Stonebridge Maryland Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryland Heights, Missouri.
- Location
- 2963 Doddridge Avenue, Maryland Heights, Missouri 63043
- CMS Provider Number
- 265486
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Stonebridge Maryland Heights during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, insomnia, and documented wandering and exit-seeking behaviors was on an elopement care plan that included q15-minute checks, a wander guard, and 1:1 supervision overnight. During an early-morning shift, a CNA twice heard a door alarm while in a resident’s room; the first time, the CNA found the resident and another wanderer at the door and redirected them, but the second time the CNA found only the other wanderer, assumed that person had triggered the alarm, turned off the alarm, and did not check outside or verify the resident’s location. Shortly afterward, a CNA from another unit observed the cognitively impaired resident outside, fully dressed and knocking on that unit’s door, and escorted the resident back while notifying the charge nurses. The facility’s investigation determined the resident had left the unit, walked through the courtyard to another building, and remained outside unsupervised for several minutes because staff did not check the outdoor area when the alarm sounded the second time, despite the resident’s known elopement risk.
A resident with diabetes experienced two hypoglycemic episodes, including one where the resident became unresponsive and required emergency intervention. Staff administered glucagon and documented the event in the shift report but did not immediately notify the physician as required by facility policy. The physician was not informed until after the resident was hospitalized following the second episode, despite clear protocols for urgent notification after significant changes in condition.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Two residents in a facility were denied necessary counseling services due to their Medicaid pending status, resulting in psychosocial harm. One resident, with depression and anxiety, expressed suicidal ideations but did not receive counseling. Another resident, grieving the loss of her husband, expressed a desire to die and also did not receive supportive services. The facility's staff cited Medicaid status as a barrier, despite the Administrator stating services should be provided regardless of payment source.
The facility failed to properly label, date, and dispose of food items in the kitchen, risking foodborne illnesses for residents. An inspection revealed multiple unlabeled and expired items, including sauces, juices, meats, and milk. The DM acknowledged the oversight, attributing it to weekend staff, and emphasized the importance of adhering to food storage policies.
The facility failed to complete TPL forms within the required 30-day timeframe for 12 deceased residents with remaining account balances. The BOM misunderstood the regulation, believing the timeframe was 60 days, leading to delays. The Administrator was misinformed about the timeframe change, resulting in non-compliance with the facility's policy.
The facility failed to provide knives with meals for two residents, making them feel infantilized, and an LPN was observed standing while feeding a resident with cerebral palsy and seizure disorder, contrary to the DON's expectations. The Dietary Manager and Registered Dietitian acknowledged the need for knives, and the LPN was unaware of the requirement to sit while feeding.
The facility failed to involve six residents in their care planning process, as they were not invited to or aware of care plan meetings. Despite being cognitively intact and interested in participating, these residents and their families were not notified or included in the meetings, as confirmed by the MDS Coordinator.
The facility failed to provide complete Medicare Part A termination notices for three residents, leading to potential misunderstandings about appeal rights and service termination. The Advanced Beneficiary Notice of Non-coverage (ABN) forms were incomplete, lacking resident choices and cost information. Interviews revealed staff were unaware of how to properly fill out these forms.
The facility failed to provide a structured activity program for three residents, leading to unmet social and recreational needs. A resident reported dissatisfaction with the activities offered, while two others were not invited to participate in their preferred activities. The facility lacked an activity director and could not provide an activity calendar or attendance logs, indicating a deficiency in the activity program.
A facility failed to maintain a medication error rate below five percent, resulting in a 15.15% error rate. A CMT administered a four percent lidocaine patch instead of the ordered five percent, and several medications were not given as scheduled, despite being signed off as administered. The CMT cited insurance coverage issues and admitted to forgetting the medications, informing the DON of the errors. The facility's policy requires proper verification and documentation of medication administration.
The facility failed to follow its menu policies, leading to residents not receiving meals as planned and their food preferences not being honored. Observations showed discrepancies between the planned and served meals, affecting multiple residents. Some residents did not receive requested items like coffee, and others reported repetitive and unsatisfactory meals. The Dietary Manager and RD acknowledged that staff should not change menus without informing residents, yet no explanation was provided for the inconsistencies.
The facility failed to provide palatable meals, as observed in four residents who complained about unappetizing food. Issues included tough and soggy bread, dry meat, and lack of seasoning. A test tray confirmed inadequate food temperatures and missing components. The Dietary Manager could not explain these deficiencies, which increased the risk of resident dissatisfaction.
The facility failed to monitor antibiotic use for three residents as required by their antibiotic stewardship program. The Infection Preventionist confirmed that the Infection Control Log lacked necessary details such as start and end dates of antibiotics and criteria for administration. Despite acknowledging that many residents did not meet the criteria for antibiotic usage, there was no documentation of discussions with the medical director. The Corporate Nurse also could not provide documentation supporting adherence to the policy, and the infection surveillance checklists were incomplete.
A resident with chronic conditions and a high BIMS score was found with an Advair inhaler at the bedside without a self-administration assessment or order. The facility staff confirmed the absence of the required assessment, and the inhaler was subsequently removed. The facility's policy mandates an evaluation of residents' abilities for self-administration, which was not conducted in this case.
A resident was inaccurately coded as receiving dialysis in their MDS assessment, despite having no physician orders for dialysis and confirming they had never been on dialysis. The MDS Coordinator admitted to the error, citing confusion with another resident, and the DON confirmed the resident was not receiving dialysis.
A facility failed to complete a PASARR Level I screen before admitting a resident with dementia and Parkinson's disease, leading to a potential oversight in identifying necessary specialized services. Staff interviews revealed confusion about the responsibility for completing the screen, with the Social Services Director and Assistant Director of Nurses unsure of the process if the hospital did not complete it.
A resident with hemiplegia and hemiparesis following a stroke did not receive necessary range of motion treatment due to her Medicaid status being pending. Despite being cognitively intact and having a care plan indicating the need for assistance with mobility, there was no evidence of a restorative plan or therapy evaluation. The facility lacked a policy for providing services during pending financial status, contributing to the deficiency.
A facility failed to monitor and document targeted behaviors for a resident with vascular dementia receiving psychotropic medications, as required by their care plan. Despite being prescribed Seroquel and Sertraline, no behaviors were documented in the resident's records, which was confirmed by staff interviews. This lack of documentation could lead to unnecessary medication use.
A facility failed to follow infection control guidelines during wound care for a resident with pressure ulcers. The Wound Care Nurse did not wear gloves or a gown, placed the resident's heel directly on the bed without a barrier, and reused gauze on the wound. The Director of Nursing confirmed these actions were against protocol.
Resident Elopes Outside After Door Alarm Not Fully Investigated
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and oversight to prevent an elopement for one cognitively impaired resident who wandered outside unsupervised. The resident had severe cognitive impairment, diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, and insomnia, and was care planned as an elopement risk and wanderer. The care plan included every 15-minute checks due to attempts to get out of the building, monitoring when pacing to ensure the resident was not attempting to exit seek, a wander guard on the right ankle each shift, and 1:1 supervision from 7 p.m. to 7 a.m. due to attempts to exit the building. The resident’s medical record documented ongoing exit-seeking and wandering behaviors, including notes that the resident remained on frequent monitoring due to continued exit-seeking behaviors and that the wander guard was in place and functioning properly. On the night of the incident, staff documented that the resident had been exit seeking and wandering, with interviews indicating the resident began exit seeking around 4:00 a.m. and was redirected from the exit door multiple times. CNA B reported that during the early morning hours, while providing care in a resident’s room, the door alarm sounded twice. The first time, around 5:30 a.m., CNA B found the resident and another known wanderer at the door, redirected both away from the exit, and returned them to the sitting area before resuming care of other residents. Approximately 15 minutes later, around 5:45 a.m., the door alarm sounded again. CNA B reported finding only the other wandering resident at the door, assumed that resident had triggered the alarm, turned off the alarm, and did not check outside the door or verify the whereabouts of the cognitively impaired resident. Subsequently, CNA C in another housing unit observed the cognitively impaired resident outside, fully dressed, knocking on the door of that unit at approximately 6:00 a.m. CNA C recognized the resident as belonging to a different unit, escorted the resident back to the correct unit, and notified the CNAs there and the charge nurse. CNA E corroborated that the resident had been exit seeking earlier in the night and stated that the resident was calm and seated in the main area before staff began morning rounds. CNA E reported not hearing the alarm while in the shower room with another resident and only became aware the resident had been outside when CNA C returned the resident. The facility’s investigation concluded that the resident had wandered from the assigned building, walked through the courtyard to another building, and was outside unsupervised for an estimated five to ten minutes between the last sounding of the door alarm and being found at the other unit’s door. The investigation determined that although alarms functioned and sounded, staff did not check the outdoor area when the alarm activated the second time, and the DON and Administrator stated it was not appropriate for staff to ignore any alarm and that they expected staff to check outside and conduct a head count when an alarm sounded. The resident’s medical record documented that when the incident was reported to the nurse, a head-to-toe assessment and neuro checks were performed, with no injuries or changes from the resident’s previous level of functioning noted. Due to poor memory, reasoning, and understanding, the resident was unable to provide an account of what had occurred. Progress notes around the time of the incident continued to describe the resident’s wandering, exit-seeking behaviors, and the use of frequent monitoring and observation precautions. Staff interviews and the facility’s written investigation emphasized that the resident had been wandering throughout the night and that, despite being on elopement precautions and having a wander guard in place, the resident was able to leave the unit and remain outside unsupervised until discovered by staff from another unit.
Failure to Notify Physician After Significant Change in Resident Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician following significant changes in the resident's physical status, specifically after two hypoglycemic episodes. The first episode occurred when the resident was found unresponsive with a blood sugar of 40, and glucagon was administered by an LPN. The LPN did not notify the physician at that time, believing the situation was resolved after the resident's blood sugar normalized and the resident ate breakfast. Documentation of the event was limited to the shift change report, and no direct communication with the physician occurred. Later, the resident experienced a second, more severe hypoglycemic episode during the following shift, where the resident was found unresponsive, hardly breathing, and foaming at the mouth. Emergency services were called, CPR was initiated, and the resident was transported to the hospital with a blood sugar of 27. The physician was not notified of the initial hypoglycemic event or the subsequent change in condition until after the second, critical episode had occurred and the resident had already been sent to the hospital. Interviews confirmed that the physician and physician's office were not contacted regarding the resident's initial hypoglycemic episode, and the physician stated that he would have altered the resident's diabetes management had he been informed. The facility's policies required immediate physician notification for significant changes in condition, including hypoglycemic episodes, but these protocols were not followed by staff. The resident's care plan and physician orders included specific instructions for diabetes management and hypoglycemia response, which were not fully adhered to in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Counseling Services Due to Medicaid Pending Status
Penalty
Summary
The facility failed to provide necessary counseling services to two residents, R65 and R113, due to their Medicaid pending status, resulting in psychosocial harm. R65, who was admitted with diagnoses including depression and anxiety disorder, expressed suicidal ideations on multiple occasions. Despite being cognitively intact and prescribed antidepressants, R65 did not receive counseling services. The facility's Social Service Designee (SSDE) acknowledged the lack of counseling, citing the pending Medicaid status as the reason. The Administrator confirmed that services should be provided regardless of payment source, but no policy was in place to address service provision during pending financial status. R113, who was also cognitively intact, experienced the unexpected death of her husband, who was her roommate in the facility. Following this traumatic event, R113 expressed a desire to die and reported that no one had provided counseling or supportive services. The SSDE admitted that R113 had not been referred for counseling due to her Medicaid status. The Assistant Director of Nursing (ADON) noted that R113 was tearful and had declined additional antidepressants, but this was not documented. The Social Services Director (SSD) was unaware of R113's statements about wanting to die, indicating a lack of communication and monitoring. The facility's failure to provide medically-related social services to R65 and R113 highlights a significant deficiency in addressing the mental and psychosocial health needs of residents. Both residents were left without appropriate interventions or referrals to mental health professionals, despite expressing severe distress and suicidal thoughts. The lack of documentation and communication among staff further exacerbated the situation, leaving the residents without the necessary support during critical times.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling, dating, and disposal of food items in the main kitchen, which could potentially lead to the spread of foodborne illnesses among residents. During an inspection, several food items were found in the kitchen's reach-in refrigerator without labels or dates, including a container of unidentified white sauce, a quart of Thick and Easy orange juice, an opened package of hot dogs, a gallon of milk, bags of mixed vegetables, hard-boiled eggs, a whole ham, sliced ham, sweet pickle relish, and lunch meat. Additionally, expired milk cartons were found in both the reach-in and walk-in refrigerators. The Dietary Manager (DM) acknowledged these issues during an interview, stating that the weekend staff was responsible for ensuring food items were labeled and not outdated. The DM expressed an expectation that all dietary staff should be aware of and adhere to the facility's food storage policy, which mandates labeling, dating, and monitoring of refrigerated food to ensure it is used by its use-by date. This oversight in food management practices posed a risk to the health and safety of 140 out of 142 residents in the facility.
Failure to Timely Complete TPL Forms for Deceased Residents
Penalty
Summary
The facility failed to complete Third Party Liability (TPL) forms within the required 30-day timeframe for residents who had expired, affecting 12 residents with remaining balances in their accounts. The facility's policy mandates that upon a resident's death, the appropriate forms must be completed and submitted to the Department of Social Services within 60 days, but the TPL forms should be completed within 30 days. However, the Business Office Manager (BOM) misunderstood the regulation, believing the timeframe for TPL completion was 60 days, leading to delays in processing these forms. The deficiency was identified through interviews and record reviews, revealing that the BOM was unaware of the correct 30-day requirement, and the Administrator was misinformed by the BOM about a supposed change to a 60-day timeframe. This misunderstanding resulted in the facility not adhering to the policy, affecting the final accounting for the deceased residents' trust funds. The residents involved had varying account balances, ranging from $0.88 to $2,018.08, which were not processed in a timely manner as per the facility's procedures.
Deficiencies in Dining Experience and Feeding Assistance
Penalty
Summary
The facility failed to uphold residents' rights to a dignified dining experience by not providing knives with meals for two residents, which made them feel infantilized. During interviews, these residents expressed dissatisfaction with the lack of knives, stating it made them feel like children. Observations confirmed that residents were only given spoons and forks, and meals were served randomly, causing some residents to wait without meals while others at the same table were served. The Dietary Manager and Registered Dietitian acknowledged that knives should be provided, and there was no reason for their absence. Additionally, the facility did not ensure proper feeding practices for a resident with cerebral palsy and seizure disorder who required assistance with eating. An LPN was observed standing while feeding this resident, contrary to the Director of Nurses' expectations that staff should sit while assisting residents with meals. The LPN was unaware of the requirement to sit, and the Director of Nurses confirmed the improper practice upon observation. The facility did not provide a policy for dining assistance, and the Administrator noted that the LPN was only helping out and should have known not to stand.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that six out of seven residents reviewed for care planning were afforded the right to participate in their care planning process. This deficiency was identified through interviews and record reviews, revealing that residents were not invited to or aware of care plan meetings. For instance, one resident, who was cognitively intact, was unaware of what a care plan meeting was and had no documentation of attending any meetings in 2024, except for one instance. The facility's administrator confirmed the lack of documentation for additional meetings. Another resident, also cognitively intact, expressed that she had not been invited to care plan conferences for several years, despite her interest in attending. The MDS Coordinator could not provide documentation of invitations or attendance for this resident. Similarly, another resident reported never being invited to a care conference, and the MDS Coordinator confirmed the absence of invitations for this resident as well. Additionally, family members of two residents reported never being invited to care plan meetings, despite being regularly present at the facility and willing to participate. The MDS Coordinator confirmed that these residents and their families had not been sent notifications or invited to care plan meetings. This lack of involvement in care planning placed residents at risk of not being aware of the goals and outcomes of their care.
Incomplete Medicare Notices for Residents
Penalty
Summary
The facility failed to issue the appropriate notice for termination of Medicare Part A benefits for three residents, which could lead to a lack of understanding of appeal rights and the termination of care against the residents' wishes. The review of the facility's policy and CMS guidelines revealed that the Advanced Beneficiary Notice of Non-coverage (ABN) forms were not filled out correctly. Specifically, the forms lacked the necessary options for residents to choose whether they wanted to continue skilled services with payment responsibility, discontinue services, or appeal for further coverage. Additionally, the forms did not include the reason why Medicare would not pay or the estimated cost of services if residents chose to pay out of pocket. For Resident 92, the Notice of Medicare Non-Coverage (NOMNC) did not specify which therapy would be discontinued after the last covered day, and the ABN form was incomplete, lacking the resident's choice and cost information. Similarly, Resident 1's NOMNC and ABN forms were incomplete, with no specific therapy discontinuation details or resident choices indicated. Resident 49, who was moderately cognitively impaired, also had incomplete forms, with the ABN lacking the necessary options and cost details, despite verbal consent from the resident's representative. Interviews with the Social Services Designee (SSDE) and the Administrator revealed a lack of knowledge and understanding regarding the completion of these forms. The SSDE admitted to not specifying which therapy would be discontinued and leaving cost information blank due to a lack of knowledge on where to obtain this information. The Administrator acknowledged the issue and stated that the SSDE is responsible for ensuring all areas of the forms are filled out completely and correctly.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of resident-preferred activities for three residents, leading to a deficiency in meeting their social and recreational needs. Resident 27, who was cognitively intact, expressed dissatisfaction with the activities offered, stating that she was only given coloring pages, which she did not enjoy. Her care plan indicated preferences for watching television and listening to music, but there was no evidence of her participation in these activities. Similarly, Resident 93, also cognitively intact, reported not being invited to any activities despite her care plan listing preferences for group activities such as bingo and trivia. The facility did not provide documentation of her participation in these activities. Resident 137, who was cognitively intact, was unaware of any activities available in the facility and expressed a desire to go outside for fresh air. Her care plan included preferences for group activities, but there was no record of her involvement. The facility's administrator acknowledged the absence of a qualified activity director since the previous director resigned, and the current activity program was being managed by CNAs and an activity assistant. However, the facility could not provide an activity calendar or attendance logs for the past six months, indicating a lack of structured activity programming.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 15.15%. This was due to five errors occurring out of 33 opportunities for error. The errors included a resident not receiving medications as ordered and receiving a medication at an incorrect strength. Specifically, a Certified Medical Technician (CMT) administered a four percent lidocaine patch to a resident's right knee, contrary to the physician's order for a five percent patch. Additionally, several medications, including Fexofenadine, Spironolactone, Artificial Tears, and Gabapentin, were not administered as scheduled during the morning medication pass, despite being signed off as given. The CMT involved stated that the insurance would not cover the five percent lidocaine patches, leading to the use of the four percent patches. The CMT also admitted to forgetting to administer the other medications and informed the Director of Nursing (DON) of the oversight. The DON acknowledged awareness of the issues but was unsure why the correct patches were not ordered and noted that the CMT was too nervous to report the medication omissions immediately. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method before administration, and documentation if a drug is withheld or given at a different time.
Failure to Follow Menus and Honor Resident Preferences
Penalty
Summary
The facility failed to adhere to its menu policies, resulting in residents not receiving meals as planned and their food preferences not being honored. The facility's policy required menus to be followed, provide a variety of foods, and be approved by a Registered Dietitian. However, observations revealed that the meals served did not match the planned menus. For instance, on a specific date, residents were supposed to receive spaghetti with meat sauce and a specific salad for lunch, but instead received peas and carrots, a slice of white bread, and oranges. Similarly, the dinner menu was supposed to include a beef and bean burrito, but residents were served chicken tenders and other items not listed on the menu. This inconsistency in meal service affected multiple residents, including those with specific dietary preferences and needs. Several residents expressed dissatisfaction with the meals, noting that their preferences were not considered, and they often received food they did not like or want. One resident, who was cognitively intact, reported not receiving coffee with breakfast despite repeated requests and was served pork patties, which she did not eat. Another resident complained about the lack of condiments and the repetitive nature of the meals. Interviews with the Dietary Manager and Registered Dietitian revealed that staff were not supposed to change the menu without informing residents, and there was no explanation for the discrepancies. The failure to follow the menu and honor residents' preferences placed a significant number of residents at risk of nutritional problems and dissatisfaction with their meals.
Failure to Provide Palatable Meals
Penalty
Summary
The facility failed to provide palatable meals for four residents, leading to dissatisfaction with the meals served. Residents reported that the food was unappetizing, with complaints about tough and soggy bread, dry meat, and lack of seasoning. Observations confirmed these issues, as one resident was seen licking the bread and leaving the table without finishing the meal, while another threw the sandwich off the plate and only ate a few French fries. The Dietary Manager's job description indicated responsibility for ensuring meal standards, but the manager could not explain the lack of seasoning or condiments. A test tray revealed further deficiencies, with food items served at inadequate temperatures and missing components like the dinner roll and pie. The ham was dry and difficult to chew, the carrots lacked seasoning and glaze, and the potatoes were dry. The Dietary Manager verified the temperatures, which were below acceptable levels, and acknowledged the absence of condiments, but could not provide an explanation for these oversights. This failure to meet meal standards increased the risk of residents not being satisfied with their meals.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor the use of antibiotics for three residents as part of their antibiotic stewardship program. The facility's policy required the implementation of an antibiotic stewardship program, including protocols and a system to monitor antibiotic use. However, the Infection Preventionist (IP) confirmed that the facility's Infection Control Log did not contain the required start and end dates of administered antibiotics or the criteria for administration. The IP acknowledged that numerous residents did not meet the criteria for antibiotic usage and had discussed this issue with the facility medical director, but could not provide documentation of this discussion. Additionally, the Corporate Nurse was unable to provide documentation supporting adherence to the antibiotic stewardship policy for the residents in question, and the infection surveillance checklists provided were incomplete.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications before allowing medications to be left at the bedside. Resident 68, who was cognitively intact with a BIMS score of 14 out of 15, was observed with an Advair inhaler at the bedside on multiple occasions. The resident had been readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, chronic diastolic congestive heart failure, and morbid obesity. Despite the resident's cognitive status, there was no documented assessment for self-administration, nor was there an order for the medication to be kept at the bedside. The deficiency was identified when the inhaler was observed at the resident's bedside on several occasions, and the facility staff could not provide a self-administration assessment document. The LPN confirmed the absence of an assessment and stated that the inhaler was removed and returned to the medication cart after being notified by the Administrator. The Director of Nursing also confirmed that the resident had not been assessed for self-administration of the inhaler, which was against the facility's policy requiring an evaluation of the resident's mental and physical abilities for self-administration of medications.
Inaccurate MDS Coding for Dialysis
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one of the sampled residents, identified as R121. R121 was admitted with diagnoses of anemia, orthostatic hypotension, and generalized weakness. The quarterly MDS assessment indicated that R121 was receiving dialysis, which was incorrect. A review of R121's physician orders showed no orders for dialysis, and during an interview, R121 confirmed never having been on dialysis. The MDS Coordinator admitted to mistakenly coding R121 as receiving dialysis due to confusion with another resident. The Director of Nursing confirmed that R121 was not receiving dialysis.
Failure to Complete PASARR Level I Screen Prior to Admission
Penalty
Summary
The facility failed to ensure the completion of a Pre-Admission Screen and Resident Review (PASARR) Level I screen prior to the admission of a resident, identified as R112, who was reviewed for PASARR among a sample of 33 residents. R112 was admitted with diagnoses including unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, as well as Parkinson's disease without dyskinesia. The resident's electronic medical record (EMR) lacked evidence of a PASARR Level I screen and determination before admission, which is crucial for identifying necessary specialized or rehabilitative services and determining the appropriateness of the resident's placement in the facility. Interviews with facility staff revealed a misunderstanding regarding the responsibility for completing the PASARR Level I screen. The Social Services Director believed the hospital was responsible for completing the screen before admission, with a 72-hour window for the facility to complete it if not done. The Assistant Director of Nurses was unsure who should complete the screen if the hospital did not. The Administrator mentioned that a C form was done but deleted since a Level 2 was not needed, and stated that if the hospital did not complete the PASARR Level I screen, the admission person and social services should follow up. This lack of clarity and communication led to the deficiency in ensuring the PASARR Level I screen was completed for R112 prior to admission.
Failure to Provide Range of Motion Treatment Due to Pending Medicaid Status
Penalty
Summary
The facility failed to provide range of motion treatment to a resident, identified as R65, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke. Despite being cognitively intact, as indicated by a BIMS score of 15 out of 15, R65 did not receive any physical therapy, occupational therapy, or range of motion exercises as noted in the Minimum Data Set assessments. The care plan indicated that R65 required assistance with activities of daily living and mobility, with a goal to improve mobility and independence. However, there was no evidence of a restorative plan or evaluation by a therapist, which was confirmed by the Restorative Aide. R65 expressed a desire for therapy to regain strength and return home, but stated that services were not provided due to her Medicaid status being pending. The Business Office Manager acknowledged that Medicaid processing could take a long time, and the Administrator stated that services should be provided regardless of payment source, yet could not explain why R65 had not received the necessary services. Additionally, the facility lacked a policy to address the provision of services during a pending financial status, contributing to the deficiency in care for R65.
Failure to Monitor Targeted Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident diagnosed with vascular dementia and hallucinations, who was receiving psychotropic medications. The resident was admitted with a diagnosis of vascular dementia and hallucinations and was prescribed Seroquel, an antipsychotic, and Sertraline, an antidepressant. The care plan for the resident included monitoring and documenting behaviors such as skin picking, agitation, hallucinations, and refusal of care. However, a review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024 and January 2025 revealed no documentation of targeted behaviors. Interviews with facility staff, including an LPN and the Minimum Data Set Coordinator, confirmed the absence of documented behaviors in the resident's electronic medical record. The facility's policies on Behavioral Assessment, Intervention and Monitoring, and Antipsychotic Medication Use require documentation of specific target behaviors and monitoring for efficacy and adverse consequences. The lack of documentation had the potential for the resident to receive medications unnecessarily, as there was no recorded evidence of the behaviors that warranted the use of psychotropic medications.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound care observation for a resident with diabetes mellitus and congestive heart failure, who had one stage four and one unstageable pressure ulcer. The resident's care plan included specific interventions for wound management, such as obtaining a culture if drainage was present and providing wound care per treatment order. However, during the wound care observation, several breaches in infection control were noted. The Wound Care Nurse (WCN) cleaned scissors and the overbed table without wearing gloves, did not wear a gown despite the resident being on Enhanced Barrier Precautions, and placed the resident's heel directly on the bed without a barrier. Additionally, the WCN used improper technique by patting the wound with a clean 4x4 gauze, folding it, and then using the same gauze to pat the wound bed again. When questioned about these practices, the WCN denied the observed breaches. The Director of Nursing confirmed that the nurse should have worn a gown, used gloves when cleaning, and used a new gauze for each patting of the wound bed, as well as a barrier for the resident's heel.
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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