U-city Forest Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Louis, Missouri.
- Location
- 1301 Partridge Avenue, Saint Louis, Missouri 63130
- CMS Provider Number
- 265736
- Inspections on file
- 31
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at U-city Forest Manor during CMS and state inspections, most recent first.
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.
A resident with significant weight loss and multiple medical conditions did not receive dietary supplements as ordered, nor was the supplement increased as recommended by the dietitian. Staff were unaware of the updated recommendations, and the supplements were not provided with meals as required.
A resident on anticoagulant therapy experienced a nose bleed that was not properly assessed or documented across all shifts, and physician orders for saline nasal spray were not followed due to its omission from the MAR and lack of administration documentation. Staff failed to consistently communicate and document the resident's change in condition, and the event was not recognized as requiring a formal assessment, despite ongoing bleeding and the resident's risk factors.
A resident with dysphagia and a history of choking was left unsupervised during lunch, leading to a fatal choking incident. The resident choked on broccoli, which was not part of their meal, indicating it was taken from another plate. The facility failed to follow policies on supervision and dietary modifications, and staff were unaware of the resident's specific needs, contributing to the incident.
A facility failed to update a resident's care plan with speech therapy recommendations for choking prevention. The resident, with severe cognitive impairment and a history of choking, did not have a care plan reflecting necessary strategies for safe swallowing. Despite speech therapy's efforts to educate staff, the care plan lacked updates due to communication failures, leading to continued choking incidents.
The facility did not ensure an RN was present for eight consecutive hours each day, as required, resulting in multiple days without RN coverage. Staff confirmed only one RN was employed full time, and recruitment efforts had not filled the staffing gaps.
The facility failed to obtain and maintain proper Power of Attorney (POA) documentation for two residents, resulting in confusion over decision-making authority. One resident with cognitive impairment was moved to a locked memory care unit after a minor behavioral incident, without assessment, alternative interventions, or required notifications to the physician or family. Documentation and communication failures were identified, including inconsistent records regarding POA status and lack of proper notification for significant changes.
A resident who was dependent for ADLs, cognitively impaired, and always incontinent was left in a urine-soaked brief without timely perineal care. Multiple CNAs removed the soiled brief but failed to clean the resident or apply a clean brief as required by facility policy. Staff interviews confirmed awareness of the need for perineal care after incontinence, but the care was not provided, leaving the resident feeling unclean and uncared for.
A cockroach was observed crawling on a resident's blanket while the resident, who was cognitively impaired and dependent for care, was in bed. Despite regular pest control treatments targeting German roaches throughout the facility, staff interviews confirmed an ongoing cockroach problem. The incident demonstrated that the pest control program was not effective in preventing pest presence in resident areas.
The facility did not follow their policy of retaining grievance logs for three years, as only logs from January 2024 to the current date were available. The ADON confirmed the change in the logging process and the inability to locate previous logs. The administrative team expected compliance with the three-year retention policy.
Facility staff failed to provide 24-hour protective oversight for two residents with a history of elopements and wandering, as well as failed to ensure smoking assessments were completed for two residents who smoked. Staff did not follow physician's orders to monitor wanderguard devices, and there was confusion about who was responsible for smoking assessments.
The facility failed to provide eight hours of RN coverage for 16 out of 92 days, potentially causing unmet health needs for all residents. Despite the facility's staffing policy requiring adequate RN and nursing staff, the Payroll Based Journal (PBJ) Staffing Data Report showed no RN coverage on 16 specific dates. Interviews with administrative staff confirmed this deficiency.
The facility failed to ensure proper labeling and storage of medications, with issues found in three out of four medication carts and one medication room. Insulin pens were opened and dated beyond 28 days, and multiple OTC medications were undated and expired. Staff interviews confirmed that medications should be dated upon opening and expired medications should not be administered, but these practices were not consistently followed.
The facility failed to ensure accurate and updated code statuses for three residents. One resident had conflicting information in their records, another had an outdated full code status despite being rarely understood, and a third resident's code status had not been updated for over a year. The Social Worker was responsible for these updates but had not performed them in a timely manner.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents. The Regional Business Office Manager indicated that SNFABN forms were provided for Medicare Part B discharges, not Medicare Part A, which was confirmed by the Administrator, DON, ADON, and Regional Operational Director.
The facility failed to ensure that residents with mental disorders had a DA-124 Level I screen (PASARR) as required. Three residents with significant cognitive impairments and psychiatric diagnoses had no PASARR Level I on file, and the facility's administration confirmed that these screenings should have been completed within 30 days of admission.
The facility failed to complete a discharge summary for a resident with high blood pressure, depression, and stroke. The resident was discharged in stable condition with necessary medications and documentation, but no discharge summary was included in the medical record. The Regional Clinical Director confirmed this oversight.
The facility failed to provide adequate ADL care for two residents who were dependent on staff for personal care. Both residents were observed with excessively long and dirty fingernails, despite expressing a need for grooming. Staff interviews revealed confusion about responsibilities for nail care, particularly for diabetic residents, leading to a lack of proper grooming.
The facility failed to ensure a resident receiving routine dialysis had accurate physician's orders, consistent communication, and a dialysis contract. The resident's care plan required monitoring of vital signs, weight, and the AVF site, but these were not documented. Staff interviews revealed that dialysis communication forms were often lost and not completed, and the facility lacked a dialysis contract with the provider.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.41% error rate. An LPN did not follow proper procedures for insulin pen use, including wiping the rubber seal with alcohol and priming the pen, for two residents with diabetes. The facility lacked a policy on insulin pen priming, contributing to the errors.
The facility failed to follow infection control standards by not properly disinfecting glucometers between uses and not adhering to proper hand hygiene and glove use during wound care for two residents. Staff used alcohol pads instead of EPA-registered disinfecting wipes for glucometers and double-gloved during wound care, contrary to facility policy.
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.
Failure to Provide and Increase Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement as ordered and did not implement the dietitian's recommendation to increase the supplement for a resident experiencing weight loss. The resident, who had diagnoses including cerebral palsy, severe cognitive impairment, and severe protein-calorie malnutrition, was on a regular pureed diet with nectar thickened liquids and was supposed to receive a house shake twice daily and Majic Cup with lunch and dinner. The dietitian recommended increasing the house shake to three times daily with meals due to ongoing weight loss, but this recommendation was not implemented. Documentation showed the resident continued to receive the supplement only twice daily, and there was no evidence of the increased frequency being provided. Observation during a meal revealed the resident did not receive the required supplements with lunch, and staff were unaware of the missed supplements and the dietitian's updated recommendation. The process for communicating dietary changes involved verbal and email notifications from the dietitian to the ADON, who was then responsible for ensuring nurses updated orders and dietary slips. However, this process was not followed, resulting in the resident not receiving supplements as ordered or as recommended by the dietitian.
Failure to Assess, Document, and Follow Physician Orders After Resident Nose Bleed
Penalty
Summary
The facility failed to properly assess and document a resident's change in condition following a nose bleed, and did not ensure physician orders were followed regarding the administration of saline nasal spray. The resident, who had diagnoses including hypertension, diabetes, major depressive disorder, and was on anticoagulant medications for a history of stroke, experienced a nose bleed that was initially addressed by an LPN with non-pharmacological interventions. The physician was notified and subsequently ordered to hold the resident's anticoagulant medications and to administer saline nasal spray three times daily. However, the saline nasal spray was not added to the Medication Administration Record (MAR), and there was no documentation that it was administered as ordered. Documentation gaps were evident across shifts. There were no nursing notes during the overnight shift following the initial nose bleed, despite evidence of continued bleeding observed the next morning. The overnight LPN did not document any care or observations in the resident's chart, and the CNA on duty was not given specific instructions regarding the resident's care. The following morning, another LPN found the resident with blood on the face and bedding, and the resident reported ongoing nose bleeds. The resident was subsequently sent to the hospital for evaluation and treatment after further assessment revealed lethargy and abnormal vital signs. Interviews with staff revealed inconsistent communication and follow-through regarding the resident's change in condition. The LPN who initially responded to the nose bleed did not complete a formal change in condition assessment. The overnight LPN and CNA did not witness active bleeding but observed evidence of it and did not document or escalate the situation. The Assistant Director of Nursing and Administrator stated they did not consider a nose bleed a change in condition, despite the resident's risk factors and care plan instructions to monitor for bleeding. The lack of documentation, assessment, and timely administration of ordered treatments contributed to the deficiency.
Inadequate Supervision Leads to Resident Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a diagnosis of dysphagia and a history of choking. The resident was left unsupervised during lunch in the dining room, which led to a choking incident. Despite staff intervention, they were unable to clear the resident's airway, and the resident eventually expired after emergency medical staff dislodged a large piece of broccoli from the resident's throat. The broccoli was not part of the resident's lunch tray, indicating that the resident may have taken it from another resident's plate. The facility's policies on safety and supervision of residents, as well as the interdepartmental notification of diet changes, were not adequately followed. The resident's care plan did not address previous choking incidents or the speech therapist's discharge recommendations for close supervision and specific dietary modifications. Staff interviews revealed a lack of awareness and implementation of these recommendations, contributing to the resident's unsupervised state during meals. The resident had a history of severe cognitive impairment, anxiety disorder, aphasia, and stroke, which increased the risk of choking. Despite these known risks, the facility did not ensure that staff were within arm's reach of the resident during meals, as recommended by the speech therapist. The failure to provide appropriate supervision and adhere to dietary restrictions directly led to the resident's choking incident and subsequent death.
Failure to Update Care Plan with Speech Therapy Recommendations
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected current needs, specifically regarding speech therapy recommended choking strategies. The resident, who had a history of choking, was not provided with a care plan that included the necessary strategies to prevent further incidents. The resident had severe cognitive impairment and was on a mechanical soft diet with thin liquids, but continued to experience choking episodes, including one incident involving a breadstick. The resident's care plan did not incorporate the speech therapy discharge recommendations, which included close supervision and specific strategies to facilitate safe swallowing. Despite the speech therapist's efforts to educate staff and provide cues to the resident during meals, the care plan was not updated to reflect these necessary interventions. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan requirements, including the need for close supervision and monitoring for signs of dysphagia. The MDS Coordinator, responsible for updating care plans, was unaware of the speech therapy recommendations due to a lack of communication from the speech therapy department. This oversight resulted in the resident's care plan not being updated to include critical strategies for preventing choking incidents. The Assistant Administrator and Assistant Director of Nursing acknowledged the deficiency and expressed that the speech therapy recommendations should have been included in the care plan.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week, as required. Review of daily assignment sheets revealed that there was no RN present in the facility on eight specific days within a fifteen-day period, despite a census of 75 residents. Interviews with the Assistant Director of Nursing (ADON) and the Assistant Administrator (AA) confirmed awareness of the requirement and acknowledged that only one RN was employed full time, resulting in gaps in RN coverage. The facility had been actively recruiting for additional RNs but had not been successful in filling the positions, leading to the deficiency.
Failure to Obtain Proper POA Documentation and Involuntary Seclusion Without Assessment
Penalty
Summary
The facility failed to uphold residents' rights to dignity, self-determination, and communication by not obtaining or maintaining proper Power of Attorney (POA) documentation for two residents. In one case, a former facility employee was listed as a resident's POA for nearly two years without the appropriate, legally valid forms, as the documentation was incomplete and not notarized. When the error was discovered, the resident's family attempted to submit new POA paperwork, but it was also found to be incomplete, resulting in the resident being considered responsible for their own decisions despite documented cognitive impairment and a diagnosis of dementia. Staff interviews confirmed that the facility acted as if the former employee was the POA without proper verification, and there was confusion and lack of clarity among staff regarding the resident's decision-making status. Additionally, the facility failed to respect a resident's right to be free from involuntary seclusion. The resident, who had moderate cognitive impairment and a history of dementia, was moved to a locked memory care unit after being observed peeling wallpaper in the facility's entryway. Staff interviews and documentation revealed that the resident was easily redirected, not a threat to themselves or others, and did not display aggressive or combative behavior. The decision to move the resident to a more restrictive environment was made without prior assessment, alternative interventions, or notification to the resident's physician, psychiatrist, or family. There was also a lack of documentation in the resident's electronic medical record regarding the incident, the rationale for the room change, and the notifications that should have occurred. For another resident with severe cognitive impairment and a diagnosis of dementia, there was inconsistency in the facility's records regarding the existence of a POA. While the care plan and face sheet indicated that the resident's family member was the POA, a faxed document from the ADON stated otherwise. Staff interviews highlighted a lack of consistent procedures for verifying, documenting, and communicating POA status, as well as failures to notify the appropriate parties of significant changes or incidents as required by facility policy.
Failure to Provide Timely and Appropriate Perineal Care After Incontinence Episode
Penalty
Summary
Facility staff failed to provide timely and appropriate perineal care to a dependent resident following an incontinence episode. The resident, who was cognitively impaired, dependent for toileting and transfers, always incontinent of bladder and bowel, and at risk for pressure ulcers, was observed lying in bed with a urine-soaked brief. Staff did not attend to the resident's incontinence needs that morning, as confirmed by the resident during an interview. During observations, two CNAs removed the urine-soaked brief but did not perform perineal care or apply a clean brief before leaving the resident covered with a blanket. Later, two other CNAs entered the room, placed a clean brief on the resident, and dressed and transferred the resident without performing perineal care. Interviews with the CNAs revealed that they were aware of the expectation to provide perineal care after incontinence episodes but failed to do so, with some staff assuming the care had already been provided by others. The resident reported feeling unclean and uncared for when perineal care was not performed after incontinence episodes and stated this occurred often. Facility policy required staff to provide incontinence care and barrier cream after each episode, and staff interviews confirmed knowledge of these expectations. The failure to provide perineal care was acknowledged by staff and administration as not meeting the resident's needs and not respecting the resident's dignity.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of a cockroach crawling on a resident's blanket while the resident was lying in bed. The resident involved was cognitively impaired, had impairment on both sides of the lower body, was dependent for toileting and transfers, and was always incontinent of bladder and bowel. Diagnoses included diabetes mellitus, stroke, and dementia. The pest control company's service report indicated ongoing efforts to address a German roach infestation, including treatments in the kitchen, therapy room, and resident rooms. Despite these measures, a cockroach was observed on the resident's blanket, and staff confirmed the ongoing presence of cockroaches in the facility. Interviews with staff revealed that cockroaches had been a persistent issue in the building, with monthly pest control treatments failing to fully eliminate the problem. The Housekeeping Supervisor confirmed the incident and acknowledged the ongoing problem, suggesting that recent treatments in other areas may have displaced cockroaches to new locations within the facility. The Assistant Administrator stated that staff and residents were expected to report sightings, but acknowledged that cockroaches had been reported earlier in the month. The deficiency had the potential to affect all residents in the facility.
Failure to Retain Grievance Logs for Required Period
Penalty
Summary
The facility failed to follow their policy by not retaining three years of grievance logs. During a review, it was found that the grievance binder only contained logs from January 2024 to the current date, with no logs available for 2022 or 2023. The Assistant Director of Nursing (ADON) confirmed that the facility had recently changed the process of logging grievances and was unable to locate any other grievance binders. The Administrator, Director of Nursing, ADON, and Regional Operational Director all stated that they expected the facility to retain grievance logs for three years, as per their policy.
Failure to Monitor Wanderguards and Conduct Smoking Assessments
Penalty
Summary
Facility staff failed to provide 24-hour protective oversight for two residents with a history of elopements and wandering. The residents resided on a secured behavior unit, and staff did not follow physician's orders to monitor the residents' wanderguard devices as ordered. Specifically, Resident #42 was discovered not wearing their wanderguard, and Resident #53's wanderguard was found to be non-functional. The facility's Elopement Policy and Procedure required that each wanderguard be checked for functionality every shift and documented on the Treatment Administration Record (TAR), but this was not done. Additionally, staff were unaware of how to check the functionality of the wanderguards, and the necessary handheld testing device was not readily available or used correctly. This lack of oversight and adherence to policy resulted in the residents being at risk of elopement without proper monitoring. The facility also failed to ensure that smoking assessments were completed for two residents who smoked. Resident #41 and Resident #39 both had care plans indicating they chose to smoke cigarettes and required monitoring during smoking times for safety. However, there were no smoking assessments documented in their medical records. Interviews with staff revealed confusion about who was responsible for completing these assessments, with the Social Worker admitting that she had not completed any smoking assessments during her tenure. This oversight left the residents at risk of smoking-related injuries without proper evaluation and monitoring. During interviews, the Assistant Director of Nurses (ADON) and other staff members acknowledged the deficiencies. The ADON was unaware of the missing or non-functional wanderguards until informed by state surveyors. The ADON also found the wanderguard testing device in its original box, indicating it had not been used. The facility's Administrator, ADON, and Director of Nursing confirmed that wanderguards should be monitored and documented as ordered, and smoking assessments should be completed annually and as needed. These failures in following established protocols and ensuring staff competency in using safety devices and conducting assessments led to significant lapses in resident safety and care.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight hours of Registered Nurse (RN) coverage for 16 out of 92 days, which had the potential to cause unmet health needs for all residents. The facility's staffing policy, dated July 2019, stated that adequate staffing would be maintained to meet residents' needs, including having licensed RN and nursing staff available to provide and monitor care. However, a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for the first fiscal quarter of 2023 showed that there was no RN coverage on 16 specific dates. Interviews with the Assistant Director of Nursing (ADON) and other administrative staff confirmed the lack of RN coverage on these dates, despite the expectation that the facility would have eight hours of RN coverage daily.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an inspection, it was found that three out of four medication carts and one medication room had issues. Specifically, insulin pens were opened and dated more than 28 days, and multiple bottles of over-the-counter (OTC) medications were undated and expired. The facility's Medication Storage Policy mandates that medications and biologicals be stored safely and securely, and that outdated or deteriorated drugs be immediately withdrawn from stock and disposed of properly. However, observations revealed that this policy was not followed, as evidenced by the presence of expired and undated medications in the medication carts and room checked during the survey. The census at the time was 73 residents. During interviews, a Certified Medical Assistant (CMT) acknowledged that medications should be dated upon opening and that expired medications should not be administered to residents. A Licensed Practical Nurse (LPN) instructed the CMT to discard expired medications. The Director of Nursing (DON) confirmed that staff were expected to date OTC medications upon opening and that insulin pens should only be used for 28 days. The DON also stated that staff should check expiration dates before administering medications and properly dispose of expired medications. Despite these expectations, the survey revealed significant lapses in adherence to the facility's medication storage policy, leading to the identified deficiencies.
Failure to Ensure Accurate and Updated Code Statuses
Penalty
Summary
The facility failed to ensure that code statuses were accurate, signed, and updated in the medical records for three residents. Resident #52 had conflicting information in their records, with a care plan indicating a full code status while the resident expressed a desire to be a Do Not Resuscitate (DNR). The Licensed Practical Nurse (LPN) confirmed the confusion, noting that both the electronic medical record (EMR) and paper chart contained conflicting code statuses. The Social Worker was identified as responsible for updating code statuses but had not done so in a timely manner. Resident #48's code status was also outdated, with records showing a full code status that had not been updated for over a year. The resident was rarely or never understood and had no speech, making it crucial for the responsible party to update the code status. Similarly, Resident #19's code status was outdated, with records showing a full code status that had not been updated for over a year. The Social Worker initially thought the Nursing Manager was responsible for updating code statuses but later clarified that it was her responsibility. The Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the Social Worker was responsible for ensuring code statuses were clear, accurate, and updated yearly or as needed.
Failure to Provide SNFABN for Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents who remained in the facility upon discharge from Medicare Part A services. Specifically, Resident #44 had Medicare Part A skilled services from 11/1/23 to 11/17/23, and Resident #34 had Medicare Part A skilled services from 4/3/24 to 4/25/24. In both cases, no SNFABN form was issued to inform the residents of their potential liability for payment for non-covered services. During interviews, the Regional Business Office Manager indicated that the facility provided SNFABN forms when residents were discharged from Medicare Part B, not Medicare Part A. Additionally, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Regional Operational Director confirmed that they would expect the SNFABN to be completed after a resident's discharge from Medicare Part A. This oversight led to the deficiency noted in the report.
Failure to Ensure PASARR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that residents with mental disorders had a DA-124 Level I screen (PASARR) as required. This deficiency was identified for three residents who had diagnoses including seizures disorder, depression, dementia, schizophrenia, and bipolar disorder. For Resident #8, admitted on 9/18/20, the medical record showed no PASARR Level I on file despite the resident having moderate cognitive impairment and multiple psychiatric diagnoses. The Corporate Nurse mentioned that the old computer system used by previous owners might have contained the PASARR, but the current facility did not have access to it. Similarly, Resident #41, admitted on 4/1/22, and Resident #3, admitted on 3/6/2013, also had no PASARR Level I on file despite having significant cognitive impairments and psychiatric diagnoses. Interviews with Social Services and the facility's administration confirmed that PASARRs should have been completed within 30 days of admission, but they were unable to locate the necessary documentation for these residents.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The resident, who had diagnoses of high blood pressure, depression, and stroke, was admitted on an unspecified date and discharged on another unspecified date. Progress notes indicated that the resident was scheduled for discharge and left the facility in stable condition with necessary medications and documentation. However, a review of the medical record showed no discharge summary was completed. During an interview, the Regional Clinical Director confirmed that the discharge summaries were not done and should have been completed prior to the resident's discharge.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents who were dependent on staff for personal care. Resident #27, who is cognitively impaired and dependent on staff for all ADLs except eating, was observed over several days with extremely long and dirty fingernails. Despite the resident expressing a desire to have their nails cut, staff interviews revealed that CNAs were unsure about their responsibilities regarding nail care for diabetic residents, leading to a lack of proper grooming for Resident #27. The care plan for this resident included goals for restorative therapy and collaboration between nursing and restorative staff, but these were not effectively implemented to address the resident's grooming needs. Similarly, Resident #67, who is cognitively impaired and at risk for poor hygiene due to dementia, was also observed with excessively long fingernails. The resident expressed a need for nail trimming, but staff interviews indicated confusion about who was responsible for this task. The care plan for Resident #67 included specific instructions for maintaining hygiene, including nail care, but these were not followed. Interviews with various staff members, including CNAs, an LPN, and the Assistant Director of Nursing, highlighted a lack of clarity and communication regarding the responsibility for nail care, ultimately leading to the deficiency in ADL care for these residents.
Failure to Ensure Accurate Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident receiving routine dialysis had accurate physician's orders, consistent communication, and a dialysis contract with the dialysis provider. The resident, who was cognitively impaired and diagnosed with heart failure, end-stage renal disease (ESRD), and dementia, had no dialysis contract, no recent dialysis communication forms, and no monitoring of the arteriovenous fistula (AVF) dialysis site documented in their medical record. The resident's care plan indicated the need for monitoring vital signs, weight, and the AVF site, but these were not reflected in the Treatment Administration Record (TAR) or physician's orders for several months. Interviews with facility staff, including an LPN, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the dialysis communication forms were often lost and not completed as required. The ADON confirmed that the resident's weight and vitals should have been documented each time the resident attended dialysis, and the dialysis site should have been checked every shift. The facility also lacked a dialysis contract with the provider, and there were discrepancies in the physician's orders regarding the resident's dialysis schedule and site monitoring.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7.41% error rate. This was observed during the administration of insulin to two residents. For Resident #44, the LPN did not wipe the insulin pen's rubber seal with alcohol and did not prime the insulin pen before administering 20 units of Novolog insulin. Similarly, for Resident #20, the LPN did not wipe the insulin pen's rubber seal with alcohol and did not prime the insulin pen before administering 9 units of Humalog insulin. Both residents have significant medical histories, including diabetes, which necessitates precise insulin administration to manage their conditions effectively. During interviews, it was revealed that the LPN was unaware of the priming steps required for insulin pens, and the Director of Nursing (DON) was unsure about the necessity of pen priming before insulin administration. The facility did not have a policy for insulin pen priming and relied on the manufacturer's instructions, which were not followed in these instances. The DON and other staff members acknowledged the expectation for staff to be free of medication errors but did not have a clear understanding or policy in place to ensure compliance with proper insulin administration procedures. The lack of adherence to the manufacturer's instructions for insulin pen use and the absence of a facility policy on insulin pen priming contributed to the medication errors observed. The facility's leadership, including the Administrator, DON, Assistant Director of Nursing, and Regional Operational Director, recognized the expectation for error-free medication administration but did not have adequate measures in place to prevent these errors, leading to the identified deficiency.
Infection Control Deficiencies in Glucometer Cleaning and Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control when it did not clean shared medical equipment between resident use with an approved Environmental Protection Agency (EPA)-registered disinfectant. Specifically, the facility did not properly disinfect glucometers between uses for two residents. Licensed Practical Nurse (LPN) G used alcohol pads instead of the required EPA-registered disinfecting wipes to clean the glucometer between uses for two residents. This practice was observed and confirmed through interviews with other staff members, who indicated that the correct procedure involved using bleach wipes or Sani wipes, not alcohol pads. The Director of Nursing (DON) and other staff members confirmed that the facility's policy required the use of Clorox wipes for disinfecting glucometers, and alcohol pads were not acceptable for this purpose. Additionally, the facility failed to ensure proper hand hygiene and glove use during wound care for two residents. LPN E did not follow the correct procedure for changing gloves and performing hand hygiene while providing wound care. The LPN was observed double-gloving and not removing all gloves before performing hand hygiene, which is against the facility's infection control standards. Interviews with other staff members, including Certified Medication Technician (CMT) F, LPN G, and the Assistant Director of Nursing (ADON), confirmed that double-gloving is not an acceptable practice and that all gloves should be removed, and hand hygiene should be performed between dirty and clean tasks. The deficiencies were observed during wound care for two residents with severe cognitive impairments and multiple diagnoses, including Alzheimer's disease, dementia, and high blood pressure. The facility's failure to adhere to proper infection control practices was confirmed through multiple observations and interviews with staff members, including the Nurse Practitioner (NP), Registered Nurse (RN) B, and the Regional Operational Director. The facility's leadership, including the Administrator, DON, ADON, and Regional Operational Director, acknowledged that staff were expected to follow acceptable infection control standards of practice.
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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