St Peters Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Peters, Missouri.
- Location
- 230 Spencer Road, Saint Peters, Missouri 63376
- CMS Provider Number
- 265589
- Inspections on file
- 27
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Peters Rehab And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including paraplegia and known osteomyelitis, was admitted with multiple pressure ulcers, including a Stage 4 sacral ulcer. The wound care physician documented signs of infection, ordered a deep wound culture, and recommended adding mupirocin 2% topical, but no corresponding order or administration of mupirocin appeared on the MAR/TAR for several days. The sacral tissue culture later grew multiple pathogens and listed systemic antibiotic options and mupirocin ointment, yet the results were not entered into the resident’s record, not communicated to the primary physician or hospice, and not used to adjust treatment. Required weekly wound documentation and skin assessments were not completed, the canceled wound care visit was not reported to the physician or family, and hospice was not informed that a culture and bone biopsy had been performed. A mupirocin order was finally entered after the resident had already been transferred to the hospital, where labs showed severe leukocytosis and elevated lactate consistent with sepsis, and the family reported ICU care and surgeries for the infected sacral ulcer.
A resident with significant cognitive and physical impairments was physically abused by a CNA who aggressively moved and handled the resident during care, resulting in the resident yelling for help, expressing fear, and sustaining multiple bruises. The incident was witnessed by an LPN and other staff, who intervened and confirmed the rough treatment and resulting injuries.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
Staff failed to follow infection control policies, including hand hygiene and Enhanced Barrier Precautions (EBP), for multiple residents with wounds, indwelling catheters, and enteral tube feedings. Staff did not consistently use PPE or change gloves as required, and EBP signage was not posted or implemented in a timely manner. Interviews revealed a lack of awareness and inconsistent application of infection prevention protocols.
A resident with impaired balance and functional limitations was left unattended in the shower room by a nurse aide who assumed the resident was independent. The resident attempted to dress themselves, lost balance, and fell, resulting in a right hip fracture. The care plan required one staff assist for bathing and dressing, which was not followed, leading to the incident.
Three residents in an LTC facility experienced significant delays in call light responses, with activations lasting from 18 minutes to over an hour. A resident with dementia and muscle weakness, another with multiple sclerosis, and a third with COPD and mobility issues all reported inadequate response times. Staff interviews revealed an expectation for call lights to be answered within five to fifteen minutes, yet documented response times exceeded these expectations.
The facility failed to obtain physician orders and conduct proper assessments for two residents with surgical wounds. One resident was admitted with fractures requiring surgical repair, but there were no specific orders to monitor the surgical sites. Another resident experienced a fall resulting in a hip fracture and surgery, but the facility did not clarify orders for surgical site care upon readmission. Additionally, the facility did not complete neurological checks per policy following the fall. Interviews with staff revealed inconsistencies in following facility policies for skin assessments and post-fall procedures.
The facility failed to provide adequate staffing, resulting in unmet hygiene and toileting needs for residents. Insufficient staff led to residents not being showered, cleaned, or having their hair and nails maintained. Additionally, call lights were not answered promptly, causing unmet toileting needs and episodes of incontinence. The facility also lacked staff to maintain cleanliness and prevent odors, affecting several residents.
The facility did not ensure that resident rooms and living spaces were clean and in good repair, compromising the residents' right to a safe and homelike environment. This deficiency was identified through observation, record review, and interviews, affecting the facility's 81 residents.
The facility failed to follow physician orders for three residents, including not administering insulin to a resident, resulting in a blood sugar level of 499. The staff did not identify the missed dose, notify the physician, or continue assessing the resident. Additionally, medications were not provided as ordered, and the physician was not contacted for further instructions when orders could not be followed.
The facility failed to ensure that food served to residents was palatable and at a safe, appetizing temperature. This deficiency, affecting a facility with a census of 81, remains uncorrected as noted in a previous report.
The facility did not ensure that two residents who needed help with ADLs received the necessary care to maintain good grooming and personal hygiene. This deficiency was identified through observation, interview, and record review, and remains uncorrected.
The facility failed to provide necessary interventions to address weight loss for two residents, including not administering physician-ordered supplements and not following RD recommendations. This deficiency was identified through observation, interview, and record review, affecting the residents' nutritional status and health.
The facility failed to protect two residents from abuse and neglect. One resident was left in bed without assistance and threatened by staff, while another was pushed by a CNA and left in a soiled brief overnight. Both incidents were reported, but no immediate action was taken.
The facility failed to ensure allegations of neglect were reported to supervisors and/or the facility's Abuse Coordinator for two residents. One resident reported a CNA's refusal to help her get out of bed, and another reported a night shift aide's refusal to provide incontinent care. Both incidents were not reported to the appropriate authorities as required by facility policy.
A resident with chronic pain conditions did not receive prescribed pain medication for three days due to an unavailable prescription refill. The facility failed to assess the resident's pain, attempt non-pharmacological interventions, or notify the DON, resulting in significant pain and harm to the resident.
The facility failed to ensure that the Activities Program was directed by a qualified professional. The Activity Director (AD) did not possess the required credentials and was not certified. The AD admitted to not maintaining activity participation records or documenting activity progress, as required by the facility's policy. The Administrator acknowledged that not all responsibilities of the AD were being fulfilled and was in the process of evaluating staff.
The facility failed to provide adequate and competent nursing staff, leading to residents not receiving medications, having call lights unanswered, and experiencing unmet needs for ADLs. Weekend staffing was particularly problematic, with frequent shortages confirmed by staffing records. Residents reported long wait times for assistance and unresponsive agency staff, despite repeated complaints in resident council meetings.
The facility failed to ensure nourishment refrigerators were clean and that temperatures were checked. Observations revealed spilled juice and unlogged temperatures in the refrigerators. The Dietary Manager was unaware of the responsibility for these tasks, potentially affecting all 82 residents.
The facility failed to ensure that the Infection Prevention and Control Program was overseen by a qualified Infection Preventionist who had completed specialized training. The IP had only completed a one-day course, which did not cover the comprehensive topics recommended by CMS and CDC, potentially affecting all 82 residents.
The facility failed to provide an adequate supply of bariatric incontinent briefs for three residents, leading to discomfort and the need to borrow briefs from others. The Central Supply Clerk admitted that the facility had recently changed suppliers and had not updated the list of sizes needed, contributing to the supply issues. Review of supply invoices revealed insufficient orders, resulting in an average of only five briefs per day per resident.
The facility failed to address grievances raised by the resident council, including issues with call lights, staff not introducing themselves, staff not responding to residents' needs, staff talking on their phones, and food palatability. Despite repeated concerns over several months, there was no formal process to resolve these issues, leading to ongoing resident dissatisfaction.
The facility failed to ensure that residents and/or their representatives received written information about and assistance with formulating advance directives for three residents reviewed. Documentation and interviews revealed that advance directives were not reviewed or provided to the residents, contrary to the facility's policy.
The facility failed to provide sufficient activities for residents, including not offering activities on weekends or outings, not documenting activity participation, and not completing quarterly activity progress notes. One resident expressed dissatisfaction with the activity program, and observations confirmed a lack of engagement. A resident council group interview revealed a desire for more activities, especially on weekends. The Activity Director admitted to not documenting attendance and being the only activity employee for 82 residents.
The facility failed to provide adequate fluids to several residents, including one with multiple health conditions who did not have a nutritional assessment completed. Observations and interviews revealed that residents frequently did not have access to ice water or preferred beverages, and staff did not consistently check water pitchers as required.
The facility failed to ensure that three residents received services in a manner that promoted their dignity and enhanced their quality of life. One resident was found with long stubble facial hair and soiled clothing, while two other residents were assisted with eating by staff standing over them, contrary to facility policy. Interviews and observations revealed that staff did not follow proper protocols, impacting the residents' dignity and quality of life.
A resident, who was cognitively intact, was not allowed to make their own decision regarding the use of a cell phone sent to them for communication. The facility opened the resident's mail, contacted the resident's POA, and followed the POA's instructions to not give the phone to the resident, leading to the resident's inability to communicate with their girlfriend and causing depression.
The facility failed to invite two cognitively intact residents to their care plan meetings, despite their expressed interest. Both residents had BIMS scores indicating cognitive intactness, but there was no documentation that they were invited or attended their care plan meetings. The facility did not adhere to its policy requiring resident and family invitations to care planning meetings.
A resident was moved to a different room without receiving the required written notice. The facility's policy mandates written notice and documentation for room changes, but the resident was only verbally informed, and no documentation was made in the EMR.
A resident reported a missing brooch, but the facility failed to document the grievance, conduct a thorough investigation, or inform the resident of the outcome. The Social Services Director contacted the resident's family, who stated the brooch never existed, but did not document informing the resident. The Assistant Director of Nursing and SSD admitted to lapses in following the grievance policy.
The facility failed to provide a bed hold notice within 24 hours of an emergent hospital transfer for a resident with multiple diagnoses, including Alzheimer's disease and diabetes. The oversight was confirmed by the Regional Nurse Consultant, placing the resident and their responsible party at risk of not knowing to request a bed hold.
The facility failed to provide adequate ADL care for a resident dependent on staff for personal hygiene and toileting. Despite being admitted with chronic kidney disease stage III and dementia, the resident did not receive a shower until nearly three weeks after admission. Interviews and record reviews confirmed the lack of documented evidence of showers being provided, highlighting a significant lapse in care.
A resident with a history of unsafe smoking practices and medical conditions that impaired her ability to handle cigarettes safely was observed smoking without a required smoking apron. Despite incidents of cigarette burns and a facility policy mandating the use of a smoking apron, staff were unaware of her need for the apron, and there was no documentation of her refusal to wear it or staff education on the matter.
The facility failed to ensure proper care for a resident with an indwelling catheter, leading to potential risks of urinary tract infections. The resident's urinary drainage bag was repeatedly observed touching the floor or floor mat, and the catheter tubing was often improperly secured. An LPN acknowledged the need for a new securement device and repositioned the tubing, but incorrectly stated that the privacy covering protected the drainage bag, indicating a misunderstanding of the facility's policy.
The facility failed to maintain oxygen therapy equipment for a resident with acute respiratory failure, resulting in unchanged and undated oxygen tubing, a dusty concentrator filter, and an improperly dated humidifier bottle. Staff interviews revealed lapses in responsibility and supply issues.
The facility failed to provide medically-related social services for three residents. One resident was not given a room change notice and had only one set of clothing for a week. Another resident was not allowed to decide about his phone, with the SSD following the POA's wishes. A third resident was not invited to his care plan meeting, with the SSD failing to document the invitation. The SSD was the only social services employee and was often assigned direct care tasks.
The facility failed to provide medications as ordered by the physician for two residents, leading to unmanaged pain for one resident and inadequate diabetes management for another. The DON admitted that the facility's policies were not followed, and there was a lack of communication and documentation regarding the residents' medication needs.
The facility failed to maintain a medication error rate below five percent, resulting in an 8 percent error rate. A resident did not receive prescribed medications Myrbetriq and Allegra due to errors in medication administration and handling. The medications were either not included in the prepared medications or misplaced on the wrong medication cart.
The facility failed to lock and secure medication and treatment carts and maintain medication refrigerator temperature logs. An LPN left a treatment cart unlocked and unattended, and another LPN left a medication cart unlocked and out of sight. The medication room was found with spillage, debris, and incomplete temperature logs. The DON could not explain the missing documentation.
The facility failed to ensure condiments were offered and served with meals for three residents. One resident reported not receiving condiments with her breakfast, another found her lunch unpalatable without salt and pepper, and a third noted inconsistent availability of condiments like tartar sauce, butter, and mayonnaise. The Dietary Manager confirmed that condiments should be offered to residents per their diet.
Failure to Follow Wound Care Orders and Communicate Culture Results for Infected Stage 4 Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure wound care services met professional standards for a resident with a Stage 4 sacral pressure ulcer and known osteomyelitis. The resident was admitted with multiple serious conditions including multiple sclerosis, paraplegia, diabetes, and osteomyelitis of the vertebra, sacral, and sacrococcygeal regions, and had multiple pressure ulcers documented on the care plan. Facility policy required licensed nurses to perform admission, readmission, weekly, and as-needed skin assessments, notify the attending physician and IDT of wounds that worsened or did not respond to treatment, obtain and monitor labs and diagnostics as ordered, and document wound status and treatment effectiveness at least weekly. Despite these policies, the facility did not consistently follow physician orders, did not complete required weekly wound documentation, and did not ensure that diagnostic results and wound status were communicated to appropriate providers. On 01/13/26, the wound care provider assessed the resident’s Stage 4 sacral ulcer, documented poor healing potential, moderate exudate, signs of clinical infection, and recommended continuing current treatment. On 01/20/26, the provider reassessed the sacral wound, noting it had increased in size, had moderate serosanguinous exudate exacerbated by infection, and again documented one or more signs of clinical infection. The provider performed fluorescence imaging, recommended adding mupirocin 2% topical twice daily, and ordered a deep wound culture. However, review of physician orders, the MAR, and the TAR from 01/20/26 through 01/29/26 showed no order for mupirocin and no documentation that mupirocin was applied. Interviews later revealed conflicting accounts: the regional nurse stated a nurse practitioner had ordered mupirocin on 01/20/26, while the NP denied ever seeing the wounds or ordering mupirocin. The regional wound nurse indicated that if the order was written in the wound provider’s note, the facility wound nurse should have checked the report the next day and followed through, but this did not occur. A wound culture of the sacral tissue collected on 01/20/26 and reported on 01/23/26 identified multiple pathogens, listed first-line and alternative systemic antibiotic options, and included mupirocin 2% ointment as an additional option. A handwritten note on the report stated "will see during next rounds" with initials, but the culture results were not entered into the resident’s medical record between 01/21/26 and 01/30/26, and there was no documentation that the primary physician, hospice, or IDT were notified of the culture findings. The DON reported she could not find culture or biopsy results in the record, and the wound nurse stated she did not obtain the culture results until surveyors asked questions, at which point she found the wound provider’s notes in the electronic record. The hospice RN, who assumed wound care on 01/26/26 based on measurements and treatment orders provided by the facility LPN, was not informed that a culture or biopsy had been done and stated that, had the culture report been shared, hospice would have consulted their physician about starting antibiotics. During the period from 01/21/26 through 01/30/26, there was no further documentation of the sacral wound in the resident’s medical record, despite facility policy requiring at least weekly wound documentation and documentation of changes in skin condition. The wound care provider did not return the week of 01/26/26 due to weather, and the LPN did not notify the primary physician or responsible party of the canceled visit or any change in wound status. The biopsy of the sacrum collected on 01/20/26, later reported on 02/04/26, confirmed acute and chronic osteomyelitis, but this result was not present in the facility record during the relevant period and was not communicated to hospice. On 01/30/26, an order for mupirocin 2% to the sacrum with daily dressing changes was finally entered, but the TAR showed the resident was already in the hospital on those dates. Hospital lab results from 01/30/26 documented markedly elevated WBC and neutrophil counts and an elevated lactate level consistent with sepsis, and the family reported the resident required ICU admission, IV antibiotics, and multiple surgeries for the infected sacral ulcer. Facility leadership, including the administrator and medical director, stated they would have expected all lab results, cultures, biopsies, and wound care provider orders to be reviewed, communicated, and followed, but this did not occur in this case.
Resident Physically Abused During Care by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) physically abused a resident during care. The CNA aggressively moved the resident in bed without explanation, causing the resident to yell for help and report pain. The resident, who had significant medical conditions including flaccid hemiplegia, contractures, generalized anxiety disorder, and Alzheimer's disease, was tearful, upset, and expressed fear of the CNA following the incident. The resident was dependent on staff for bed mobility and toileting, had impaired cognition, and was known to bruise easily due to underlying hematological issues. The incident was witnessed by a licensed practical nurse (LPN), who observed the CNA handling the resident roughly, rolling and moving the resident without communication, and using excessive force. The LPN intervened after the resident screamed for help, instructing the CNA to stop and leave the room. Additional staff entered the room after hearing the resident's distress, and they took over the resident's care. The resident was found to be partially undressed and covered only by a sheet, and the CNA's actions resulted in the resident being placed dangerously close to the edge of the bed and in the spread of feces throughout the room. Subsequent assessments and interviews confirmed the resident sustained multiple bruises to the right arm, as documented in the facility's skin assessments and corroborated by photographs provided by the resident's next of kin. The resident consistently reported being hurt and scared by the CNA, and staff interviews supported the account of rough and aggressive handling. The deficiency was identified based on direct observation, staff and resident interviews, and review of medical records and skin assessments.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement and Enforce Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Nursing staff failed to perform appropriate hand hygiene and change gloves during the provision of care for a resident who was dependent on staff for toileting and personal hygiene, incontinent of bowel and bladder, and had open wounds. Staff provided incontinent care, handled soiled linens, and touched various surfaces without removing gloves or performing hand hygiene as required by facility policy. Additionally, staff did not wear gowns or follow Enhanced Barrier Precautions (EBP) during high-contact care activities, and there was no signage posted to alert staff to the need for EBP. Multiple residents with conditions such as wounds, indwelling catheters, and enteral tube feedings were not properly identified for EBP, and staff did not consistently use personal protective equipment (PPE) as required. For example, a resident with an indwelling catheter and a wound infection was observed with catheter tubing and bags touching the floor, and staff failed to don gowns when providing care. Another resident with third-degree burns and an indwelling catheter was not placed on EBP, and staff entered the room and provided care without PPE or appropriate signage. Interviews with staff revealed a lack of awareness regarding EBP requirements and inconsistent implementation of infection control policies. The Assistant Director of Nursing/Infection Preventionist acknowledged delays in identifying residents who met criteria for EBP and confirmed that nurses were expected to implement precautions upon admission or when criteria were met. The Director of Nursing and Administrator both stated that staff were expected to follow hand hygiene and EBP policies, but observations and interviews demonstrated that these protocols were not consistently followed.
Resident Left Unattended in Shower Room Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and prevent injury for a resident when staff left the resident unattended in the shower room. The resident, who required assistance for bathing, hygiene, and dressing due to impaired balance and functional limitations, was left alone by a nurse aide who assumed the resident was independent. The resident attempted to dress themselves, lost balance, and fell, resulting in a right hip fracture. The resident's care plan indicated the need for one staff assist for bathing and dressing, which was not followed. The resident was found on the floor after calling for help, having attempted to pull up their pants without assistance. The resident experienced pain and was later diagnosed with a right hip fracture, requiring hospitalization and surgery. Interviews with staff revealed a lack of awareness regarding the resident's need for assistance, and the nurse aide admitted to leaving the resident alone in the shower. The Assistant Director of Nursing and Director of Nursing confirmed that the resident should not have been left alone, and the care plan should have been followed to ensure the resident's safety.
Removal Plan
- Conducted an investigation.
- Notified appropriate parties.
- Educated all facility staff on assistance with showers, to provide assistance with showers per care plan.
- Inserviced all staff.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner for three residents, leading to significant delays in providing necessary assistance. Resident #12, who has dementia, arthritis, and muscle weakness, experienced multiple instances where the call light was activated for extended periods, ranging from 15 minutes to over an hour. The resident expressed frustration during an interview, stating that staff often took a long time to respond, requiring multiple activations of the call light before receiving help. Resident #3, diagnosed with multiple sclerosis and requiring substantial assistance for daily activities, also faced delays in call light responses. The call light log indicated several instances where the call light was activated for durations ranging from 18 minutes to over an hour. The resident reported that staff response times were inadequate, sometimes taking up to 30 minutes, and noted that staff occasionally turned off the call light without providing immediate assistance, leading to further delays. Resident #8, with chronic obstructive pulmonary disease and other mobility issues, experienced similar delays, with call light activations lasting from 18 minutes to over an hour. The resident noted that response times were particularly poor on weekends and that staff sometimes turned off the call light without returning promptly. Interviews with facility staff, including LPNs, RNs, and the Director of Nursing, revealed an expectation for call lights to be answered within five to fifteen minutes, yet the documented response times significantly exceeded these expectations.
Failure to Obtain Physician Orders and Conduct Proper Assessments
Penalty
Summary
The facility failed to clarify and obtain physician orders for two residents who sustained fractures and had surgery to repair them. Upon admission from the hospital, the facility did not complete the necessary assessments and treatments for the residents' surgical incisions. Specifically, one resident was admitted with fractures requiring surgical repair, but there were no specific orders to monitor the surgical sites on the left ankle or knee. The facility's records showed no documentation of assessments of the surgical sites or dressings, and the staff did not contact the physician for order clarification. Another resident experienced a fall in the facility, resulting in a hip fracture and subsequent surgery. Upon readmission, the facility did not clarify orders for the resident's surgical site care. The facility's records lacked documentation of assessments of the surgical wound dressing, and the staff did not contact the physician for clarification until two weeks after the resident's return. Additionally, the facility did not complete neurological checks per policy following the resident's fall, failing to conduct the required 72-hour monitoring. Interviews with facility staff, including LPNs, the Assistant Director of Nursing, and the Director of Nursing, revealed inconsistencies in following the facility's policies for skin assessments and post-fall procedures. Staff acknowledged the need for full skin assessments on admission and readmission, as well as the necessity to obtain wound care orders from physicians. The facility's failure to adhere to these protocols resulted in deficiencies in the care provided to the residents.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing and oversight, resulting in unmet hygiene and toileting needs for residents. Specifically, the facility did not have enough staff to ensure that residents requiring assistance were showered, clean, had their hair maintained, were shaved, and had their nails trimmed. Additionally, the facility did not respond to resident call lights in a timely manner, leading to unmet toileting needs and episodes of incontinence, with residents being left soiled for extended periods. The facility also lacked sufficient staff to maintain cleanliness and prevent odors within the facility. These deficiencies affected eight residents in a sample of 25, with a total facility census of 81.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents. This deficiency was identified through observation, record review, and interviews conducted by surveyors. The facility, with a census of 81 residents, did not ensure that resident rooms and living spaces were maintained in a clean and good state of repair. This failure compromised the residents' right to a safe and homelike environment, as required by regulations.
Failure to Follow Physician Orders for Medications
Penalty
Summary
The facility failed to adhere to physician orders for three residents, resulting in a deficiency. Resident #305 did not receive the prescribed insulin, leading to a blood sugar level of 499, which exceeded the physician's acceptable parameters. The staff did not identify the missed insulin dose, failed to document proper notification of the physician, and did not continue assessing the resident's condition. Additionally, the facility did not administer medications as ordered by the physician and did not contact the physician for further instructions when orders could not be followed. These failures were identified through observation, interview, and record review during the survey, with the facility census at 81.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained at a safe and appetizing temperature. This deficiency was identified through observation, interviews, and record reviews conducted by surveyors. The issue remains uncorrected, as noted in a previous Statement of Deficiency dated 4/12/24. The facility has a census of 81 residents, indicating that a significant number of individuals may be affected by this ongoing issue.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary care and services for two residents who required assistance with activities of daily living (ADL) to maintain good grooming and personal hygiene. This deficiency was identified through observation, interview, and record review. The issue remains uncorrected, as noted in a previous Statement of Deficiencies. The facility's census at the time was 81 residents.
Failure to Address Weight Loss in Residents
Penalty
Summary
The facility failed to provide adequate interventions to address weight loss for two residents, as observed through a review of 25 sampled residents. This included not providing physician-ordered supplements and not following registered dietician recommendations, which were necessary to prevent further weight loss. The deficiency was identified through observation, interview, and record review, and it affected the nutritional status of the residents, compromising their health. The facility census at the time was 81.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that two residents, R16 and R20, were free from abuse and neglect. On 4/7/24, CNA 7 refused to assist R16 out of bed, resulting in the resident remaining in bed until the next shift arrived. On 4/8/24, R16 used her call light to request help for repositioning, but no one responded. Two agency staff members later entered her room, accused her of calling too much, and one of them yanked the call light out of her hand, threw it on the floor, and threatened her. R16 reported these incidents to facility staff, but no action was taken, and CNA 7 continued to work on R16's hall on 4/9/24, placing the resident at risk for continued abuse and neglect. R20 experienced similar neglect and abuse. On 4/7/24, the CNA assigned to R20 refused to help her get out of bed, told her to hurry up, and pushed her. When R20 asked the CNA not to push her, the CNA told her to hurry up. R20 felt this was mental abuse but did not report it. On 4/8/24, the night shift aide refused to help R20 into bed and provide incontinent care, leaving her in her wheelchair until 3:00 AM. R20 attempted to change her own brief but could not reach it and remained in the same brief until the day shift when NA1 changed it. R20 reported this incident to NA1, who confirmed the neglect but did not take further action. The facility's policy on abuse prevention and prohibition was not followed, as staff failed to report and address the allegations of neglect and abuse. The facility census was 82, and the administrator was notified of the Immediate Jeopardy on 4/9/24. The facility provided an acceptable plan for removal of the immediate jeopardy on 4/11/24, and the survey team validated the removal on the same day. However, the deficient practice remained at a D scope and severity following the removal of the immediate jeopardy.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to ensure allegations of neglect were reported to supervisors and/or the facility's Abuse Coordinator for two residents. Resident 16, who was cognitively intact and required substantial assistance with transfers, reported that a CNA refused to help her get out of bed and was verbally dismissive. The resident remained in bed until the evening shift when she was assisted by an LPN and another CNA. The LPN did not report the allegation to the on-call supervisor, the Director of Nursing, or the Administrator, who was the facility's Abuse Coordinator, despite being aware of the facility's policy to do so immediately. Similarly, Resident 20, who was also cognitively intact and required moderate assistance with transfers, reported that a night shift aide refused to help her into bed and provide incontinent care, leaving her in the same brief until the day shift. The resident reported the incident to a Nurse Aide, who also failed to report the allegation to her supervisor or the facility's Abuse Coordinator. The Administrator confirmed that he had not been informed of any allegations of neglect related to these residents, despite the facility's policy requiring immediate reporting of such incidents.
Removal Plan
- The facility will re-educate all staff on the Abuse Prevention and Prohibition Program policy, emphasizing the importance of immediate reporting of any allegations of abuse, neglect, or theft.
- The facility will conduct in-service training sessions for all staff members to ensure they understand their roles as Mandatory Reporters.
- The facility will implement a system to ensure that all allegations of abuse, neglect, or theft are reported to the appropriate supervisors and the facility's Abuse Coordinator.
- The facility will audit compliance with the reporting policy by conducting random interviews with residents and staff to ensure that any allegations are being reported and addressed.
- The facility will review and revise, if necessary, the current policies and procedures related to abuse, neglect, and theft to ensure they are comprehensive and up-to-date.
- The facility will ensure that the Administrator, Director of Nursing, and other key personnel are informed of any allegations of abuse, neglect, or theft.
- The facility will monitor and document the implementation of these corrective actions to ensure ongoing compliance and effectiveness.
Failure to Provide Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident (R20) who was without pain medication for three days. R20, who had diagnoses including poly osteoarthritis, polyneuropathy, chronic pain, and fibromyalgia, was prescribed hydrocodone-acetaminophen for pain relief. Despite the prescription, R20 did not receive the medication from 03/28/24 through 03/30/24 due to an unavailable prescription refill. During this period, there was no documented evidence that R20's pain level was assessed, nor were any non-pharmacological interventions attempted to alleviate her pain. Additionally, the Director of Nursing (DON) was not notified of the situation, which resulted in R20 experiencing significant pain without appropriate management or intervention from the staff. R20's medical records indicated that she was frequently in pain, with her pain occasionally interfering with daily activities. She rated her pain at a 9 on a zero to 10 scale. Despite this, the facility did not take necessary actions to manage her pain when the prescribed medication was unavailable. Interviews with R20 and staff confirmed that R20 experienced severe pain during the three-day period without her medication, and no alternative measures were offered to help manage her pain. The DON and Regional Nurse Consultant (RNC) were unaware of the situation until the surveyor's inquiry, indicating a lapse in communication and protocol adherence within the facility. The facility's policy on pain management required staff to assess and document pain levels and to notify the DON if pain medication was unavailable. However, these procedures were not followed in R20's case. The failure to provide timely pain management and to explore alternative interventions resulted in actual harm to R20, highlighting significant deficiencies in the facility's pain management practices and communication protocols.
Failure to Ensure Qualified Activity Director
Penalty
Summary
The facility failed to ensure that the Activities Program was directed by a qualified professional. The Activity Director (AD) did not possess the required credentials and was not certified, as verified by the Administrator. The AD, who was previously a certified nursing assistant (CNA), had been in the role for about a year and a half without obtaining the necessary certification. The AD admitted to not maintaining activity participation records or documenting activity progress in quarterly notes, as required by the facility's policy. The Administrator, who had been in his position for less than a month, acknowledged that not all responsibilities of the AD were being fulfilled and was in the process of evaluating staff, including the AD. The facility's policy required the Activity Director to develop individualized care plans, review and update them quarterly, and maintain accurate records of each resident's participation in activities. However, the AD was unaware of these requirements and did not document activity participation or progress. This lack of proper documentation and oversight created the potential for the activity program to not meet the needs, interests, and preferences of all 82 residents in the facility.
Inadequate Nursing Staff and Unmet Resident Needs
Penalty
Summary
The facility failed to ensure adequate and competent nursing staff were available to meet the needs of residents, resulting in several deficiencies. Residents reported not receiving their medications, having call lights unanswered, and experiencing unmet needs for activities of daily living (ADLs). Specific incidents included residents not receiving their evening medications, with one resident missing pain medication and another missing blood pressure medication, leading to concerns about potential health risks. Additionally, residents reported that agency staff were often unresponsive, did not introduce themselves, and were seen using earbuds and talking on their phones while providing care. These issues were repeatedly raised in resident council meetings but remained unresolved. Weekend staffing was particularly problematic, with reports of only two aides being available for the entire building on some occasions. Residents described long wait times for assistance with toileting and other needs, with one resident waiting up to four hours to be toileted. Another resident reported being left in a wheelchair for extended periods without being changed. The facility's staffing records confirmed frequent shortages, especially on weekends, with several instances of fewer CNAs working than scheduled. This led to delays in care and unmet needs for residents. The facility's policies required sufficient nursing staff to meet resident needs, but these were not adhered to. Interviews with staff and residents revealed that the facility often relied on agency staff who were not adequately trained or familiar with the residents' needs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issues but stated that staffing was considered adequate based on the facility's census. However, the persistent complaints and documented incidents indicated otherwise, highlighting a significant gap between policy and practice in ensuring resident care and safety.
Failure to Maintain Cleanliness and Temperature Logs in Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure nourishment refrigerators were free from grime and food residue and that temperatures were checked. Observations revealed that the nourishment refrigerator in the front dining hall had spilled juice at the bottom and contained two sandwiches, while the refrigerator in the back dining hallway contained three gallons of milk without temperature logs. During an interview, the Dietary Manager (DM) was unaware of the responsibility for checking temperatures and maintaining cleanliness, stating that their only job was to stock snacks and beverages. This failure had the potential to affect all 82 residents.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the Infection Prevention and Control Program (IPCP) was overseen by a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control (IPC). The IP had only completed a one-day course that awarded six contact hours, which did not cover the comprehensive topics recommended by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). The IP could not recall the specifics of the training and admitted to following instructions from her corporate boss without verifying the adequacy of the training. This deficiency had the potential to affect all 82 residents in the facility. During the survey, it was revealed that the Director of Nursing (DON), who had been employed for two months, had completed the CDC IP training and was actively involved in infection control activities. However, the IP had not completed the CDC's recommended training. The Regional Nurse Consultant (RNC) confirmed that the IP had started but not finished the CDC training. The facility's policy required the IP to coordinate and monitor infection control policies, but the lack of adequate training compromised the effectiveness of the IPCP.
Inadequate Supply of Bariatric Incontinent Briefs
Penalty
Summary
The facility failed to provide an adequate supply of bariatric incontinent briefs to meet the needs of three residents, all of whom were cognitively intact and required larger-sized briefs due to their medical conditions. Resident 4, admitted with severe obesity, reported that the facility frequently ran out of the required 3xl to 4xl briefs, leading to discomfort and the need to borrow briefs from other residents. Similarly, Resident 14, who had muscle weakness and difficulty walking, also experienced frequent shortages of the appropriate size briefs, causing discomfort and necessitating the use of smaller, ill-fitting briefs. Resident 20, suffering from polyarthritis, chronic pain, and fibromyalgia, reported similar issues with the facility's supply of bariatric briefs, often having to wear briefs that were too tight for comfort. Nurse Aide 1 confirmed that the facility had ample supplies of smaller briefs but frequently ran out of the larger sizes needed by these residents. The aide also mentioned that the Assistant Director of Nursing was informed about the shortages but would often respond that a new shipment was expected. The Central Supply Clerk (CS) admitted that the facility had recently changed suppliers and was still adjusting to the new sizing and ordering requirements. The CS also acknowledged that the list of sizes needed for each resident had not been updated to reflect the new supplier's products, contributing to the supply issues. Review of the supply invoices revealed that the facility had been ordering an insufficient number of bariatric briefs, with only two cases delivered weekly until the week of the survey, when the order was increased to five cases. This resulted in an average of only five briefs per day per resident, which was inadequate to meet their needs. The CS confirmed that the facility had recently increased the order to five cases per week but had not yet updated the list of sizes needed for each resident. The Regional Nurse Consultant confirmed the shortage of 3xl briefs during an inspection of the supply closet, further highlighting the facility's failure to adequately accommodate the needs of its residents.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure grievances raised by the resident council were addressed and attempts were made to resolve the grievances for six residents. The issues included call lights, staff not introducing themselves, staff not responding to residents' needs, staff talking on their phones, and food palatability issues. The facility's policy on grievances did not include specific information related to grievances expressed during the resident council meeting, leading to repeated unresolved concerns from the residents over several months. During a resident council group interview, all six residents stated that the issues raised in the resident council group did not get resolved and the same issues were presented repeatedly. Specific complaints included staff not introducing themselves, dietary issues such as too much rice and beans, and missing clothing. The residents expressed frustration over the lack of progress in addressing their concerns, despite the new Administrator attending a meeting and being aware of the issues. Interviews with facility staff, including the Social Service Director, Activity Director, Director of Nursing, and Assistant Director of Nursing, revealed a lack of a formal process to address grievances raised during resident council meetings. The staff acknowledged repeated concerns but did not initiate grievances for issues raised in the meetings. The Administrator, who had been employed for a month, stated that efforts were being made to address the concerns, including ensuring staff wore name tags and recruiting nursing staff to reduce reliance on agency staff.
Failure to Provide Information and Assistance with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received written information about and assistance with formulating advance directives for three residents reviewed. Resident 4, who was admitted with diagnoses including osteomyelitis, type 2 diabetes mellitus, and severe obesity, had no documentation in the electronic medical record (EMR) indicating that advance directives were reviewed or that the resident was provided education on the matter. The Social Services Quarterly Note for Resident 4 indicated no change in status but lacked evidence of review or involvement of the resident in the process. Similarly, Resident 16, admitted with diagnoses including contractures, difficulty walking, and hemiplegia and hemiparesis of the left side, also had no documentation in the EMR regarding advance directives. The Social Services Quarterly Note for Resident 16 showed no change in status but did not document any review of resident rights related to advance directives or involvement of the resident in the process. The Social Services Director (SSD) confirmed that advance directives were not reviewed with residents except during care plan meetings, and no education on advance directives was provided during these meetings. Resident 14, admitted with diagnoses including muscle weakness and difficulty in walking, also had no documentation in the EMR related to advance directives. The Social Services Quarterly Note for Resident 14 indicated no change in status but lacked evidence of review or involvement of the resident in the process. The facility's policy on advance directives required that residents be provided with information and assistance upon admission and that the Interdisciplinary Team annually review the advance directive with the resident or responsible party, but this was not followed as per the findings and interviews with the SSD and Regional Nurse Consultant.
Facility Fails to Provide Sufficient Activities for Residents
Penalty
Summary
The facility failed to ensure sufficient activities were provided to residents, including one sample resident and five supplemental residents. The deficiencies included not offering activities on weekends or outings, not documenting activity participation, not completing quarterly activity progress notes, and not developing a care plan for one resident as directed by the facility's policy. The facility's policy required a variety of activities to be offered daily, including weekends and evenings, and for activity participation to be documented daily. However, these requirements were not met, leading to a lack of engagement and stimulation for the residents involved. One resident, who was moderately cognitively impaired, expressed dissatisfaction with the activity program, stating that there was not much to do and that she stayed in her room a lot. Observations confirmed that this resident spent significant time in her room without engaging in activities. The Activity Director (AD) admitted to not documenting residents' attendance at activities and not completing quarterly assessments of activities for residents. The AD also confirmed that there were no scheduled activities on weekends and no outings being offered currently. A resident council group interview revealed that residents liked the AD and the activities offered but desired more activities, especially on weekends. They expressed a need for more bingo sessions, music during meals, and outings, such as trips to Walmart. The AD, who was also the van driver, stated that she was the only activity employee for the 82 residents in the facility, which contributed to the lack of scheduled activities and outings. The facility's failure to adhere to its activity program policy resulted in insufficient engagement and stimulation for the residents, impacting their overall well-being.
Failure to Provide Adequate Fluids to Residents
Penalty
Summary
The facility failed to provide adequate fluids to maintain the health of several residents, as observed during a survey. Specifically, two residents and four supplemental residents were not offered or provided with sufficient fluids such as ice water and other beverages. One resident, who was moderately cognitively impaired and had multiple health conditions including Parkinson's disease and chronic kidney disease, did not have a nutritional assessment completed by the Registered Dietitian since admission. This resident's fluid intake was inadequately documented, and observations revealed that the resident frequently did not have access to ice water or other beverages in her room despite expressing thirst and requesting water multiple times. During a resident council group interview, several residents expressed concerns about the availability of ice water and beverages in their rooms. They reported that they were rarely provided with ice water and often did not receive drinks they preferred, such as coffee, juice, and milk. Instead, they were routinely served Kool-Aid, and iced tea was not available. The facility's policy required CNAs to check water pitchers at the start of their shifts and every two hours, but this was not consistently done. Interviews with staff, including a CNA, LPN, and the Registered Dietitian, confirmed that the facility did not ensure residents had ice water available in their rooms. The Registered Dietitian acknowledged that full nutritional assessments had not been completed for all residents and that she was unaware of the residents' concerns about the lack of beverages. The Director of Nursing and Regional Nurse Consultant stated that the expectation was for residents to have ice water available in their rooms, which was not met in this case.
Failure to Promote Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to ensure that three residents received services in a manner that promoted their dignity and enhanced their quality of life. One resident was observed with long stubble facial hair and wearing clothing covered with food spills, residue, and crumbs. This resident required substantial assistance with personal hygiene and dressing but was found in a soiled state multiple times over two days. The staff did not document any refusals of care, and the resident's care plan did not specifically address shaving or identify any concerns with refusals of care. Interviews with staff revealed that the resident should have been shaved during showers, which were scheduled twice a week, but this was not consistently done. Additionally, the resident's clothing was not changed despite having clean clothes available in the closet, and the staff failed to maintain the resident's dignity by not addressing these issues promptly. Two other residents required assistance with eating, and facility staff were observed standing over them while assisting with meals. This practice was contrary to the facility's policy and the expectations set by the Registered Dietitian and the Director of Nursing, who stated that staff should be seated while assisting residents to create a homelike atmosphere. The observations and interviews indicated that the staff did not follow the proper protocol for assisting residents with meals, which compromised the residents' dignity and quality of life. The Director of Nursing and the Assistant Director of Nursing confirmed that staff should not stand over residents when assisting them with meals. The facility's failure to adhere to its own policies and procedures regarding resident care and dignity was evident in the observations and interviews conducted. The staff's inactions and lack of adherence to care plans and policies led to the deficiencies observed in the care provided to these residents, impacting their dignity and quality of life.
Failure to Respect Resident's Right to Make Decisions
Penalty
Summary
The facility failed to ensure that a resident retained their right to exercise their rights. The resident, who was cognitively intact with a BIMS score of 14, was not given the opportunity to make their own decision regarding the use of a cell phone sent to them for communication. The facility opened the resident's mail containing the cell phone, read a note inside the package intended for the resident, and contacted the resident's medical Power of Attorney (POA). The POA instructed the facility to not give the phone to the resident, even though the resident had not been adjudged incompetent by the court and legally retained his rights. The facility did not ask the resident if they wanted to keep the phone and instead followed the POA's instructions, which led to the resident not being able to communicate with their girlfriend, causing the resident to become depressed. Interviews with the Social Service Director (SSD) and a Licensed Practical Nurse (LPN) confirmed that the resident was cognitively able to make their own decisions and that the resident's phone was taken away based on the POA's instructions. The SSD admitted to opening the package containing the phone and contacting the POA without consulting the resident. The facility's Resident Rights policy and the resident's Admission Agreement both indicated that the resident had the right to make their own decisions unless deemed incapacitated, which was not the case for this resident. The failure to respect the resident's rights and autonomy led to a violation of the resident's dignity and self-determination.
Failure to Invite Cognitively Intact Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite two cognitively intact residents to participate in their care plan meetings, despite their expressed interest in doing so. Resident 11, who had a BIMS score of 15 out of 15, indicating cognitive intactness, was not invited to his care plan meetings. The Social Service Director (SSD) stated that the meetings were scheduled around the availability of Resident 11's Power of Attorney (POA), and there was no documentation that Resident 11 was invited or attended these meetings. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that there should have been documentation of the resident being invited and attending the care plan meetings, but such documentation was missing. Similarly, Resident 4, who also had a BIMS score of 15 out of 15, indicating cognitive intactness, was not consistently invited to her care plan meetings. Although she attended one care plan meeting in November 2023, there was no other documented evidence that she was invited, encouraged, or assisted in attending her care plan meetings. The SSD confirmed that there was no sign-in sheet or other documentation to show that Resident 4 was invited to or attended her care plan meetings. The facility's policy required that residents and their families be invited to care planning meetings and that efforts be made to schedule these meetings at convenient times. However, the lack of documentation and the failure to invite the residents to their care plan meetings indicate that the facility did not adhere to its own policy. Both the DON and the Administrator acknowledged that residents should be invited to their care plan meetings and that there should be documentation of their attendance, which was not done in these cases.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident (R43) before initiating a room change. R43, who was cognitively intact with a BIMS score of 15 out of 15, was moved from her room on the same day she was verbally informed of the change. The facility's policy requires that residents receive timely advance written notice of room changes, including the reasons for the change, but this was not followed in R43's case. The Social Service Director (SSD) admitted that the resident was only verbally informed and no written notice was provided. Additionally, there was no documentation in R43's electronic medical record (EMR) regarding the room change or the reasons for it, which included the resident releasing medical information to her roommate's friend and having alcohol in her room. Interviews with the SSD, Licensed Practical Nurse (LPN), Director of Nursing (DON), and Regional Nurse Consultant (RNC) confirmed that the facility's process for room changes involves notifying the resident's family first and then the resident, but this was done verbally and not in writing. The SSD and other staff members verified that R43 was moved without written notice and that the reasons for the move were not documented in the EMR. The facility's policy and the staff's statements indicate that residents should be notified 24 to 48 hours before a facility-initiated room change, but this protocol was not followed in R43's case.
Failure to Investigate and Communicate Grievance Outcome
Penalty
Summary
The facility failed to complete an investigation for a resident's grievance regarding a missing brooch. The resident, who was cognitively intact with a BIMS score of 15 out of 15, reported the missing brooch in January 2024. However, the facility's grievance logs for that period showed no documented evidence of the grievance. The resident's property inventory list did not include the brooch, and the Social Services Director (SSD) contacted the resident's family, who stated the resident never had a brooch. Despite this, the SSD did not document informing the resident of the investigation's outcome, and no grievance/complaint was filed as per the facility's policy. The Assistant Director of Nursing (ADON) and SSD both admitted to lapses in following the facility's grievance policy, and the resident confirmed that no one from the facility had met with her regarding the investigation. The facility's policy mandates prompt review, investigation, and resolution of grievances, with the findings communicated to the resident. In this case, the facility failed to adhere to its policy, as evidenced by the lack of documentation and communication with the resident. The SSD's unfamiliarity with the current grievance policy further contributed to the deficiency. The resident expressed frustration over the lack of communication and resolution, indicating a failure in the facility's grievance handling process.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice within 24 hours of an emergent transfer to the hospital for one resident. The resident, who was moderately cognitively impaired and had diagnoses including benign intracranial hypertension, Alzheimer's disease, diabetes mellitus type two with neuropathy, and adult failure to thrive, was transferred to the hospital due to altered mental status. Despite the facility's policy requiring written notification of bed hold duration, no such notice was given to the resident or their responsible party within the required timeframe. The deficiency was identified during a review of the resident's electronic medical record, which showed no documented evidence of a bed hold notice being provided at the time of the emergency transfer. The facility's Regional Nurse Consultant confirmed that no bed hold notice was issued. This oversight placed the resident and their responsible party at risk of not knowing to request a bed hold to ensure the resident's return to the facility.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident (R176) who was totally dependent on staff for personal hygiene and toileting. R176, admitted with chronic kidney disease stage III and dementia, did not receive a shower until nearly three weeks after admission. The resident's care plan indicated a self-care deficit, requiring substantial to maximum assistance with personal hygiene. Despite this, there was no documented evidence of showers being provided until 04/10/24, as confirmed by the resident's ADL sheet and shower/bath sheets. Family members also reported instances where the resident soiled himself due to lack of timely assistance to the bathroom and noted that the resident had not received a shower since admission. Interviews with staff, including a CNA and the Director of Nursing (DON), revealed that the resident had only received one shower since admission. The CNA confirmed giving the resident a shower on 04/10/24 but was unaware of any previous showers. The DON could not find any additional shower sheets for the resident, indicating a failure to provide the necessary ADL care as per the resident's care plan. This deficiency highlights a significant lapse in the facility's duty to ensure proper hygiene and care for its residents.
Failure to Ensure Resident Wore Smoking Apron
Penalty
Summary
The facility failed to ensure that a resident, identified as R16, was offered and wore a smoking apron to prevent accidents while smoking, as per her care plan. Despite the facility's policy requiring residents who are not able to smoke independently and safely to wear a smoking apron, R16 was observed smoking without the apron on multiple occasions. R16 had a history of unsafe smoking practices, including dropping lit cigarettes and causing a fire incident, which necessitated the use of a smoking apron for her safety. However, there was no documentation indicating that R16 refused to wear the apron or that staff were educated on what to do if she refused it. Additionally, staff members were not aware of R16's need for a smoking apron, as evidenced by their failure to identify her as requiring one during interviews. R16's medical history included muscle wasting and atrophy, need for assistance with personal care, contracture of the left hand, and hemiplegia and hemiparesis following a stroke. These conditions contributed to her inability to handle cigarettes safely. An incident note revealed that R16 had a blister on her left upper thigh from a cigarette burn, which she did not report to the staff. Despite this injury and her known unsafe smoking practices, R16 continued to smoke without wearing a smoking apron, and there was no documentation of any steps taken to address this issue. During observations, R16 was seen smoking without a smoking apron, and staff members supervising the smokers did not ensure she wore one. Interviews with R16 and other residents confirmed that she sometimes smoked without the apron. Staff members, including her assigned nurse and aide, were unaware of her need for a smoking apron. The facility's failure to ensure R16 wore a smoking apron and to educate staff on the necessary interventions for her safety led to the deficiency identified in the report.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter, leading to potential risks of urinary tract infections. The resident, who was severely cognitively impaired and totally dependent on staff for activities of daily living, had a urinary drainage bag that was repeatedly observed touching the floor or floor mat. The facility's policy required that the collection bag should not touch the floor and should be kept below the level of the bladder to prevent obstruction and kinking of the catheter tubing. However, observations over several days showed that the drainage bag was not properly positioned, and the tubing was often found lying on the floor or improperly secured to the resident's thigh. During an observation with an LPN, it was noted that the securement device on the resident's thigh was not properly attached, and the drainage bag was resting on the floor mat. The LPN acknowledged the need for a new securement device and repositioned the tubing to promote proper drainage. Despite these actions, the LPN incorrectly stated that the privacy covering protected the drainage bag, indicating a misunderstanding of the facility's policy. This series of observations and interviews highlighted the facility's failure to adhere to its own catheter care policy, potentially compromising the resident's health and safety.
Failure to Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to maintain oxygen therapy equipment for a resident, leading to deficiencies in the care provided. The resident, who was admitted with acute respiratory failure with hypoxia, had oxygen tubing and a humidifier bottle that were not changed or dated as required by the facility's policy. Additionally, the oxygen concentrator filter had a heavy accumulation of gray dust debris. Observations over several days revealed that the oxygen tubing remained unlabeled, the humidifier bottle was not changed timely, and the concentrator filter was not cleaned, despite the facility's policy and physician's orders specifying weekly maintenance. During an interview, a Certified Medication Technician (CMT) confirmed the condition of the equipment and stated that the night shift nurse was responsible for the maintenance tasks, which had not been performed. The CMT attempted to change the humidifier bottle but found that the central supply was out of the correct bottles. The Central Supply Clerk later confirmed that the current supply of humidifier bottles did not fit the oxygen concentrators and that new bottles would need to be ordered from another company.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services to ensure residents maintained their highest practicable wellbeing for three out of 28 sampled residents. One resident was not provided with a room change notice prior to a room change and had only one set of clothing to wear for a week following the room change. The Social Service Director (SSD) did not document the reason for the move or that the resident had moved in the resident's electronic medical record (EMR). Additionally, the SSD's questioning about who the resident notified about the lack of clothing made the resident uncomfortable, and the SSD did not follow through with the room change properly. Another resident was not given the opportunity to make his own decisions regarding the possession of his phone. The SSD followed the Power of Attorney's (POA) wishes without determining what the resident wanted. The SSD did not ask the resident if he wanted to keep the phone that was mailed to him by his girlfriend and instead contacted the POA, who instructed the SSD to retrieve the phone and send it back to the girlfriend. The SSD verified that the resident was his own decision-maker but did not act accordingly. A third resident was not invited to his care plan meeting; instead, the resident's family was invited, and the meeting was scheduled around the family's availability. The SSD stated that residents were also invited to their care plan meetings but did not document that the resident had been invited. The Assistant Director of Nursing (ADON) confirmed that the resident did not attend the care plan meetings. The SSD was the only social services employee and was routinely assigned to provide direct care service tasks, which may have contributed to these deficiencies.
Failure to Provide Medications as Ordered
Penalty
Summary
The facility failed to provide medications as ordered by the physician for two residents, leading to significant deficiencies in their care. Resident 20, who was admitted with diagnoses including polyosteoarthritis, polyneuropathy, chronic pain, and fibromyalgia, did not receive her prescribed hydrocodone-acetaminophen for pain management from 03/28/24 through 03/30/24. Despite the physician's orders and the facility's pain management policy, the medication was unavailable, and the staff failed to obtain a new prescription in a timely manner. This resulted in Resident 20 experiencing unmanaged pain, which she rated as a 9 out of 10 on a pain scale. The Director of Nursing (DON) and Regional Nurse Consultant (RNC) were unaware of the missed doses and did not follow the expected protocol of notifying the physician and providing alternative pain management options. Resident 4, who was admitted with diagnoses including osteomyelitis, type 2 diabetes mellitus, and severe obesity, did not receive her prescribed Ozempic for diabetes management on multiple occasions. The facility's records indicated that the medication was on backorder or unavailable, but there was no documentation that the physician was notified of the missed doses. Despite the medication being delivered to the facility on 03/18/24 and 04/08/24, there was no record of it being administered to Resident 4. The DON acknowledged that the physician had not been informed of the missed doses and that the resident should have been kept informed about the status of her medication. The facility's failure to provide the necessary medications as ordered by the physician and to follow proper protocols for reordering and notifying the physician of missed doses resulted in significant deficiencies in the care of both residents. The DON admitted that the facility's policies were not followed, and there was a lack of communication and documentation regarding the residents' medication needs. This led to unmanaged pain for Resident 20 and inadequate diabetes management for Resident 4, highlighting serious lapses in the facility's pharmaceutical services.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent, resulting in an error rate of 8 percent. During medication administration, two errors were made for a resident out of 25 opportunities. The errors involved the medications Myrbetriq and Allegra, which were not included in the resident's prepared medications. The Certified Medicine Technician (CMT) stated that the medications had not arrived from the pharmacy, and the Licensed Practical Nurse (LPN) was informed about the missing medications. However, it was later found that the Myrbetriq had been delivered but was placed on the wrong medication cart, and the Allegra was a stock medication that needed to be ordered with the stock medications. The resident involved had multiple diagnoses, including fecal impaction, pneumonitis, chronic kidney disease stage II, partial intestinal obstruction, and diabetes mellitus. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) stated that it was their expectation for nurses to notify the pharmacy in advance when a resident's medication was running low to avoid missed doses. Despite this expectation, the resident did not receive the prescribed medications due to the errors in medication administration and handling.
Medication Storage and Temperature Log Deficiencies
Penalty
Summary
The facility failed to ensure that medication and treatment carts were locked and secured, and that medication refrigerator temperature logs were maintained. Specifically, one treatment cart on the 400 hall was left unlocked and unattended with a tube of Santyl ointment and dressing supplies on top. The LPN responsible for the cart did not realize it was left unattended. Additionally, a medication cart on the 300 hall was found unlocked and unattended while the LPN was administering medications in a resident's room, out of the line of sight of the cart. These actions were in direct violation of the facility's policy on medication storage, which mandates that medication carts must be locked when not in use and not left unattended. Further observations revealed significant issues in the medication room on the front hall. The room had a large amount of dried purple spillage, dust, dirt debris, discarded breakaway locks, and paper trash on the floor. There was also a light brown dried residue next to the narcotic refrigerator. Additionally, the temperature logs for the medication refrigerator and freezer were incomplete, with no temperatures recorded for several days in March and April. The Director of Nursing was unable to explain the missing documentation and acknowledged that the spillage should have been cleaned up, indicating a lapse in maintaining a clean and safe medication storage environment.
Failure to Provide Condiments with Meals
Penalty
Summary
The facility failed to ensure condiments were offered and served with meals for three residents. During an initial tour, a resident who had been admitted a few days prior reported that no condiments were served with her meals. An observation confirmed that her breakfast tray lacked condiments such as salt, pepper, sugar, butter, and jelly. A CNA who set up the tray did not ask the resident if she needed anything else and later stated that residents could request condiments if they wanted them. Another resident, who was moderately cognitively impaired, reported that her lunch meal was terrible and that she was not offered salt or pepper, which she believed would have improved the taste of her meal. An observation confirmed that she had not eaten her meal except for the dessert, and she expressed a desire for salt and pepper to enhance the flavor of her food. A third resident, who was cognitively intact, participated in a resident council group interview and stated that the facility did not consistently serve condiments. She provided examples such as not receiving tartar sauce with fish, no butter being available, and a sandwich being served with only mustard and no mayonnaise. She also mentioned that salt and pepper were not always available. The Dietary Manager confirmed that residents who could have condiments per their diet should be offered them, indicating a lapse in the facility's adherence to its policy on providing nutritionally adequate and well-balanced meals that accommodate resident preferences.
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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