St Sophia Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Florissant, Missouri.
- Location
- 936 Charbonier Road, Florissant, Missouri 63031
- CMS Provider Number
- 265120
- Inspections on file
- 39
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at St Sophia Health & Rehabilitation Center during CMS and state inspections, most recent first.
A CNA confronted a resident and others for being outside to smoke without supervision, leading to a verbal altercation in which both the CNA and the resident yelled and exchanged remarks. During this exchange, the CNA took a metal fork from a meal tray and threw it toward the resident in the hallway, with the facility’s investigation documenting that the fork struck the resident’s arm, though no injury was noted. The resident had no cognitive impairment or documented behavioral symptoms on a recent MDS, and staff accounts varied on whether the resident typically displayed aggressive behavior. Multiple staff, including an RN, CMT, CNAs, and the ADON, stated that throwing a fork or any object at a resident constitutes abuse under the facility’s abuse policy, which defines abuse as the willful infliction of injury or punishment, including hitting or flicking with an object.
Two residents with significant medical and behavioral histories, including PTSD, MS, bipolar disorder, and a tracheostomy, were involved in repeated verbal and physical altercations in which one resident attempted to choke the other and the other resident pulled out the aggressor’s trach, causing a reddened neck and a knee bruise. Documentation and interviews showed conflicting accounts about how many incidents occurred and when, with some staff and leadership aware of only one event and others describing at least two separate encounters and prior verbal conflicts. The facility’s abuse investigation treated the situation as a single incident, did not clearly reconcile differing reports, and left staff unsure of the residents’ history with each other, demonstrating a failure to fully implement the abuse prevention policy’s requirement for thorough investigation of resident‑to‑resident abuse.
A resident with a PICC line and multiple comorbidities, including ESRD and a stage 4 sacral pressure ulcer, had physician orders and a care plan for weekly PICC dressing changes on the left brachial vein. MARs showed the dressing changes as completed on each scheduled date, and a progress note documented a dressing change on the same day as the survey. However, surveyors observed an old, lifting PICC dressing with an illegible date, and the resident could not recall when it was last changed. The ADON later confirmed the dressing appeared old and that the date might have been from a prior month, acknowledging that staff had documented weekly dressing changes as done when they had not been performed, resulting in failure to follow physician orders and professional standards of practice.
A resident with multiple sclerosis, a left tibia fracture, and a history of chronic pain had a standing order for scheduled oxycodone every four hours, but after a pharmacy change the facility failed to administer the ordered opioid for four days because the medication was not in stock and new prescriptions had not been processed. MAR entries and nursing notes documented repeated missed doses and ongoing unavailability of the drug, while the resident reported significant pain and was observed crying and overwhelmed. Staff acknowledged the pharmacy transition issues, reported giving only PRN acetaminophen and anxiety medication, and leadership confirmed that the resident should not have been without the ordered pain medication for that length of time.
The facility failed to honor residents’ financial rights by keeping resident personal funds in the facility’s operating account instead of a separate resident fund account and by not issuing timely refunds. Record review showed that dozens of residents had personal funds, ranging from small amounts to several thousand dollars, held in the operating account, including a large credit balance for a resident who had overpaid for services. Personal fund balance reports for multiple deceased residents were not sent to the state’s Medicaid division until after an investigation began. The BOM reported that a previous BOM had left without processing at least one refund, that refund requests for several residents were only later sent to the home office, and that some residents’ balances had been written off as bad debt rather than refunded.
A resident with multiple comorbidities, including paraplegia and osteoarthritis, had an order for Morphine Sulfate ER 60 mg q12h but no order or assessment to self-administer medications. Surveyors observed a brown pill and water left at the bedside with no staff present, which the resident then self-administered, contrary to facility policy requiring staff to remain until medications are swallowed and prohibiting leaving meds at the bedside. Later, during a skin assessment, an ADON found a white pill under the resident, initially assumed it was morphine, then crushed and disposed of it at the med cart; review of the narcotic box showed the pill was actually Oxycontin, a Schedule II opioid not prescribed to this resident, while another resident on the unit had Oxycontin. Staff interviews confirmed that controlled meds should not be left in the room and that the resident was not known to pocket or spit out medications.
A cognitively intact resident with quadriplegia and other medical conditions remained in a shared room for nearly four hours after a roommate was pronounced dead, while the deceased’s body remained in the room until removal by a funeral home. Staff closed the privacy curtain and likely the room door but did not ask the surviving resident if he/she wished to leave or if he/she was okay. The resident reported feeling very upset and uncomfortable. In interviews, an LPN, a CNA, the Administrator, and the DON all stated that staff are expected to remove or at least offer the option for a roommate to leave the room when a co-resident dies, and the Administrator and DON acknowledged that leaving the roommate in the room under these circumstances was not dignified.
Surveyors found that the facility did not meet professional standards when a resident with multiple comorbidities and a documented nutritional problem experienced significant weight loss and a dietician-requested reweight was never completed or documented, despite an established process for communicating reweight requests to the restorative aide. In a separate case, another resident with liver cancer and Alzheimer’s had oncology-ordered CBC/CMP labs that were marked complete, but the CMP specimen was reported as hemolyzed with instructions to reschedule, and facility staff did not ensure a timely redraw or communicate results to the oncology office, which ultimately had to perform the labs itself after the resident’s follow-up appointment was cancelled for transportation issues.
A resident with hemiplegia, HTN, and a sacral pressure ulcer had no EBP precautions ordered or care-planned despite multiple open areas, contrary to facility policy requiring gowns and gloves for high-contact care such as wound care. During an observed wound treatment, two LPNs performed high-contact wound care: one LPN donned gloves and a gown, while the other wore only gloves and did not use the gown made available, even while holding and positioning the resident during the procedure. The DON and Administrator later stated they expected staff to follow the EBP policy and for both nurses to wear appropriate PPE.
A staff member gave an after-visit summary containing PHI for a resident to the family of another resident, including details such as name, date of birth, and medical information. When notified of the error, the staff member showed indifference and did not retrieve the document, resulting in a breach of confidentiality.
Surveyors found that the facility did not maintain a homelike environment, as evidenced by unswept rooms, protruding screws on furniture, and dirty plates left in resident rooms for days. Additionally, due to a shortage of regular dining plates, residents were frequently served meals on Styrofoam plates, which led to dissatisfaction and complaints about food quality and temperature. Staff and supervisors acknowledged these issues and cited staffing shortages and supply problems as contributing factors.
A resident with opioid dependence and other medical conditions received Oxycodone for pain management. The facility lost one narcotic count sheet for a card of 30 Oxycodone tablets, resulting in no reconciliation for those doses. While the MAR showed administration of the medication, the required controlled substance documentation was incomplete, and staff interviews confirmed the missing record.
A resident with significant mobility and cognitive impairments, including hemiplegia, dementia, and legal blindness, was transferred by two CNAs using a gait belt instead of the ordered mechanical Hoyer lift. The transfer was performed with the wheelchair unlocked, and the resident showed signs of discomfort. Staff interviews confirmed that the resident's care plan and physician orders required use of a mechanical lift for all transfers, but this protocol was not followed.
A facility allowed an LPN, licensed only in Illinois, to work and provide direct care without a Missouri nursing license. The LPN performed duties such as medication administration, wound care, and care for residents with tracheostomies and tube feedings, often without direct supervision. HR did not verify the LPN's Missouri licensure status, and facility leadership was unaware of the issue until it was identified by a state surveyor.
Two residents with histories of aggression were involved in a physical altercation resulting in injury, but staff failed to conduct a thorough investigation or report the incident as required by the facility's Abuse Prevention Policy. Key witnesses were not asked for statements, and the event was not documented or reported to the State Survey Agency. Facility leadership acknowledged the lapse but could not explain the failure to follow policy.
A resident with multiple medical conditions experienced significant unplanned weight loss over a two-month period, but the facility failed to notify the physician or RD as required by policy. Documentation showed missed meal consumption records, lack of follow-up on hospital recommendations for nutritional supplements, and no evidence of assessment or intervention by the RD, despite the resident's ongoing weight loss and expressed concerns.
Staff failed to consistently notify physicians when residents' blood glucose levels exceeded ordered parameters and did not consistently document blood glucose levels or provide explanations for not administering insulin as indicated on the MAR. Several residents with diabetes experienced undocumented or unreported abnormal blood glucose readings, and staff interviews confirmed that required notifications and documentation were not always completed.
Several residents did not have access to oral care supplies or receive assistance with oral hygiene, despite care plans indicating the need for such support. Staff interviews confirmed that oral care was not consistently offered, and supplies were missing from residents' rooms. The DON and other staff acknowledged that oral care should be provided daily, but observations and resident reports showed this was not occurring.
Several residents with mobility limitations and restorative therapy plans did not receive prescribed ROM exercises and restorative interventions as ordered. Staff interviews and documentation revealed that the restorative aide was frequently reassigned to other duties, resulting in inconsistent delivery of restorative services. The DON and therapy staff were aware of the ongoing failure to provide restorative care as planned.
A resident with a history of bipolar disorder and anxiety, who was homeless and their own legal representative, was admitted to the facility and placed on a locked unit after expressing a desire to leave. The facility did not promptly develop a discharge plan, seek timely psychiatric evaluation for decision-making capacity, or document appropriate discharge planning efforts. Social services documentation was incomplete, and staff interviews revealed confusion about policies for guardianship and locked unit placement, resulting in a failure to provide necessary social services.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision, resulting in an increased risk of accidents for residents.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Two residents with cognitive impairment and toileting needs were denied access to their shared bathroom after staff removed the doorknobs, requiring them to rely on staff to access the main bathroom. Despite care plans and staff interviews lacking clear evidence of recent toilet clogging by these residents, both were left without independent bathroom access, leading to incontinence and use of inappropriate alternatives such as urinals and trash cans.
Staff did not maintain a safe, clean, and homelike environment for two residents with moderate cognitive impairment and incontinence issues. Their shared bathroom was left in unsanitary condition with missing doorknobs, soiled towels, and fecal smears, while one resident's room contained a trash can regularly used for urination. Housekeeping and maintenance staff were aware of these issues, and the facility's policy required prompt cleaning and reporting of such concerns.
A resident with severe cognitive impairment and a history of aspiration pneumonia was not provided with the prescribed pureed meat texture diet and nectar-thick liquids, leading to potential choking hazards. The resident's care plan failed to address the risk of aspiration, and staff did not provide adequate supervision during meals, resulting in the resident chewing on non-food items. Interviews revealed a lack of communication and understanding of the resident's dietary needs among facility staff.
The facility failed to maintain a clean and homelike environment for several residents, with issues such as unclean floors, dirty bedding, and empty soap dispensers persisting over multiple days. Residents expressed dissatisfaction, and housekeeping staff were uncertain about cleaning procedures, leading to deficiencies in maintaining a sanitary and comfortable environment.
Surveyors found expired medications and biologicals in two medication rooms and two medication carts at the facility. Expired items included ESwab kits, eye drops, allergy relief tablets, control solution, and zinc sulfate tablets. Staff interviews revealed no single person was responsible for auditing these areas, leading to lapses in compliance with the facility's Medication Storage policy.
The facility failed to maintain cleanliness in the kitchen, with observations of food debris, trash, and dust accumulation in various areas, including the walk-in refrigerator and freezer, kitchen floors, and preparation stations. Staff interviews revealed discrepancies in cleaning practices and expectations, contributing to the unsanitary conditions.
The facility failed to provide adequate ADL care for four residents, resulting in deficiencies in personal hygiene and grooming. A resident with severe cognitive impairment was observed with unwanted facial hair, while another had greasy hair and dirty hands. Two residents wore the same clothing over several days, with one reporting a lack of available clothing. Staff acknowledged expectations for cleanliness and care planning, but these were not met, as evidenced by observations and interviews.
A resident with communication and mobility impairments was left without access to their call light and was not assisted back to bed despite expressing a desire to do so. The resident, who had a history of stroke and required substantial assistance, was observed with their call light out of reach and was kept in a geri-chair against their preference. Staff interviews revealed a lack of adherence to the resident's care plan and rights, as the resident's needs and preferences were not adequately addressed.
A resident admitted to hospice with cerebrovascular disease did not have a significant change MDS assessment completed within the required 14 days. The MDS Coordinator, responsible for assessments, missed the change due to it not being listed on the electronic physician order sheet. The Administrator confirmed the expectation for timely completion of such assessments.
The facility failed to ensure accurate MDS assessments for two residents. One resident's hospice status and life expectancy were not documented, and another resident's fall was omitted from the MDS. The MDS Coordinator, responsible for all assessments, missed these critical details.
The facility failed to transcribe physician orders correctly for two residents, leading to discrepancies in tube feeding administration times. Additionally, a resident received crushed medications without a physician's order, as staff relied on an unofficial list instead of the MAR. Interviews revealed lapses in ensuring orders were accurately reflected in the MAR.
Two residents with COPD experienced deficiencies in oxygen therapy management. One resident self-adjusted their oxygen flow rate without staff awareness, and their pulse oximetry results were not documented. Another resident's nasal cannula was frequently found on the floor, with the oxygen concentrator left running. Staff interviews revealed inconsistencies in documenting and implementing physician orders, and infection control practices were not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, as required by CMS. Despite EBP signage and PPE availability, staff did not consistently wear gowns during high-contact care activities for residents with central lines, gastrostomy tubes, or wounds. Interviews revealed inconsistent understanding and implementation of EBP protocols among staff.
A facility failed to maintain resident dignity and privacy, as one resident was left exposed during transport and in bed, with full urinals in sight while eating. Another incident involved a staff member making a video call with a resident visible in the background, violating the facility's phone policy and potentially breaching HIPAA. Interviews confirmed these actions were inappropriate and not in line with facility policies.
The facility failed to assess and supervise two residents for self-administration of medications. One resident with fluctuating cognitive status had medications and an inhaler at their bedside without a physician's order. Another resident, capable of using inhalers, lacked physician orders for self-administration. Staff interviews revealed inconsistencies in policy implementation, leading to deficiencies.
The facility failed to maintain accurate records of residents' personal possessions, as observed through interviews and record reviews. Several residents' inventory sheets were incomplete, unsigned, or not updated to reflect current belongings. Staff interviews revealed inconsistencies in the process of documenting and maintaining personal property inventories, leading to discrepancies in residents' personal property records.
A facility failed to obtain written authorization to use a discharged resident's personal funds, resulting in an unauthorized deduction of $875.00 after receiving an updated bill from the resident's co-insurance. The facility did not notify the resident or their family about the additional charges, leading to a balance owed of $103.00. The Business Office Manager and Regional Business Manager acknowledged delays in processing a refund request and a lack of communication with the resident's family regarding the outstanding balance.
A resident was discharged with a credit balance of $772.00, but the facility failed to refund the amount within 30 days. The Business Office Manager sent a refund request to the corporate office, but the process was delayed due to waiting for confirmation of expenses and third-party payments. The Regional Business Manager acknowledged the delay, and the Administrator expected timely refunds.
A resident was readmitted to a facility from a hospital stay, but their medication and treatment orders were not reentered into the EMR for two days, resulting in missed medications. The resident had a history of schizophrenia, anxiety, high blood pressure, and COPD. The nurse completed an assessment and contacted the physician but failed to activate the orders in the EMR, preventing the administration of medications. The DON and Administrator acknowledged the oversight, and the physician confirmed no adverse effects occurred.
A resident with severe cognitive impairment and multiple health issues received incorrect g-tube feeding care, with the machine infusing at 80 ml/hr instead of the ordered 70 ml/hr and not being turned off at the prescribed time. The LPN acknowledged the error, and the facility's leadership confirmed the expectation to follow physician's orders.
A resident with Alzheimer's and schizophrenia, known for elopement risk, left a secured unit unnoticed due to staff's failure to perform visual checks. The resident exited through a tampered window and was found 12 hours later, two miles away. Staff interviews revealed a lack of awareness and adherence to elopement policies.
A resident with colon cancer did not receive prescribed Capecitabine medication due to a failure in documentation and administration processes at the facility. The resident's medical records lacked documentation of medication orders and appointments, leading to missed administrations in December and February. Staff interviews revealed a breakdown in the process of transcribing and auditing medication orders, contributing to the deficiency.
CNA Threw Metal Fork at Resident During Verbal Altercation
Penalty
Summary
The deficiency involves a failure to protect a resident from physical abuse when a CNA deliberately threw a metal fork at the resident during a verbal altercation. The facility’s own Abuse and Neglect Policy defines abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress, and specifically includes corporal punishment and hitting or flicking with an object. On the day of the incident, the CNA was passing lunch trays on the 300 hall near the courtyard door and observed several residents outside smoking during an unscheduled or unsupervised time. The CNA confronted the group about being outside without supervision, and a verbal exchange began between the CNA and the resident. According to the facility’s investigation and multiple interviews, the CNA and the resident engaged in back‑and‑forth yelling and cursing. The CNA reported that the resident began screaming and cussing and walked toward the CNA with a cane, which the CNA perceived as threatening. The CNA stated that as the resident approached, the CNA threw a metal fork taken from a meal tray toward the resident in an attempt to stop the resident’s forward movement. The resident reported that the CNA became angry during the argument, went behind the counter, grabbed a fork, and threw it, striking the resident’s arm near the elbow. The resident stated that he or she blocked the fork with an arm and expressed surprise that staff would throw an object. A nurse (RN E) and a CMT both described hearing or seeing a verbal exchange in the hallway, with the resident and CNA yelling at each other, and confirmed that the CNA threw a fork at the resident while the resident was in the hallway moving toward the nurses’ station. The resident involved had no cognitive impairment documented on a recent MDS and no recorded history of physical, verbal, or other behavioral symptoms directed toward others. Diagnoses included anemia, seizures, and hypertension. Staff interviews were inconsistent regarding the resident’s typical behavior; some staff described the resident as calm and not aggressive, while others stated the resident could be aggressive, intimidating, or have a temper when not getting his or her way. However, the MDS indicated no behavioral symptoms were present. The facility’s investigation documented that the fork made contact with the resident’s arm, though no discoloration or injury was noted and no medical treatment was required. Multiple staff, including CNAs, an LPN, RN E, and the ADON, characterized throwing a fork or any object at a resident as abuse, and the Administrator acknowledged that throwing and yelling at a resident constituted abuse under the facility’s policy.
Failure to Thoroughly Investigate and Track Resident‑to‑Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse and Neglect Policy by not conducting a thorough investigation into resident‑to‑resident physical altercations and by not clearly identifying or tracking multiple incidents between the same two residents. The policy requires protection from abuse, including resident‑to‑resident physical abuse, and mandates thorough investigation of alleged incidents. An investigation document identified a single altercation in which one resident entered another resident’s room, an argument ensued, and one resident attempted to choke the other, resulting in a reddened neck and dislodgement of the aggressor’s inner tracheostomy cannula. The investigation summary concluded that one resident initiated physical contact by attempting to choke the other, that both residents were assessed, and that no significant injuries were found beyond a slightly reddened neck and a bruise to a knee. However, progress notes, resident interviews, and staff interviews describe more than one altercation or conflict between these same two residents, and staff and leadership were inconsistent and uncertain about how many incidents occurred and when they occurred. One resident’s medical record notes an altercation on one date with a slightly reddened neck and no bruising, followed by another note several days later documenting that residents in the hallway reported they were fighting, and that the same resident again reported being choked by the same peer, with a slightly reddened neck observed. The resident later described two separate encounters: an initial episode where the other resident came into the room cursing and was made to leave by a nurse, and a subsequent episode where the same resident returned, blocked the doorway, pushed the resident against the wall, went for the airway, and the resident responded by pulling out the other resident’s tracheostomy. The resident also reported ongoing headache and feeling unsafe around the other resident. The other resident’s record documents being found in the peer’s room holding the inner cannula, reporting that the peer told them to get out of the room, and admitting to trying to choke the peer because they did not like being yelled at. Later documentation shows that this resident’s tracheostomy was found decannulated days after the altercation, with uncertainty about when it had been removed and conflicting accounts between staff, the resident, and the guardian. Interviews with staff and the Administrator show confusion about whether there was one or two incidents, with some staff only aware of a single event and others acknowledging that the resident should not have been allowed back into the room after an initial altercation. The Administrator stated she believed there were two incidents but that they occurred on the same day and that she should have been informed of more than one incident. The ADON acknowledged prior non‑physical problems between the residents involving inappropriate words. This inconsistent awareness and documentation of multiple altercations, and the lack of a clearly defined history between the two residents, demonstrate that the facility did not fully investigate or track all related events as required by its abuse prevention policy. The residents involved had significant medical and psychosocial histories relevant to the incidents. One resident had no cognitive impairment documented on the MDS but had multiple sclerosis, a tibia fracture, depression, PTSD related to prior traumatic experiences, seizures, and asthma, and a care plan identifying a history of sexual, physical, and emotional abuse with a focus on minimizing trauma triggers and promoting de‑escalation. The other resident had diagnoses including diabetes, generalized muscle weakness, bipolar disorder, chronic respiratory failure, and a tracheostomy, with a care plan identifying potential for physical aggression related to anger and poor impulse control. Despite these known conditions and behavioral risks, the facility’s investigation did not clearly reconcile the differing accounts, did not clearly delineate the number and sequence of altercations, and left leadership and direct care staff unsure about the history between the two residents, constituting a failure to implement the abuse prevention policy’s investigative requirements.
Failure to Follow Physician Orders for Weekly PICC Line Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of practice by not following physician orders for a resident’s peripherally inserted central catheter (PICC) line dressing changes. The resident, who was cognitively intact and admitted with diagnoses including end stage renal disease, a stage 4 sacral pressure ulcer, diabetes, depression, muscle weakness, and cognitive communication deficit, had a care plan and physician order specifying that the PICC dressing on the left brachial vein be changed weekly, on the night shift every Thursday, and that the insertion site be kept clean and protected with a sterile dressing. Review of the February medication administration record (MAR) showed the weekly PICC dressing changes were documented as completed on each scheduled date, and the March MAR showed the same weekly schedule. A progress note dated the day of the survey indicated the PICC dressing had been changed that afternoon with no difficulty and that the line remained patent and intact. However, during observation earlier that same day, the resident was seen in bed with a PICC line to the left upper arm, and the dressing date was worn off and illegible, with the dressing lifting at the corners and not adhering properly. The resident was unsure when the dressing was last changed but reported receiving antibiotics through the PICC line. The Assistant Director of Nursing (ADON) confirmed that the PICC dressing should be changed once a week and that the date on the dressing should reflect the prior week, not have an older date. The following day, the ADON reported that when the dressing was changed the previous day, it appeared old and the date was difficult to read, possibly from mid-February or even January, and acknowledged that the date should have been more recent and that staff should not have charted the dressing change as completed when it had not been done. The Administrator and the Registered Nurse Consultant both stated they expected staff to follow physician orders and not document treatments as done if they were not actually performed.
Failure to Provide Prescribed Opioid Pain Medication During Pharmacy Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed opioid pain medication to a resident for four days following a pharmacy change, despite an active physician order for scheduled oxycodone. The resident had a history of pain related to neuropathy, bilateral lower extremity pain, and a left tibia fracture, with care plan goals for adequate pain relief and interventions that included administering analgesia as ordered and monitoring and reporting pain complaints. The physician order, in place since 11/19/25, directed that oxycodone 5 mg, two tablets by mouth every four hours, be given for pain related to the left tibia fracture, and the March MAR showed this medication scheduled at six times per day. Documentation showed the medication was administered at midnight and 4:00 a.m. on 3/1/26, but all subsequent scheduled doses from later that morning through at least the morning of 3/5/26 were marked as not administered. Nursing progress notes repeatedly documented that the oxycodone was not available or not in stock, and that a pharmacy change and need for new prescriptions were preventing administration. Notes on 3/1/26 indicated the medication needed a prescription and was not in stock, and multiple entries on 3/2/26 and 3/3/26 stated that the medication was not available due to a pharmacy change, that new e-prescriptions were required, and that the facility was awaiting medication from the new pharmacy. Additional notes on 3/4/26 continued to document that the oxycodone was not available. During this period, the facility’s own policies required that physician orders be transcribed and implemented in accordance with professional standards and that medications be ordered to ensure prompt delivery, including use of emergency drug supplies or an automatic dispensing unit for first doses when available. The pain management policy also required systematic recognition, evaluation, treatment, and monitoring of pain, and directed nursing to notify the practitioner if pain was not controlled by the current regimen. Resident interviews and staff statements further described the impact of the unavailability of the ordered pain medication. On 3/4/26, the resident, who was in a wheelchair with a boot on the left foot, reported being out of oxycodone for several days since the pharmacy switch and stated they were hurting without the pain pill because of the broken foot. On 3/5/26, the resident was observed in the hallway in a wheelchair, crying and not wearing the boot, and stated feeling overwhelmed and in a lot of pain, reporting that they had asked for pain medication overnight and instead received anxiety medication. A CMT reported giving the resident PRN Tylenol and stated that the resident did not seem to be in pain and had asked for anxiety medication rather than pain medication, while an LPN acknowledged that the resident did seem to be in pain and that the oxycodone was not in the new pharmacy system, but was unsure how long the resident had been without it. The Administrator and the RN consultant both stated that residents should not be without pain medications for four days, and the RN consultant confirmed that the prescription was not received by the pharmacy until 3/4/26 and that being out of the medication since 3/1/26 was not acceptable.
Failure to Maintain Separate Resident Fund Accounts and Issue Timely Refunds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to manage their financial affairs by not placing resident personal funds in an account separate from the facility’s operating account and not issuing timely refunds. Record review of the facility’s Accounts Receivable Aging Report showed that 39 residents had personal funds, totaling $39,158.17, held in the facility’s operating account rather than in a separate resident fund account. Individual amounts ranged from small balances of a few dollars to larger sums exceeding $11,000 for some residents. One resident had a credit balance of $1,834.00 due to paying for two months of services that should not have been paid, and this credit remained unrefunded for a period of time despite the issue being brought to the Business Office Manager’s (BOM) attention. The report also shows that the facility did not provide Personal Fund Account Balance Reports for multiple deceased residents to the Missouri HealthNet Division Third Party Liability Unit until after a case-managed investigation had already begun. These deceased residents’ personal fund balances were not timely reported as required. During interviews, the BOM acknowledged that a prior BOM had left without processing at least one resident’s refund and that refund requests for several residents had only been sent to the home office later. The BOM further stated that he or she was working with corporate staff to determine why some residents’ balances had been written off as bad debt instead of being refunded, indicating that these residents did not receive refunds of their personal funds when due.
Improper Handling and Administration of Controlled Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oral medication administration and controlled substance policies when handling a resident’s opioid pain medications. The resident, admitted with diagnoses including depression, diabetes, right above-knee amputation, and paraplegia, had an order for Morphine Sulfate ER 60 mg by mouth every 12 hours for osteoarthritis and no order or assessment to self-administer medications. Facility policy required staff to remain with residents until medications were swallowed and prohibited leaving medications at the bedside unless specifically ordered. During observation, surveyors saw a brown pill in a medication cup with water on the resident’s bedside table with no staff present; the resident stated it was his/her medication and then self-administered it. An LPN reported having given the resident morphine earlier and speculated the resident must have spit it out, while a CMT stated the resident’s medications had not yet been given and that medications should not be left in the room. Further observations showed additional failures in controlled substance handling. During a skin assessment, the ADON found a small round white pill under the resident in bed, initially assumed it was morphine, placed it on the bedside table, and later crushed and disposed of it at the medication cart. Upon checking the narcotic box, the ADON determined the pill was Oxycontin, a Schedule II opioid for which the resident had no physician order, and noted that another resident on the unit had a card of Oxycontin in the narcotic box. The resident’s prescribed morphine was described as a small brown pill matching the medication seen at the bedside earlier. The DON and Administrator stated they would not expect controlled medications to be in a resident’s bed or for a resident to have medications not prescribed to him/her, and another ADON stated that nurses should sign out narcotics as they are pulled and ensure residents take medications before leaving the room. Resident #7 was not known to pocket or spit out medications.
Failure to Offer Roommate Option to Leave After Co-Resident’s Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated in a dignified manner after his/her roommate died in their shared room. According to medical record review, Emergency Medical Services (EMS) pronounced the roommate deceased at 1:47 A.M., and the funeral home did not remove the body until 5:09 A.M. During this time, the surviving resident, who was cognitively intact and had diagnoses including quadriplegia, malnutrition, diabetes, and general muscle weakness, remained in the same room. The surviving resident was in the bed farthest from the door, and staff closed the privacy curtain between the beds and likely closed the room door, but did not remove the resident from the room. In an interview, the surviving resident reported that no one came in to ask if he/she wanted to leave the room or if he/she was okay, and stated that he/she did not like the situation and felt very upset and uncomfortable, particularly in light of a recent loss of his/her son. Staff interviews indicated that both an LPN and a CNA understood that standard practice when a resident passes away is to take the roommate out of the room or at least offer the option to leave, especially when family comes to see the deceased resident. The Administrator and DON confirmed they would expect staff to ask the roommate to leave the room after a death and stated it was not dignified to leave the roommate in the room or to have family see the deceased with the roommate still present.
Failure to Complete Dietician-Requested Reweight and Timely Follow-Up of Oncology-Ordered Labs
Penalty
Summary
The facility failed to ensure services met professional standards when staff did not obtain a repeat weight as requested by the registered dietician for a resident with multiple comorbidities, including diabetes, aphasia, dysphagia, dementia, and delusional disorder. The resident’s care plan identified a nutritional problem or potential nutritional problem, with goals to maintain weight within 5–10% of usual weight and consume at least 75% of 2–3 meals daily. The weight summary showed a decline from 192.5 lbs to 187.2 lbs and then to 166.2 lbs over three consecutive monthly weights, with no further weights documented. On a dietician progress note, a “weight warning” was documented with a request for a reweight. The restorative aide/CNA, who was responsible for obtaining and documenting weights, reported that the dietician’s reweight requests were communicated via email from the ADON and acknowledged that the resident was on the reweight list but the reweight could not be found in the record. When the resident was weighed during the survey, the weight was 163.7 lbs, confirming that the requested reweight had not been completed and documented within the expected timeframe. The facility also failed to ensure that requested laboratory tests from an outside oncology provider were completed and followed up on in a timely manner for another resident with diagnoses including liver cancer, generalized muscle weakness, and Alzheimer’s disease. An order for a CBC and CMP was entered and marked complete, and progress notes documented calls to the oncologist’s office indicating that labs had been drawn and were pending. The lab report later showed that the CMP specimen was hemolyzed with a directive to call to reschedule, but there was no documented follow-up or redraw by facility staff. The oncology office social worker reported that after a December appointment, lab orders were sent with the resident and CNA, and also called and faxed to the facility, with instructions for labs to be completed between Christmas and New Year. The resident’s follow-up appointment was cancelled by the facility due to transportation issues, and the ordered labs were not actually completed until later at the oncology office, which had not received any lab results from the facility and was unaware of the hemolyzed specimen.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure staff followed its Enhanced Barrier Precautions (EBP) policy and failed to implement EBP for a resident with multiple open areas. The facility’s EBP policy, last reviewed 5/15/24, required the use of gowns and gloves during high-contact resident care activities, including wound care and dressing changes, for residents with wounds and/or indwelling medical devices, and directed that EBP signage be posted and PPE be available in the room. Review of the resident’s medical record showed diagnoses including hemiplegia following a left-sided stroke and high blood pressure. The resident’s care plan identified a pressure ulcer to the sacrum related to immobility and bowel and bladder episodes, with interventions to administer treatments as ordered and follow facility policies for treatment and prevention of skin breakdown, but there was no mention of EBP precautions. Further review of the electronic physician order sheet and January 2026 Treatment Administration Record showed no order for EBP precautions. During observation of wound care, two LPNs prepared to treat the resident’s large open wound to the buttocks. At the treatment cart outside the room, one LPN gathered wound care supplies, entered the room, and placed the items on a disposable pad on the bedside table. Both LPNs washed their hands; one LPN donned gloves and a gown from a shelf on the resident’s door and placed an extra gown on the bed, pointing to the other LPN, who donned gloves but did not put on the gown. Both staff assisted in rolling the resident to the left hip to expose the wound, during which the extra gown fell to the floor. One LPN removed the old dressing, cleansed the wound, changed gloves with hand hygiene in between, and applied the ordered treatment while the other LPN held the resident’s hips to maintain position, remaining gloved but ungowned throughout the high-contact wound care activity. After completing treatment, the gowned LPN removed the gown and gloves, performed hand hygiene, and removed trash from the room, while the ungowned LPN repositioned the resident and exited the room. In a subsequent interview, the DON and Administrator stated they would expect staff to follow the policy and for both nurses to wear appropriate PPE for EBP.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information (PHI) when a staff member provided an after-visit summary containing personal and medical details of one resident to the family member of a different resident. The summary included the resident's full name, date of birth, medical record number, referrals for further testing, and results of a recent x-ray. The family member who received the document reported the error to the staff member, but the staff member responded indifferently, stating they did not care and did not want the paperwork back, allowing the family member to keep the document. The incident was confirmed through interviews, observation, and record review. The family member retained the after-visit summary and provided it to the surveyor as evidence. The facility's posted resident rights statement included confidentiality, and management acknowledged that only residents, their guardians, or POAs should have access to such records. The administrator stated that, in such cases, staff are expected to retrieve the documents and notify management, but this did not occur in this instance.
Failure to Maintain Homelike Environment and Adequate Dining Service
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. One resident with moderate cognitive impairment, a history of stroke, aphasia, hemiplegia, and schizophrenia was found in a room that was not swept daily, with trash on the floor and a bedside table with screws protruding from the surface. The condition persisted over two days, and the housekeeping supervisor acknowledged that the screws were not homelike and that the table was an older, unused piece of furniture. Housekeeping staff were expected to clean rooms daily, but staffing shortages were noted. Another resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and hemiplegia, had two dirty plates with dried food left on the air conditioning unit in their room for at least two days. The resident reported that the plates were from previous meals, and the housekeeping supervisor stated that staff should remove such items or notify nursing. The supervisor also noted that trash should be removed in the morning and rooms checked again before staff leave, but acknowledged recent short staffing. Additionally, the facility did not provide a sufficient number of regular dining plates, resulting in residents being served meals on Styrofoam plates wrapped in plastic. Multiple residents reported dissatisfaction with the use of Styrofoam, stating that it made food cold and unappetizing, and that plates were often removed before they finished eating so they could be washed for the next meal. Observations confirmed that regular plates were in short supply, with staff switching to Styrofoam when plates ran out. The dietary manager and staff confirmed the ongoing shortage, and the administrator provided documentation of a recent order for a small number of plates, but could not locate records of previous orders.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of receipt and disposition of all controlled drugs for a resident, resulting in the loss of a narcotic count sheet for one card of 30 Oxycodone 20 mg tablets. The pharmacy delivered a 30-day supply of 120 tablets, divided into four cards of 30 tablets each, and records confirmed receipt by the facility. While three of the four controlled substance sheets were available and reconciled, one sheet was missing, leaving no documentation or reconciliation for the administration of 30 tablets. The medication administration record (MAR) showed that doses were given and documented, but the corresponding narcotic count sheet for one card could not be located. Interviews with staff revealed that narcotic medications are signed in upon delivery and are supposed to be accounted for on controlled substance sheets, with reconciliation at the beginning and end of each shift. The LPN interviewed did not recall any discrepancies or resident complaints regarding pain medication. The DON confirmed the missing narcotic sheet and stated that all sheets should be accounted for, with staff expected to sign out and document administration of controlled medications. The administrator also acknowledged the expectation for accurate reconciliation of narcotics.
Failure to Use Mechanical Lift for Dependent Resident Transfer
Penalty
Summary
Facility staff failed to follow the established policy and physician orders regarding safe transfer methods for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, hemiparesis, a history of falls, unsteadiness, dementia, and legal blindness, was care planned and ordered to be transferred using a mechanical Hoyer lift with an appropriate sling for all transfers. Despite these orders and the facility's Total Lift Transfer policy, two CNAs transferred the resident from a wheelchair to a bed using a gait belt instead of the required mechanical lift. During the transfer, the wheelchair was not locked, and the resident was lifted by the gait belt while their feet did not touch the floor, and they did not stand up as instructed. The resident exhibited discomfort, moaning, and yelling during the transfer. Interviews with staff, including CNAs, an LPN, and the interim DON, confirmed that staff were expected to follow transfer orders and care plans, and that the resident should have been transferred using the Hoyer lift at all times. The CNAs involved did not adhere to these expectations, resulting in a transfer that was not in accordance with the resident's care plan or physician orders. The Administrator and Regional Director of Operation also stated that staff were expected to follow appropriate transfer methods as ordered and care planned.
Failure to Verify Nursing Licensure for LPN
Penalty
Summary
The facility failed to ensure that nursing staff were properly licensed to practice in the state of Missouri. An LPN, who had obtained a nursing license in Illinois, was employed and worked as a GPN and later as an LPN in the facility without holding a Missouri nursing license. Review of records showed that the LPN had completed a practical nursing program and began working as a GPN, but after passing the licensure examination, continued to work as an LPN without Missouri licensure. The LPN provided direct care, including medication administration, wound care, and care for residents with tracheostomies and tube feedings, often without direct supervision or pairing with an experienced nurse. Interviews with facility staff revealed that there was an expectation for GPNs to work under the oversight of a licensed nurse and for HR to verify and track licensure status, including the 90-day limit for GPNs to obtain licensure. However, HR did not verify that the LPN was licensed in Missouri, and neither the new DON nor the Administrator were aware of the situation until it was brought to their attention by the state surveyor. The LPN resigned after the issue was discovered. The failure to verify and ensure proper licensure had the potential to affect all residents in the facility.
Failure to Investigate and Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy when two residents were involved in a physical altercation. Both residents had documented histories of potential aggression, with care plans indicating the need for interventions and monitoring. Following the incident, one resident was observed to have a mark under the eye, and a family member reported the resident had a black eye as a result of being punched. Staff interviews confirmed that a physical altercation occurred, with one resident grabbing and hitting the other, leading both to fall to the floor. Immediate assistance was called, and both residents were assessed by nursing staff, with recommendations for hospital evaluation. Despite the clear evidence of a resident-to-resident altercation resulting in injury, the facility did not initiate a thorough investigation as required by its Abuse Prevention Policy. There was no documentation of an investigation, and key staff members, including the Activity Director and Certified Nurse Aide who witnessed or responded to the incident, were not asked to provide written statements. The incident was not reported to the State Survey Agency or other required officials, and there was no documentation of the event in the residents' nurse's notes beyond the initial hospital referral. Interviews with facility leadership, including the Regional Director of Nursing and the Administrator, revealed that the incident was not reported or investigated according to policy. The Administrator acknowledged responsibility for ensuring the policy is followed and for reporting abuse and neglect allegations but was unable to explain why the required actions were not taken. The lack of investigation and reporting represents a failure to protect residents from abuse and to comply with regulatory requirements.
Failure to Notify Physician and Dietitian of Significant Weight Loss
Penalty
Summary
The facility failed to follow its own policies regarding the monitoring and management of significant weight loss for a resident. The resident, who had diagnoses including high blood pressure, diabetes, asthma, dehydration, severe protein-calorie malnutrition, and gastro-esophageal reflux disease, experienced an 11.5-pound weight loss over 56 days. Facility policy required that significant, insidious, or unintentional weight loss be reported to the Registered Dietitian (RD) and the physician, with subsequent assessment and intervention. However, there was no documentation that the RD or physician were notified of the resident's weight loss or of the hospital's recommendation for nutritional supplements upon the resident's return from hospitalization. The resident's care plan included monitoring for signs and symptoms of malnutrition and significant weight loss, with specific thresholds for reporting. Despite this, records showed gaps in meal consumption documentation and a lack of follow-up on the resident's nutritional status after multiple hospitalizations for conditions including hypoglycemia and diabetic ketoacidosis. The resident's weight continued to decline, and the resident reported concerns about weight loss and not having seen the RD for assistance. Interviews with staff, including the RD and physician, confirmed that they were not made aware of the resident's weight loss or the need for intervention. Facility staff interviews revealed that procedures for reviewing hospital records and implementing recommendations were not consistently followed. The RD stated that notification of significant weight loss was expected but did not occur. The physician also indicated that the facility should have identified the weight loss and involved the RD. The lack of communication and failure to implement required assessments and interventions directly contributed to the deficiency in providing adequate nutrition and monitoring for the resident.
Failure to Notify Physicians and Document Blood Glucose Management
Penalty
Summary
The facility failed to ensure that staff consistently notified physicians when residents' blood glucose levels exceeded the parameters ordered by the physician or those outlined in facility policy. In several instances, staff did not document blood glucose levels on the Medication Administration Record (MAR) or provide explanations when using codes such as NA (not administered), NI (no insulin required), or HD (hold) on the MAR. This deficiency was identified among four residents sampled from a group of forty-eight who required routine blood glucose monitoring. For one resident with a history of diabetes, high blood pressure, renal disease, and stroke, there were multiple occasions where blood glucose readings were either critically low or high, but there was no documentation that the physician was notified as required by the physician's orders. Additionally, there were instances where insulin was not administered as ordered, and no explanation or blood glucose level was documented. Similar issues were observed with other residents, including missing documentation for blood glucose levels, lack of physician notification when levels were outside of ordered parameters, and unexplained use of MAR codes indicating insulin was not given or held. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to notify physicians when blood glucose levels were outside of specified parameters and to document these notifications and any reasons for not administering insulin in the progress notes. Despite inservices and reminders, the problem persisted, with staff failing to follow protocols for physician notification and documentation, as evidenced by the review of records and staff interviews.
Failure to Provide Oral Care Supplies and Assistance
Penalty
Summary
The facility failed to ensure that residents had access to oral care supplies, such as toothbrushes, toothpaste, and mouthwash, and did not consistently provide oral care assistance as required by their care plans. Observations and interviews revealed that several residents did not have these supplies in their rooms and reported that staff did not offer to assist with oral hygiene. Specifically, three residents stated they had not received oral care supplies since admission and that staff had not offered to help with oral care, despite their expressed desire for assistance. Review of the residents' medical records and care plans showed that some required setup or clean-up assistance, while others needed substantial or maximal assistance with oral hygiene due to physical or cognitive limitations. For example, one resident with muscle weakness and chronic kidney disease required setup assistance, while another with end-stage renal disease and diabetes needed substantial help. Despite these documented needs, staff interviews confirmed that oral care was not consistently offered, and supplies were not available in the residents' rooms. Staff members, including CNAs, a Certified Medication Technician, and an LPN, acknowledged during interviews that oral care should be part of the daily routine for all residents. The DON also confirmed the expectation that each resident should have oral care supplies and receive assistance as needed. However, direct observations and resident interviews demonstrated that these expectations were not being met, resulting in a deficiency related to the provision of oral hygiene care.
Failure to Provide Prescribed Restorative Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative services as prescribed for residents referred to the restorative program by the therapy department. Nineteen residents were identified as receiving restorative services, and four of these had specific restorative exercise plans developed by therapy. However, these four residents were not receiving the services according to their restorative therapy plans. Observations and interviews revealed that residents were not receiving the required range of motion (ROM) exercises and other restorative interventions as ordered, with some residents reporting that they had not received services for weeks or could not recall the last time they received them. Documentation showed that these residents only received restorative therapy twice in the previous ten days, despite plans calling for three sessions per week. Staff interviews indicated that the restorative aide was frequently reassigned to other duties, resulting in restorative services not being delivered consistently. The restorative aide confirmed being pulled to the floor almost daily, and the Director of Nursing acknowledged that the restorative program was not functioning as intended. The physical therapist was aware that restorative services were not being provided as ordered due to staffing issues. Review of staffing sheets confirmed that the restorative aide was reassigned to other duties on seven out of twelve days reviewed. Residents affected by this deficiency included individuals with significant mobility limitations, such as incomplete quadriplegia, muscle weakness, and impaired range of motion. These residents required assistance with activities of daily living and had care plans specifying the need for restorative interventions to maintain or improve their functional status. Despite these documented needs and therapy recommendations, the facility did not ensure that restorative services were delivered as planned.
Failure to Provide Timely Discharge Planning and Capacity Assessment
Penalty
Summary
The facility failed to provide necessary social services by not promptly developing a discharge plan or seeking professional medical or psychiatric evaluations to determine if a resident, who was homeless and their own legal representative, had the right to discharge to the community, discharge against medical advice (AMA), or if legal guardianship should be pursued. The resident, with diagnoses including bipolar disorder and anxiety, was admitted from a hospital and placed on a locked unit after expressing a desire to leave and attempting to do so. Despite repeated expressions of wanting to leave, confusion, and fluctuating cognitive status, there was no timely assessment or documentation regarding the resident's capacity to make discharge decisions or the appropriateness of their placement on a locked unit. The social services documentation was inconsistent and incomplete. Discharge planning reviews and care plans lacked critical information, such as the resident's living situation, support network, and overall summary of potential for discharge. There was no evidence that referrals to local contact agencies or community resources were made in a timely manner, and the care plan did not address the resident's placement on the locked unit or discharge planning. The psychiatric nurse practitioner was not asked to evaluate the resident's decision-making capacity until months after admission, despite ongoing concerns about the resident's ability to safely live independently and repeated requests to leave the facility. Interviews with staff revealed a lack of clarity regarding policies for seeking legal guardianship or managing residents on locked units. The social services department experienced turnover, further disrupting continuity of care and discharge planning. The resident continued to express a desire to leave, called 911 alleging being held against their will, and was found to have diminished capacity only after a delayed psychiatric evaluation. Throughout this period, the facility did not adequately coordinate or document efforts to address the resident's psychosocial needs, discharge planning, or legal status, resulting in a failure to provide necessary social services as required.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Accommodate Resident Bathroom Access Due to Locked Adjoining Bathroom
Penalty
Summary
The facility failed to provide reasonable accommodations for the individual needs and preferences of two residents by denying them access to their adjoining bathroom. Staff removed the doorknobs from the bathroom doors, locking the bathroom and requiring the residents to request staff assistance to access the main bathroom in the hallway. This action was taken despite a lack of clear documentation or evidence that either resident was responsible for clogging the toilets, and staff interviews revealed uncertainty about which resident, if any, had caused the issue. Both residents were observed to have their bathroom doors locked and inaccessible without maintenance assistance. One resident had moderate cognitive impairment, was wheelchair-bound, and was dependent on staff for toileting and transfers. The resident's care plan did not document any history of clogging toilets, and there was no evidence in progress notes of such behavior. The resident reported having to use a urinal or hold their bowels until staff could assist them to the main bathroom, sometimes resulting in incontinence. Staff interviews confirmed the resident did not have access to the bathroom in their room and did not know the code to the main bathroom, requiring staff intervention each time toileting was needed. The second resident also had moderate cognitive impairment and required partial to moderate assistance with toileting. Their care plan mentioned a history of behavior problems and clogging the toilet with foreign objects, but there was no documentation of specific incidents. Observations showed the resident's bathroom was also locked, and the resident resorted to urinating in a trash can in their room. Staff interviews indicated a lack of knowledge about the reason for the bathroom's inaccessibility and no awareness of recent clogging incidents. The administrator confirmed that the bathroom was locked due to uncertainty about which resident was responsible for previous clogs and flooding, and both residents were instead provided with bedside commodes and access to the main bathroom only with staff assistance.
Failure to Maintain Sanitary and Homelike Environment for Two Residents
Penalty
Summary
Staff failed to maintain a safe, clean, and homelike environment for two residents who shared an adjoining bathroom. Observations revealed that the bathroom doorknobs were missing and inaccessible to the residents, and the bathroom itself was left in unsanitary condition, with soiled towels piled on the floor, brown smears above the tile, and a solid dark substance in the toilet bowl. The wall across from the toilet was covered with brown cardboard instead of tile. Maintenance staff reported that the doorknobs were removed due to residents' behaviors of clogging the toilet and smearing feces, and that the bathroom was locked as a result. One resident had moderate cognitive impairment, was dependent on staff for toileting and transfers, and had a history of urinary and occasional bowel incontinence, as well as diagnoses including hypertension and Alzheimer's disease. The other resident also had moderate cognitive impairment, required partial to moderate assistance with toileting, and had diagnoses including heart failure, pulmonary edema, diabetes, and hypertension. Observations in the second resident's room showed a trash can with a plastic liner containing yellow liquid, which staff confirmed was urine, and reported that the resident frequently urinated in the trash can and defecated in inappropriate places in the room. Housekeeping staff stated that they cleaned the resident's room daily, removed soiled trash liners, and replaced them, but acknowledged that the resident regularly urinated in the trash can. The facility's policy required maintaining a sanitary and comfortable environment, including prompt cleaning and reporting of environmental concerns. The administrator was aware of the unsanitary bathroom conditions and stated that the staff responsible was no longer employed, but expected all staff to follow cleaning policies.
Failure to Provide Appropriate Diet and Supervision for Resident at Risk of Aspiration
Penalty
Summary
The facility failed to ensure that a resident, who was assessed to be at risk for aspiration, was served meals in accordance with physician's orders. The resident, who had a history of transient ischemic attack and severe cognitive impairment, was supposed to receive a pureed meat texture diet and nectar-thick liquids following a recent hospitalization for aspiration pneumonia. However, observations revealed that the resident was given un-thickened liquids and mechanical-soft sausage instead of the prescribed diet, which posed a risk of choking and further aspiration. The resident's care plan did not adequately address the risk of aspiration or specify the level of assistance and supervision required during meals. Despite the resident's known behavior of chewing on non-food items, such as linens and napkins, staff failed to provide the necessary supervision. On one occasion, the resident was observed chewing on a milk-soaked napkin without staff intervention, highlighting a lack of awareness and monitoring by the facility staff. Interviews with facility staff, including LPNs, CNAs, and the Dietary Manager, revealed a lack of communication and understanding of the resident's dietary needs and supervision requirements. The dietary slips used during meal service were outdated, and staff were not informed of the updated dietary orders. This lack of coordination and oversight contributed to the resident receiving inappropriate meals, which could have led to further health complications.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for eight of 33 sampled residents, as evidenced by unclean conditions in resident rooms and common areas. Observations revealed that Resident #8's room had a gray film of grime on the floor and dried red liquid stains, with fecal material splattered inside the toilet bowl. Despite the resident's complaints, the room remained unclean over several days. Similarly, Resident #119's room had dirty floors with trash and food debris, dirty bedding with a brown substance, and a strong fecal odor, which persisted over multiple observations. Resident #38's room was noted to have dust accumulation on the air conditioning unit and trash and food debris around the bed. Resident #62's room had a dresser door hanging off and food and trash debris on the floor. Resident #15's room had dust, crumbs, and dried red splatters on the floor and bed frame, with the resident expressing dissatisfaction with the cleanliness. Housekeeping staff expressed uncertainty about cleaning around oxygen equipment, indicating a lack of clear guidance. Additionally, soap dispensers in the rooms of Residents #20 and #140 were found empty over several days, despite residents' complaints. Resident #105's tube feeding equipment was observed with layers of dry, flaky matter, and the 400 hallway dining room had sticky floors with food debris over several days. Interviews with housekeeping staff and supervisors revealed expectations for daily cleaning and maintenance, but these were not met, leading to the deficiencies observed.
Expired Medications Found in Facility Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During observations, surveyors found expired medications and biologicals in two of the facility's medication rooms and two of the three medication administration carts. Specifically, expired ESwab Liquid collection kits, CareAll Tetrahydrolozine HCl Eye Drops, ProCure Allergy Relief tablets, Assure Dose Accucheck Control Solution, and GeriCare Zinc Sulfate tablets were identified. These findings indicate a lapse in the facility's adherence to its own Medication Storage policy, which mandates the removal and destruction of expired medications. Interviews with facility staff revealed a lack of clear responsibility for auditing medication storage areas for expired items. Certified Medication Technicians and floor nurses were expected to check for expired medications weekly, but no single staff member was designated to ensure compliance. The night nurses were tasked with auditing medication carts weekly, while the Assistant Directors of Nursing were supposed to audit medication rooms daily. However, the presence of expired medications suggests that these procedures were not effectively implemented or monitored, leading to the observed deficiencies.
Facility Fails to Maintain Kitchen Cleanliness Standards
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the kitchen, as observed during multiple inspections. On several occasions, the walk-in refrigerator and freezer were found with food debris and trash on the floors. The kitchen floors, particularly around the dishwashing sinks and preparation stations, had accumulated dark matter, dead bugs, and spilled liquids. Additionally, the ceiling and vents above the main food preparation station were covered in dust and cobwebs, while the bulk bin lids had food debris and white powder buildup. The deep fryer and oven were observed with sticky liquid substances and food particles, indicating a lack of regular cleaning. Interviews with staff revealed discrepancies in cleaning expectations and practices. The kitchen cleaning checklists, which were undated, outlined daily and weekly cleaning tasks, but these were not being adhered to. Staff members, including the Dietary Supervisor and the Administrator, expressed expectations for cleanliness that were not being met. The Dietary Supervisor mentioned that maintenance was responsible for cleaning the ceilings weekly, and that the deep fryer and oven should be cleaned twice a week, with oil changes occurring weekly. However, observations indicated that these tasks were not being performed as required, leading to the unsanitary conditions documented in the report.
Deficiencies in ADL Care and Hygiene Observed
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for four residents, leading to deficiencies in personal hygiene and grooming. Resident #22, who has severe cognitive impairment and requires extensive assistance with ADLs, was observed with unwanted facial hair despite expressing a desire to be free from it. This indicates a failure in grooming assistance as outlined in the resident's care plan. Resident #32, also with severe cognitive impairment, was not care planned for ADL care and was observed with greasy hair, dirty hands, and food debris on clothing. This lack of planning and oversight resulted in the resident not receiving necessary hygiene care. Similarly, Resident #62, with moderately impaired cognition, was observed with oily hair, long nails with dark matter underneath, and wearing the same clothing over several days. The resident reported not having other clothing, and staff confirmed missed showers due to behavioral issues in the hallway. Resident #71, with severe cognitive impairment, was not care planned for ADL or hygiene care and was observed wearing the same clothing over multiple days. The facility's staff, including a Certified Medication Technician and an LPN, acknowledged expectations for residents to have clean clothing, hands, and hair, and for care plans to reflect ADL assistance needs. However, these expectations were not met, as evidenced by the observations and interviews conducted during the survey.
Failure to Accommodate Resident's Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with significant communication and mobility impairments. The resident, who had a history of stroke, hemiplegia, and aphasia, was observed with their call light out of reach, pinned to a privacy curtain on their non-functional side. Despite the resident's attempts to communicate their inability to reach the call light, staff did not rectify the situation, leaving the resident without a means to call for assistance. Additionally, the resident expressed a desire to return to bed, which was not honored by the staff. The resident was observed in a geri-chair at the nurse's station and later in their room, repeatedly stating their wish to lie down. Staff, including CNAs, indicated that the resident needed to remain up to prevent pressure ulcers and due to staffing requirements for using a Hoyer lift. Despite the resident's clear communication of their preference, the staff did not assist the resident back to bed until after lunch, contrary to the resident's wishes. Interviews with staff, including a CNA, RN, and the Director of Nurses, revealed a lack of adherence to the resident's rights and care plan. The staff acknowledged the resident's ability to make their needs known and the necessity of having the call light within reach. However, the care plan did not adequately address the resident's communication difficulties or mobility limitations, nor did it reflect the resident's preferences for being in bed. The facility's failure to ensure the resident's call light was accessible and to honor their request to return to bed demonstrated a disregard for the resident's rights and preferences.
Failure to Complete Timely Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment within 14 days for a resident who was admitted to hospice care. The resident, who had a primary diagnosis of cerebrovascular disease, was admitted to hospice on May 15, 2024. However, the facility did not complete the required significant change Minimum Data Set (MDS) assessment within the mandated timeframe. The facility's policy requires that a significant change MDS be completed when a resident enters hospice, but this was not done for the resident in question. The MDS Coordinator, responsible for completing all MDS assessments, acknowledged that the significant change MDS was not completed. She mentioned that she is informed of changes in residents' status during department head risk meetings, but the resident's hospice admission was not listed on the electronic physician order sheet, which may have led to the oversight. The Administrator confirmed that the MDS Coordinator is expected to ensure timely completion of significant change MDS assessments, indicating a lapse in the facility's adherence to its own policies and federal requirements.
Inaccurate MDS Assessments for Hospice and Fall Incidents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. One resident, who was admitted to hospice with a primary diagnosis of cerebrovascular disease and a life expectancy of less than six months, was not accurately reflected in the MDS. The MDS did not indicate the resident's hospice status or their life expectancy, which was a critical oversight. This discrepancy was attributed to the hospice admission not being listed on the resident's electronic physician order sheet, which the MDS Coordinator missed. Another resident, who had a history of significant medical conditions including an amputation, hemiplegia, and muscle weakness, experienced a fall during the assessment review period. However, this fall was not documented in the resident's quarterly MDS. The MDS Coordinator acknowledged the oversight after reviewing the incident note. The facility's policy requires that such incidents be accurately recorded in the MDS, but the coordinator, who was solely responsible for completing all MDS assessments, failed to include this information.
Failure to Transcribe Physician Orders Correctly and Unauthorized Medication Crushing
Penalty
Summary
The facility failed to ensure that physician orders were correctly transcribed to the Medication Administration Record (MAR) for two residents, leading to discrepancies in the administration of tube feedings. Resident #105, who has aphasia, stroke, and seizure disorder, was receiving parenteral tube feeding. The physician's order specified that the tube feeding should be administered from 6:00 A.M. to 12:00 A.M., but the MAR incorrectly listed the administration times as 7:00 A.M. and 7:00 P.M., omitting the specific start and stop times. Similarly, Resident #49, with a seizure disorder and traumatic brain injury, had a physician's order for tube feeding from 6:00 A.M. to 10:00 P.M., but the MAR did not reflect the time to stop the feeding at 10:00 P.M. Additionally, the facility administered crushed medications to Resident #72 without a physician's order. This resident, diagnosed with dysphagia, Parkinsonism, dementia, and Alzheimer's disease, was observed receiving crushed medications mixed with applesauce, despite the absence of an order to do so. The Certified Medication Tech (CMT) responsible for administering the medications relied on an unofficial list from the narcotic binder, which was not part of the facility's policy or orders, instead of the MAR or physician orders. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that there was an expectation for physician orders to be accurately transcribed to the MAR, including specific times for tube feedings and orders for crushing medications. The ADON acknowledged that the orders had not been checked recently due to being off work, and the DON confirmed that the unofficial list used by the CMT was not recognized as part of the facility's procedures. The failure to adhere to professional standards of practice in transcribing and implementing physician orders led to these deficiencies.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to adhere to physician orders and proper infection control techniques for two residents requiring oxygen therapy. Resident #15, who has a history of COPD and other respiratory issues, was observed to have increased the oxygen flow rate to 5 liters per minute without staff awareness, contrary to the physician's order of 3 liters per minute. The resident's pulse oximetry results were not documented, and the oxygen tubing was not dated as required. Interviews with nursing staff revealed a lack of awareness regarding the resident's self-adjustment of oxygen levels and inconsistencies in documenting pulse oximetry readings. Resident #315, also diagnosed with COPD and chronic respiratory failure, was observed to have their nasal cannula frequently on the floor, with the oxygen concentrator left running when not in use. The resident reported difficulty retrieving the nasal cannula, and staff interviews indicated a lack of clarity regarding the resident's oxygen orders. The facility's expectations for maintaining infection control by keeping the nasal cannula off the floor and turning off the concentrator when not in use were not met. Interviews with the facility's administration and nursing leadership highlighted discrepancies in the documentation and implementation of physician orders. The Assistant Director of Nursing acknowledged that the orders were entered incorrectly into the system, leading to improper documentation and execution of care. The facility's policies on oxygen administration and storage were not followed, resulting in deficiencies in the care provided to the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) for residents with specific medical conditions, as recommended by the CDC and required by CMS. The deficiency was observed in three residents who had central lines, gastrostomy tubes, or wounds requiring treatment. Despite the presence of EBP signage and PPE caddies in the residents' rooms, staff did not consistently wear gowns during high-contact care activities, such as changing incontinence briefs and providing perineal care. Resident #97, who was cognitively intact and received dialysis, had a dialysis catheter and a recent leg amputation. Although an EBP sign was posted, staff did not wear gowns while providing care, including during the use of a Hoyer lift. Similarly, Resident #105, who was rarely understood and received parenteral tube feeding, had an EBP sign and PPE available, but staff did not wear gowns during care activities. Resident #265, who had a g-tube and was admitted with conditions such as diabetes and hemiplegia, also had an EBP sign, yet staff failed to wear gowns during care. Interviews with facility staff, including a Registered Nurse, a CNA, and the Assistant Director of Nursing, revealed a lack of consistent understanding and implementation of EBP protocols. Staff acknowledged the requirement for gown and glove use during high-contact care for residents with MDROs, dialysis catheters, and other medical devices, but this was not consistently practiced. The facility's administration expected EBP to be included in care plans and physician orders, but this was not always the case, contributing to the deficiency.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple observations and interviews. One resident, who required staff assistance with mobility and personal care, was left with their buttocks exposed while being transported through common areas of the facility. Additionally, the resident was left uncovered in bed with their genitals exposed, visible from the hallway. Staff also failed to empty the resident's urinals, leaving them full and in the resident's line of sight while they ate lunch. Interviews with staff confirmed that these actions were inappropriate and did not align with the facility's policies on resident dignity and privacy. Another incident involved a staff member making a video call on their personal cell phone in a common area, with a resident visible in the background. This action was in violation of the facility's phone policy, which restricts phone use to break rooms or areas away from resident care, and posed a potential HIPAA violation. Interviews with other staff members and the facility's administration confirmed that such actions were not appropriate and breached resident privacy. The facility's policies on resident rights, last reviewed in April 2023, emphasize treating residents with kindness, respect, and dignity, and ensuring privacy and confidentiality. However, the observed incidents indicate a failure to adhere to these policies, resulting in a lack of respect for resident dignity and privacy. The facility's administration acknowledged these deficiencies and the need for staff to follow proper procedures to maintain resident dignity and privacy.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were appropriately assessed for self-administration of medications, obtain necessary physician orders, and adequately supervise residents during medication administration. Specifically, two residents were involved in this deficiency. Resident #20, who has diagnoses including schizophrenia, dysphagia, and myasthenia gravis, was found with medications and an inhaler on their bedside table without a physician's order for self-administration. The resident's cognitive status was noted to fluctuate, and there was no recent assessment to determine their ability to self-administer medications safely. Resident #214, diagnosed with asthma, shortness of breath, obstructive sleep apnea, and heart failure, was also found with inhalers on their bedside table. Although an assessment indicated the resident was capable of self-administering inhalers, there were no physician orders to support this practice. The baseline care plan did not specify which medications the resident was authorized to self-administer, leading to a lack of clarity and potential safety concerns. Interviews with facility staff, including a CMT, LPN, RN, and the Director of Nurses, revealed inconsistencies in the understanding and implementation of the facility's policies regarding self-administration of medications. Staff acknowledged that medications should not be left at the bedside without proper assessment and physician orders, and residents should be observed during medication administration to ensure safety. The facility's failure to adhere to these protocols resulted in the identified deficiencies.
Failure to Maintain Accurate Resident Property Records
Penalty
Summary
The facility failed to maintain accurate records of residents' personal possessions for four residents, as observed through interviews and record reviews. Resident #97's inventory sheet, dated 8/28/24, did not reflect the personal items observed in the room, such as clothing and hygiene items. Resident #38's inventory sheet was incomplete and unsigned, and the resident reported receiving clothing from the facility's lost and found, which was not labeled with their name. Resident #15's inventory sheet was undated and unsigned, and Resident #265's sheet was not signed by staff, with missing items reported by a family member. Interviews with staff revealed inconsistencies in the process of documenting and maintaining personal property inventories. A CNA mentioned using a blank sheet of paper for inventory, while an LPN stated that forms were available at the nurses' desk. The Concierge was responsible for updating inventory lists, but there was confusion about the process when new items were brought in. The Administrator and DON expected staff to complete and update inventory sheets, ensuring they were signed and dated, but this was not consistently done, leading to discrepancies in residents' personal property records.
Failure to Manage Resident's Financial Affairs and Communicate Billing Issues
Penalty
Summary
The facility failed to obtain written authorization to use the personal funds of a resident who was discharged in January 2024 with a credit of $772.00. The resident was later charged $875.00 in October 2024 after an updated bill was received from the resident's co-insurance, resulting in a balance owed of $103.00. The facility did not notify the resident or their responsible party about the additional charges before deducting the amount, which led to the deficiency. The facility's Admission Agreement stated that payments are due by the fifth of the month and that any overpayments would be withheld until all third-party payments were received. Despite this, the Business Office Manager (BOM) sent a refund request in March 2024, which was acknowledged in April 2024, but the refund was not processed in a timely manner. The Regional Business Manager indicated that refunds should be processed within five to thirty days, but the resident's refund was delayed due to waiting for confirmation of out-of-pocket expenses. Interviews with the BOM and the Regional Business Manager revealed a lack of communication with the resident and their family regarding the outstanding balance and the delay in processing the refund. The BOM mentioned that the resident's daughter inquired about the funds, and the Administrator expected timely refunds and communication with the resident's family about any billing issues. The deficiency was identified due to the facility's failure to manage the resident's financial affairs appropriately and communicate effectively with the resident and their family.
Delayed Refund of Resident Funds
Penalty
Summary
The facility failed to refund resident funds within 30 days of discharge for a resident who was discharged in January 2024 with a credit balance of $772.00. Despite attempts to notify the corporate office to issue the refund, the facility did not process the refund in a timely manner. The resident was a private pay from January 6, 2024, until January 16, 2024, and had overpaid for room and board charges. The Business Office Manager (BOM) sent a refund request to the corporate office on March 27, 2024, which was acknowledged on April 1, 2024, but the refund was not issued. Interviews with the BOM and the Regional Business Manager revealed that the refund process was delayed due to waiting for confirmation of any out-of-pocket expenses owed to the facility and ensuring that all third-party payments were received. The Regional Business Manager stated that a refund should be processed within five to thirty days, but could not explain the delay in this case. The BOM mentioned that managed care and Medicare charges take longer to process, which contributed to the delay in submitting the refund request. The Administrator expected refunds to be returned timely, but the facility's process did not meet this expectation.
Failure to Reactivate Medication Orders Post-Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the resident's medication and treatment orders were not reentered into the electronic medical record (EMR) until two days after the resident was readmitted from a hospital stay. The resident, who had a history of mild cognitive impairment, schizophrenia, anxiety, high blood pressure, and chronic obstructive pulmonary disease (COPD), returned to the facility on 9/24/24, but the orders were not entered into the EMR until 9/26/24. This delay resulted in the resident not receiving their prescribed medications and treatments during this period. Upon the resident's return, the nurse completed an assessment and contacted the physician for order verification. However, the nurse failed to activate the orders in the EMR, which meant that the medications and treatments were not visible on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Consequently, the Certified Medication Technician (CMT) or nurse could not administer the medications or treatments as there were no active orders to sign off on. The Director of Nursing (DON) and Administrator acknowledged that the orders should have been verified and activated within 24 hours of the resident's readmission. Interviews with facility staff revealed that the nurse responsible for the readmission had asked another nurse to verify the admission process, but the verification was not completed. The DON later discovered that 42 orders were queued but not activated, and some CMTs reported administering medications based on previous orders, although there was no documentation to confirm this. The physician was informed of the situation and confirmed that the resident did not experience any adverse effects from the missed medications.
Failure to Follow G-Tube Feeding Orders
Penalty
Summary
Facility staff failed to provide appropriate care and services to a resident with a gastrostomy tube (g-tube) by not ensuring the g-tube machine infused the correct amount of feeding formula and by not turning off the g-tube machine at the prescribed time. The resident, who had severe cognitive impairment and multiple diagnoses including cancer, kidney failure, and malnutrition, was observed to have the g-tube infusing at 80 ml/hr instead of the ordered 70 ml/hr on two consecutive days. Additionally, the g-tube was not turned off at 8:00 A.M. as ordered, with the Licensed Practical Nurse (LPN) acknowledging the delay and the incorrect infusion rate. The resident's care plan required continuous nocturnal tube feeding with specific goals to maintain adequate nutritional and hydration status. However, observations showed discrepancies in the infusion rate and timing, with the LPN initially unaware of the correct settings. The facility's Administrator and Director of Nursing confirmed that staff are expected to follow physician's orders, and the nurse is responsible for ensuring the g-tube machine is set correctly. These failures were observed during a survey with a sample size of 14 and a census of 166.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide protective oversight for a resident identified as at risk for elopement. The resident, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia and was assessed to have moderate cognitive impairment. Despite a known history of elopement, the staff failed to visibly confirm the resident's whereabouts during routine rounds. As a result, the resident left the building without staff knowledge and was missing for approximately four hours before staff realized the absence. The resident was found 12 hours later, approximately two miles away from the facility, having crossed a busy intersection. The facility's investigation revealed that the resident likely exited through a tampered window in the dining room, as evidenced by removed retaining screws and a torn screen. Staff interviews indicated that the resident was last seen in the dining room and later assumed to be in bed, but upon closer inspection, it was discovered that the resident was not present, leading to the initiation of a Code Gray. The facility's policies and procedures, including the Missing Resident/Elopement policy, were not effectively followed, as staff did not perform visual checks during rounds. The resident's care plan indicated a risk for elopement, yet the staff did not adequately monitor the resident's location. Interviews with staff members revealed a lack of awareness regarding the resident's exit-seeking behavior and the potential for windows to be fully opened, contributing to the oversight that allowed the resident to elope.
Removal Plan
- Educated all nursing staff on visual checks during rounds
- Educated all staff on the facility's elopement policy and procedures
- Completed an audit of all residents at risk for elopement and updated care plans accordingly
- Performed an elopement drill
- Audited all windows and alarmed doors
Failure to Administer Prescribed Cancer Medication
Penalty
Summary
The facility failed to administer a prescribed cancer medication, Capecitabine, to a resident with colon cancer. The resident had a history of moderate cognitive impairment, anemia, congestive heart failure, high blood pressure, dementia, and depression. The resident returned from a doctor's appointment with a new order for Capecitabine, but the medication was not documented or administered as ordered in December 2023 and February 2024. The resident's medical records lacked documentation of the medication orders and the resident's appointments. Interviews with facility staff revealed a breakdown in the process of transcribing and auditing medication orders. LPN A stated that new orders were given to the ADON, but was unaware of the subsequent steps. ADON B admitted to being behind in updating the resident's medical records. The DON explained that the Charge Nurse should transcribe orders and ensure communication with the responsible party, but this was not documented. The Pharmacy Representative confirmed the absence of orders for the medication during the specified periods. The resident's oncologist was unaware of the missed medication administrations and emphasized the importance of the medication in preventing cancer recurrence. The resident's CEA levels, a cancer marker, increased significantly over time, indicating a potential issue with cancer management. The facility's failure to administer the medication as prescribed and document the resident's medical appointments and orders contributed to the deficiency.
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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