confirmed that the bed hold notice did not include the necessary financial information, and there was no evidence of the notice being mailed promptly.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to serve food to residents at an appetizing temperature. Observations, interviews, and record reviews revealed that residents who ate meals in their rooms reported that the food was cold when served most of the time. The facility had a census of 115 residents at the time of the survey.
Failure to Inform Residents of Non-Covered Service Charges
Penalty
Summary
The facility failed to inform five residents or their representatives about the potential charges for respiratory therapy services that were not covered under Medicare/Medicaid or by the facility's per diem rate. This deficiency was identified during interviews and record reviews, where it was found that these residents were charged for the services without prior notification. The review included 16 sampled residents, and the facility census was 115.
Failure to Administer Prescribed Medications Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received the appropriate medications as ordered by the physician to treat a urinary tract infection (UTI). The Assistant Director of Nursing (ADON) received a verbal order from the resident's physician to administer Florastor, a probiotic, and later to discontinue Macrobid, an antibiotic, and start Cipro, another antibiotic. However, these orders were not entered into the resident's medication administration record, resulting in the resident not receiving the necessary medications. The resident, who had a history of Alzheimer's disease, type two diabetes with diabetic nephropathy, hemiparesis, hemiplegia, and aphasia, was at risk for activities of daily living and mobility decline. The resident's condition required substantial assistance from staff for toileting and transfers. Despite the physician's orders and the resident's medical needs, the failure to administer the prescribed medications led to the resident being hospitalized with vomiting, an abnormal urine analysis, possible pneumonia, and a diagnosis of pyelonephritis, a severe kidney infection. Interviews with the ADON and the Director of Nursing (DON) revealed that the ADON had delegated the task of entering the Cipro order to another nurse, which was not completed, and the DON expected immediate notification of abnormal lab results. The resident's physician was unaware that the resident did not receive the prescribed medications and emphasized the importance of administering the correct antibiotic to prevent serious infections like pyelonephritis. The oversight in medication administration and communication contributed to the resident's hospitalization.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to comply with state laws by not having a licensed nursing home administrator in place, which had the potential to affect all 117 residents. The facility's policy required a licensed administrator to oversee daily operations, and in the event of a license expiration, a fully licensed administrator was to be appointed within 10 days. However, the administrator's temporary emergency license expired, and he continued to perform duties similar to those of an administrator, including issuing a discharge notice, which he acknowledged was invalid due to his lack of a valid license. The interim administrator was expected to start on a specific date but was not present in the facility for a full day after her initial entry. The Regional President of Operations was aware of the expired license and acknowledged that the administrator did not meet the guidelines for license application review. The administrator believed the facility had a 10-day window to appoint a licensed administrator, but this was not adhered to, leading to a lapse in compliance with state regulations.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, as required by their policy. The facility, with a census of 117, did not have an IP for some time, and the Director of Nursing (DON) only recently obtained her IP certification. During this period, there was no tracking of infections or antibiotics, and although the DON noticed a trend in urinary tract infections, she was unaware of which residents were affected or the measures being taken. The Administrator acknowledged the absence of an IP until the DON's recent certification and expressed an expectation for infection tracking within the facility.
Failure to Follow Planned Menu and Serve Correct Portions
Penalty
Summary
The facility failed to adhere to the planned menu reviewed by the Registered Dietician, resulting in discrepancies between the menu and the meals served to residents. On multiple occasions, the meals served did not match the menu items, and the correct serving sizes were not provided. For instance, on one occasion, the lunch menu was supposed to include chicken rice soup, but it was not prepared, and no substitute was available. Instead, a turkey burger was served, which many residents found unappealing due to its appearance. Additionally, the dinner menu was supposed to include a garden salad and roasted Brussels sprouts, but these items were not served, nor were any equivalent substitutions provided. The dietary staff also failed to serve consistent portion sizes, as observed with the Jello served to residents, which varied in quantity and was melted. A resident expressed dissatisfaction with receiving only half a BLT sandwich and noted that the kitchen often ran out of food or served items different from the menu. The Dietary Manager admitted to making adjustments to the menu based on availability and resident preferences, such as substituting homemade potato chips with store-bought ones, without ensuring that the nutritional requirements were met. The Registered Dietician was unaware that the facility was not following the approved spreadsheets for meal preparation, which were intended to meet the residents' dietary needs, including necessary vitamins. The Administrator assumed that the spreadsheet menus met the requirements and should be followed by the Dietary Manager. However, the lack of communication and adherence to the planned menu led to residents not receiving the intended meals, impacting their nutritional intake.
Inadequate Discharge Notice and Documentation for a Resident
Penalty
Summary
The facility failed to issue an appropriate discharge notice for a resident, resulting in several deficiencies. The discharge notice lacked a proper discharge location and did not include the necessary information for the resident's right to appeal, such as the contact details for the state entity handling appeal requests. Additionally, the facility did not ensure that the resident's physician documented in the medical record the specific needs that the facility could not meet, nor did it provide an explanation of what the facility had attempted to do to meet those needs. The resident, who had severe cognitive impairment and exhibited behaviors that endangered themselves and others, was discharged without a clear plan or proper documentation. The resident's Durable Power of Attorney (DPOA) was informed of the discharge decision via a phone call and received the discharge notice by email. The facility's social worker attempted to refer the resident to a psychiatric facility, but the referral was not accepted, and the DPOA was told it was their responsibility to find alternative facilities. The administrator admitted to not having the correct appeals information on the discharge notice and was unaware of the requirement for physician documentation in non-emergency discharge cases. This was the first time the administrator had issued a discharge notice.
Failure to Maintain Kitchen Faucet
Penalty
Summary
The facility failed to maintain the water faucet in the food preparation area of the kitchen, resulting in a continuous flow of water at approximately half capacity. The issue was first reported by the Dietary Manager on 7/1/24, who submitted a work order for a leaking sink that would not shut off. The Maintenance Director marked the issue as resolved, but the problem persisted, as the faucet continued to run without stopping. A subsequent work order was submitted on 8/13/24 for the lack of hot water in the same sink, which was also marked as resolved by the Maintenance Director. However, the faucet continued to run continuously, as observed on 8/20/24 and 8/21/24. Interviews with the Maintenance Director and the Dietary Manager revealed a communication breakdown, as the Maintenance Director claimed not to have received a work order for the running faucet, while the Dietary Manager confirmed submitting multiple requests. The Administrator was unaware of the ongoing issue and expected the maintenance department to address it upon receiving a work order. This deficiency highlights a failure in the facility's maintenance processes, as the problem was not effectively communicated or resolved, leading to a persistent issue with the kitchen faucet.
Delayed X-ray and Pain Management for Resident After Fall
Penalty
Summary
The facility failed to provide timely care and treatment for a resident who sustained a fall and was in pain. After the fall occurred at 2:15 A.M., the responsible party opted for a mobile x-ray instead of hospital transport. A STAT mobile x-ray was ordered at 3:00 A.M., but the x-ray provider did not arrive until 10:30 A.M. The results were sent to the facility at 10:50 A.M., but staff delayed communicating these results to the physician until 1:30 P.M. The resident was eventually sent to the emergency room and diagnosed with a fractured right shoulder. Additionally, the facility did not follow the emergency room discharge orders for pain medication, delaying appropriate pain management until the resident was seen by their physician 12 days after the injury. The facility census was 117.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately address significant weight loss in three residents, as identified through observation, interview, and record review. Resident #2 experienced a 5.9% weight loss over five months, Resident #3 had a 9.3% weight loss in three months, and Resident #4 suffered a 17% weight loss over seven months. The facility did not notify the physician or registered dietician about these weight losses, nor did it implement or evaluate the effectiveness of interventions for these residents. Specifically, for Resident #4, the facility failed to communicate and implement the interventions recommended by the Registered Dietician to prevent further weight loss. The facility's census at the time was 117.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed by surveyors. The kitchen floors were not kept clean, with food, debris, and rodent feces present. Additionally, surfaces of kitchen equipment were found to have rodent feces. The staff did not label and date food items when opened, leading to improper food storage. Furthermore, compromised food items, including ice cream and apples, were not discarded appropriately. The facility had a census of 117 residents at the time of the survey.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents in the kitchen. This deficiency was identified through observation and interview during a survey. The facility had a census of 117 residents at the time of the survey.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate services for a resident diagnosed with dementia, which affected the resident's well-being and that of others. Despite identifying that the resident exhibited behaviors impacting themselves and other residents, the facility did not evaluate or implement further approaches to address these care needs. The resident experienced an increase in behaviors, leading to the administration of anti-anxiety intramuscular medication and psychotropic medication without attempting alternative interventions first. Although the resident's physician ordered a psychiatric consultation due to the increase in behaviors, the facility did not schedule this consultation. Consequently, the resident continued to exhibit behaviors, resulting in an increased administration of psychotropic medications by staff as an intervention.
Delayed X-ray and Pain Management for Resident After Fall
Penalty
Summary
The facility failed to provide timely care and treatment for a resident who sustained a fall and was in pain. The resident, who had severe cognitive impairment and required maximum assistance for transfers, fell at 2:15 A.M. and complained of right shoulder and arm pain. A STAT mobile x-ray was ordered at 3:00 A.M., but the x-ray provider did not arrive until 10:30 A.M. The facility did not administer pain medication or alternative interventions for the resident's pain during this time. The x-ray results, which showed a fractured right shoulder, were not communicated to the physician until 1:30 P.M., leading to a delay in sending the resident to the emergency room for further evaluation. The facility also failed to follow the emergency room discharge orders for pain management. After the resident returned from the hospital with instructions to use a lidocaine patch for pain, the facility did not apply the patch for 12 days. The Medication Administration Record (MAR) showed no order for the lidocaine patch until 7/16/24, despite the hospital's discharge orders. This oversight resulted in the resident experiencing prolonged pain from the fractured shoulder. Interviews with facility staff and representatives from the mobile x-ray provider revealed communication breakdowns and a lack of awareness regarding the x-ray results. The facility did not have a policy for reporting x-ray results or expectations for following discharge instructions. Additionally, the facility's contract with the x-ray provider did not include phone call notifications for positive fracture results, and the text message alerts were sent to former management personnel who were no longer employed at the facility.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in three residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #2 experienced a 5.9% weight loss over five months, Resident #3 had a 9.3% weight loss in three months, and Resident #4 suffered a 17% weight loss in seven months. The facility did not notify the physician or the registered dietician about these weight losses, nor did they implement or evaluate interventions to address the issue. Resident #2, who had severe cognitive impairment and a diagnosis of malnutrition, was observed not being assisted with meals and was left without food when he/she did not come out for lunch. The care plan did not include interventions for when the resident missed meals, and there was no documentation from the dietician or physician regarding the weight loss. Similarly, Resident #3, also with severe cognitive impairment, was not assisted with meals and experienced a significant weight loss without weekly weights being documented or the physician being notified. Resident #4, who was at risk for malnutrition, was not provided with fortified foods as ordered, and there was no follow-up from the dietician or notification to the physician about the continued weight loss. The dietary manager was unaware of the resident's fortified diet order, and the registered dietician assumed nursing was following through with recommendations without verification. The facility's staff, including the Unit Manager and DON, failed to ensure accurate weight monitoring and communication of weight loss to the physician, contributing to the deficiency.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and kitchenette areas, leading to a health deficiency. Observations revealed that the kitchen floors and equipment surfaces were contaminated with rodent feces, and food items were improperly stored, labeled, and dated. Specific issues included a refrigerator containing unlabeled and undated food items, such as a cup of liquid from a fast-food restaurant, a plastic container with an unidentified green liquid, and a partially full container of ice cream with ice buildup. Additionally, withered apples and open food packages were found in a cabinet. The main kitchen had numerous black pellets resembling rodent feces on a stainless steel preparation table, under the steam table, and around a large trash can. Food particles and rodent feces were also found under the stove, beverage dispenser, and behind the refrigerator. Interviews with facility staff, including the Dietary Manager, Maintenance Director, Registered Dietician, and Medical Director, confirmed awareness of the rodent problem and the unsanitary conditions in the kitchen. The Dietary Manager acknowledged the issue of mice in the kitchen and reported it to the Administrator and Maintenance Director. The Maintenance Director and Registered Dietician both noted the need for cleanliness to prevent rodent infestation, with the Dietician conducting monthly inspections and sharing reports with the administration. The Medical Director emphasized the expectation for the kitchen to be cleaned after every meal and at the end of the day. Despite these acknowledgments, the facility's policies on sanitization and pest control were not effectively implemented, contributing to the deficiency.
Failure to Inform Residents of Non-Covered Respiratory Therapy Charges
Penalty
Summary
The facility failed to inform five residents or their representatives about respiratory therapy services that were not covered under Medicare/Medicaid or by the facility's per diem rate before these services were provided. This deficiency was identified during interviews and record reviews, revealing that residents were charged for services without prior notification. The facility did not have a policy in place for the respiratory therapy department or to outline the responsibilities of the respiratory therapist, contributing to the lack of communication regarding non-covered services. Resident #5, who was a private pay and Medicare Part B recipient, received respiratory therapy services without being informed of the charges that would not be covered by Medicare. The resident's power of attorney was unaware of these charges until receiving a bill, which was later credited by the facility. Similarly, Resident #13, who was on hospice care, received respiratory therapy services without the responsible party's knowledge, under the assumption that all care was provided by the hospice company. The facility's billing statements showed significant amounts waiting to be billed to Medicare, with the remainder expected to be covered by the resident. The facility's failure to notify residents or their representatives of non-covered charges was further evidenced in the cases of Residents #14, #15, and #16. These residents, who were either on hospice or had a combination of Medicare, Medicaid, and private insurance, received respiratory therapy services without prior notification of potential charges. Interviews with the residents' representatives revealed a lack of awareness about the services and the associated costs. The respiratory therapist and business office manager confirmed that no consent was obtained for non-covered charges, and there was confusion about the notification process for these services.
Failure to Provide Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for five residents who were unable to perform their own activities of daily living. Observations and interviews revealed that these residents had food particles and white substances built up on their teeth, indicating a lack of proper oral care. The facility's policy required staff to assist residents with oral hygiene, but there was no specific care plan for oral hygiene for these residents, and the oral status sections in their assessments were left blank. Resident #1, diagnosed with Alzheimer's disease and depression, required supervision for oral hygiene but had no care plan addressing this need. Resident #2, with multiple diagnoses including heart disease and dementia, reported missing electric toothbrushes and had not received assistance with brushing teeth for a long time. Resident #3, with diabetes and Parkinson's disease, needed help with oral care but did not receive it, as evidenced by unused and dirty oral care supplies in their bathroom. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, indicated that agency staff were not consistently providing the required oral hygiene care. The Assistant Director of Nursing acknowledged receiving complaints about oral hygiene and had attempted to in-service staff, but faced challenges with agency staff compliance. The Director of Nursing confirmed that oral hygiene should be performed according to policy, but noted difficulties with agency staff completing all required tasks, attributing the issues to newer problems identified with agency staff.
Failure to Follow Menu and Serve Correct Portions
Penalty
Summary
The facility failed to ensure that the planned menu, reviewed by the Dietary Consultant, was followed, and the correct serving sizes were provided to residents. Observations revealed that the dining room was full of residents, and staff served meals in a random order, causing some residents to watch others eat while waiting for their meals. The menu items were not served as planned; for instance, the ham was served without gravy, and the pieces of ham varied in size. Additionally, staff did not use measured scoops to serve food, and there was a lack of drinks and sugar available for residents. Further observations showed that some residents did not receive the chicken and rice soup as the dietary staff claimed they were out, despite a stock pot of soup being available in the kitchen. The turkey burgers were served as half portions on a piece of bread, and potato wedges were served by hand without using tongs or measuring tools. The apple slaw was missing from the serving line, and the dietary aide expressed confusion and agitation when questioned about the soup shortage. Interviews with dietary staff and consultants revealed a lack of recipes in the kitchen and inconsistencies in menu planning and execution. The Registered Dietitian and Medical Director expected the dietary staff to follow menus and recipes, maintain cleanliness, and provide timely service. However, the facility was without a dietary manager, leaving the Administrator responsible for overseeing the dietary staff. The Dietary Consultant noted that the current menus were difficult to follow due to being pieced together by a previous manager, and the dietary staff should have been following recipes to ensure proper meal preparation.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food to residents at an appetizing temperature, as observed through interviews and record reviews. Residents who ate meals in their rooms reported that the food was often cold when served. The facility did not provide a policy for food temperatures upon request, and the dietary cook's job description required recording food temperatures for each meal. However, the facility's Tray Line Food Temperatures records showed that no food temperatures were taken for several meals over multiple days, indicating a lack of adherence to the policy that hot foods should be 135 degrees Fahrenheit or greater and cold foods should be 41 degrees Fahrenheit or less. Observations on a test tray revealed that the food was not served at the appropriate temperatures, with a turkey burger on a bun at 92 degrees Fahrenheit and potato wedges at 90 degrees Fahrenheit. Additionally, the tray was missing several items listed on the menu, such as chicken and rice soup, apple slaw, and dessert. Interviews with residents confirmed that the food was usually cold when received in their rooms. The dietary consultant stated that food temperatures should be taken before meals are served, and the Administrator acknowledged the issue, noting that the Dietary Manager had recently quit, leaving her to oversee the kitchen until a new manager was hired.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement a policy for Enhanced Barrier Precautions (EBP) to reduce the transmission of multi-drug resistant organisms (MDROs) among residents. The existing policy for isolation and transmission-based precautions did not address EBP, including criteria for placement, required personal protective equipment (PPE), or whether residents needed to be in isolation or private rooms. This deficiency was observed in the care of four residents who met the criteria for EBP due to conditions such as indwelling catheters, pressure ulcers, and feeding tubes. Interviews with staff, including the Director of Nursing, Licensed Practical Nurses, Certified Nurse Aides, and the Assistant Director of Nurses, revealed a lack of awareness and understanding of EBP. Staff members were not consistently using PPE when providing care to residents who required EBP, and there was no signage or clear instructions on when and why PPE should be used. Some staff members were unaware of what EBP meant, and there was no facility policy to guide them in implementing these precautions. Observations of the residents' rooms showed a lack of signage indicating the need for PPE and the absence of PPE supplies readily available for staff. Residents with indwelling catheters and pressure ulcers did not have care plans addressing EBP, and there were reports of staff not adhering to infection control practices, such as wearing gloves when handling urinary catheters. The Director of Nursing acknowledged the absence of a specific EBP policy, relying instead on the general contact isolation policy, which was insufficient to address the specific needs of residents requiring EBP.
Rodent Infestation in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents in the kitchen. Observations revealed numerous instances of rodent feces on various surfaces, including a stainless steel preparation table, a cart with plate covers, under the main steam table, and around a large trash can. Food particles and rodent feces were also found under the stove, beverage dispenser, and on the floor behind the refrigerator. The Dietary Manager acknowledged the ongoing issue with mice, which had been reported to the Administrator and Maintenance Director. Despite efforts to keep the kitchen clean, a shortage of staff was noted. Interviews with the Maintenance Director, Registered Dietician, and Administrator confirmed awareness of the rodent problem. The Maintenance Director mentioned that the pest control company had been involved, placing traps and spraying outside, but the issue persisted, particularly in the past three weeks. The Registered Dietician's monthly inspections consistently reported a dirty kitchen with mouse droppings, and these reports were shared with key facility personnel. The Administrator attributed the problem to nearby construction and stated that treatment efforts were ongoing. The Medical Director emphasized the importance of maintaining a clean kitchen to prevent rodent infestations.
Medication Mismanagement in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications were not left in resident rooms without proper orders for self-administration, affecting three residents out of a sample of thirteen. Resident #2 was found with a container of Nystatin Powder in their bathroom, labeled with another resident's name, and the resident reported that staff occasionally applied the powder but had not done so recently. Additionally, an opened bottle of artificial tears with no label or resident name and an expired date was found in a shared bathroom, with the Assistant Director of Nursing unable to identify the owner of these items. Resident #4's room contained an opened bottle of Clear Eyes eye drops and a container of Mineral Cream, both without proper labeling or orders for use, and the resident was unaware of how these items came to be in their room. Resident #10 was observed with a tube of triple antibiotic ointment labeled with another resident's name, and there was no order for its use. The Director of Nursing confirmed that medications should not be left in resident rooms without orders for self-administration and that staff should only use medications with the correct resident name on the label.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate services to a resident diagnosed with dementia, leading to a deficiency in care. The resident exhibited behaviors affecting themselves and others, but the facility did not evaluate or implement further approaches to address these behaviors. Instead, the resident was administered anti-anxiety and psychotropic medications without attempting alternative interventions first. Despite an order for a psychiatric consultation due to increased behaviors, the facility failed to schedule the consultation, resulting in continued behavioral issues and increased medication administration. The resident's care plan included interventions for cognitive impairment and psychosocial behavior, but these were not effectively implemented or adjusted in response to the resident's needs. The resident's behaviors, such as verbal and physical aggression, exit-seeking, and agitation, were documented, but there was a lack of documentation regarding alternative interventions before administering medications. The facility's policies emphasized non-pharmacological interventions and the involvement of the interdisciplinary team, but these were not adequately followed. Interviews with facility staff revealed a lack of communication and follow-through regarding psychiatric consultations. The former DON had been working on a contract with psychiatry, but after their departure, no further actions were taken. The Medical Director acknowledged that medications should be reviewed for behaviors and alternative interventions should be used before administering intramuscular medications. The facility's failure to adhere to its policies and ensure timely psychiatric consultation contributed to the deficiency in care for the resident.
Unlicensed Acting Administrator in Facility
Penalty
Summary
The facility failed to comply with state laws by not designating a person as an administrator who is currently licensed in the state as a nursing home administrator. This deficiency was observed during a survey when it was noted that the facility did not have a current administrator's license displayed, although the facility's license to operate and various association memberships were visible. The acting administrator, who had been in the role for about a week, admitted during an interview that he did not hold a license to be an administrator in the state of Missouri. He also acknowledged that he had not contacted the state licensing board or the state regulatory agency to obtain a temporary license, nor was he or his company aware that such a temporary license could have been applied for prior to his appointment as acting administrator. This oversight had the potential to affect all 118 residents of 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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