Westchester House, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterfield, Missouri.
- Location
- 550 White Road, Chesterfield, Missouri 63017
- CMS Provider Number
- 265338
- Inspections on file
- 23
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Westchester House, The during CMS and state inspections, most recent first.
The facility did not consistently safeguard or document residents' personal belongings, resulting in missing items such as clothing, jewelry, wallets, and cash for several residents. Inventory sheets were incomplete or missing, and staff interviews revealed inconsistent practices in handling and recording personal property, despite facility policies requiring thorough documentation and efforts to prevent loss or theft.
A resident with multiple comorbidities and a history of wounds did not receive required weekly skin assessments, and a new wound caused by cellulitis was not identified, documented, or reported to the physician for new treatment orders. Outdated wound care orders were not discontinued, and inaccurate documentation was made in the TAR, resulting in confusion and failure to follow facility policy.
The facility failed to complete weekly skin assessments and did not promptly identify, document, or notify the physician about new and existing pressure ulcers for two residents. One resident's new Stage II pressure ulcer was not recognized or reported in a timely manner, and another was admitted with pressure ulcers that were not measured or treated according to hospital discharge instructions. Staff did not follow facility policy for wound assessment and notification, resulting in delayed care.
A facility failed to provide adequate mealtime assistance and nutritional support, leading to significant weight loss in three residents. One resident experienced a 9.43% weight loss due to lack of assistance with meals, while another resident's physician was not notified of a 6.34% weight loss, and dietary recommendations were not implemented. A third resident did not receive prescribed double portions and fortified shakes, contributing to weight loss. Observations and interviews revealed a lack of communication and follow-through on dietary needs.
The facility failed to provide meals at a safe and appetizing temperature, affecting several residents. Observations showed food temperatures below the safe range, and residents reported receiving cold and unappetizing meals. The Dietary Manager and Administrator acknowledged the issue, emphasizing the need for timely and palatable meal service.
The facility failed to involve residents or their responsible parties in care planning, affecting six residents. Despite policy requirements, several residents and their representatives were not invited to participate in care plan meetings, and there was no documentation of such meetings in their records. The Social Services Director admitted to not holding care plan meetings for long-term residents, and the MDS coordinator confirmed inconsistency in scheduling these meetings.
The facility failed to notify families of room changes for three residents who tested positive for COVID-19. Despite the facility's policy, there was no documentation that families were informed when residents were moved off the isolation unit. Interviews with staff revealed inconsistencies in the notification process, with different expectations for who should inform families.
The facility failed to maintain complete and individualized care plans for three residents, omitting critical information such as the use of catheters, bed rails, and mental health evaluations. Observations confirmed the use of these devices, yet they were not documented in the care plans. Staff interviews revealed inconsistencies in updating care plans, leading to deficiencies in addressing residents' specific needs.
The facility failed to provide adequate assistance with ADLs for three residents, leading to deficiencies in personal care. One resident with Parkinsonism was left in a soiled gown and bed sheets without meal assistance. Another resident was found soaked in urine due to lack of regular checks. A third resident with contracted hands struggled to eat without help, despite recommendations for staff assistance. The facility's administrator and DON acknowledged these failures.
The facility failed to provide an ongoing activity program based on resident preferences, leading to dissatisfaction among residents. Observations and interviews revealed that no activities were taking place, and residents were confined to their rooms due to a COVID outbreak. Despite care plans indicating the need for in-room activities, these were not provided. Staff confirmed that activities had been suspended, and the Administrator and DON acknowledged that activities should have continued and been documented.
The facility failed to follow physicians' orders for respiratory evaluations for five residents diagnosed with COVID-19, resulting in numerous missed assessments. Despite care plans emphasizing the need for ongoing respiratory monitoring to prevent complications, the facility did not consistently complete these evaluations. Interviews with staff confirmed the expectation for assessments every shift, but significant gaps were found in adherence to these protocols.
A long-term care facility failed to maintain a medication error rate below 5%, resulting in a 12.12% error rate. Errors included improper insulin administration and incorrect medication dosages. Staff interviews revealed inconsistencies in following medication administration policies, contributing to the high error rate.
The facility failed to maintain an effective infection prevention and control program, as staff did not wear appropriate PPE during high-contact activities with residents on enhanced barrier precautions. Observations showed non-compliance with gown and glove use, improper perineal care techniques, and failure to follow TB testing protocols for employees. These deficiencies were noted in the care of multiple residents and among staff, indicating a lack of adherence to facility policies.
The facility failed to complete discharge summaries for two residents, one with heart and kidney failure and another with quadriplegia and cognitive deficits. Despite documentation of discharge processes, the medical records lacked summaries recapping their stays and final statuses. Staff interviews indicated a lack of recollection or documentation of these summaries.
A resident with an arterial ischemic ulcer did not receive wound care as ordered, resulting in a dirty and unchanged dressing. Despite the care plan's directives, the resident reported that the dressing was not changed over the weekend, and staff interviews confirmed that the assigned nurse was responsible for wound care in the absence of the wound nurse. The facility's administrator expected adherence to wound treatment orders and policies.
A resident with multiple diagnoses, including calciphylaxis and end-stage renal disease, did not receive consistent wound care as per physician orders. The facility's failure to adhere to the care plan resulted in missed treatments and inadequate management of the resident's pressure ulcer and other wounds. Observations and staff interviews confirmed that dressings were not changed as required, and there was significant drainage from the wounds.
Failure to Safeguard and Document Residents' Personal Possessions
Penalty
Summary
The facility failed to ensure the safety and proper documentation of residents' personal possessions, as required by its own policies. For four sampled residents, inventory sheets were either incomplete or missing, and there was no consistent documentation of personal belongings upon admission or when new items were brought in. The facility's policies required the laundry department and nursing staff to mark and account for each item of clothing and personal property, but these procedures were not reliably followed. In several cases, there was no record of valuable items such as a faux fur blanket, makeup bags, perfume, an electric toothbrush, a gold wedding band, wallets, or cash, despite residents or their families reporting these items as missing. One resident, who was cognitively intact and dependent on staff for transfers, reported missing $700 worth of personal belongings, including a faux fur blanket that was taken to the laundry and not returned. The resident felt the facility was not taking the loss seriously and had not provided updates. Another resident, also cognitively intact and newly admitted to hospice, was reported by staff and family to have been wearing a gold wedding band, which was missing after the resident's death. Staff searched for the ring but could not locate it, and there was no documentation of the ring on the inventory sheet or in progress notes. Additional deficiencies included a resident with moderate cognitive impairment who reported a missing wallet with cash, and another resident who reported missing $100 from a wallet, despite refusing to keep money in the resident trust account. In both cases, inventory sheets did not accurately reflect the presence or loss of these items, and there was no documentation in progress notes regarding the missing property. Interviews with staff and administration revealed inconsistent practices and a lack of clarity regarding responsibility for maintaining and updating inventory records, as well as for ensuring the security of residents' personal property.
Failure to Complete Skin Assessments and Notify Physician of New Wound
Penalty
Summary
The facility failed to complete weekly skin assessments and did not identify or document an open wound caused by cellulitis on a resident. There was no documentation of weekly skin integrity data collection assessments for over a month, and the facility did not notify the resident's physician or obtain new orders for wound care when a new wound was discovered on the resident's left posterior thigh. The wound was not assessed or documented in the medical record, and the responsible party and Director of Nursing were not notified as required by facility policy. The resident involved had multiple medical conditions, including heart failure, kidney disease, respiratory disease, diabetes mellitus, and was dependent on staff for most activities of daily living. The resident had a history of multiple wounds, including a significant wound on the right thigh, and was at high risk for skin breakdown. Despite these risks, the facility did not ensure that weekly skin assessments were completed or that new wounds were promptly identified, assessed, and communicated to the physician for appropriate treatment orders. Additionally, the facility failed to discontinue outdated wound care orders and documented inaccurately in the Treatment Administration Record (TAR), showing treatments as administered under multiple, conflicting orders. This resulted in false documentation and confusion regarding which wound care orders were current. The wound nurse acknowledged not discontinuing previous orders and not documenting the new wound or notifying the physician in a timely manner, contrary to facility policy and expectations.
Failure to Complete Skin Assessments and Timely Wound Care Notification
Penalty
Summary
The facility failed to complete weekly skin assessments and to identify and document a Stage II pressure ulcer for one resident, as well as failed to notify the physician and obtain treatment orders for the wound. The resident, who was cognitively intact but dependent on staff for activities of daily living and incontinent of bowel and bladder, was at risk for pressure ulcers and had multiple comorbidities including heart failure, kidney disease, respiratory disease, and diabetes. There was no documentation of weekly skin integrity assessments for over a month, and new open areas on the resident's left buttock were not identified or reported until observed by the wound nurse. The wound nurse did not notify the physician, the resident's responsible party, or the DON of the new wounds, nor did she document a wound assessment or obtain new treatment orders in a timely manner. Another resident was admitted with existing pressure ulcers to the sacrum, gluteal area, and bilateral heels, but there was no documentation of wound measurements or treatment orders for these areas upon admission. The progress notes and medication records did not reflect any treatment orders for the pressure ulcers until several days after admission, despite the presence of hospital discharge orders for wound care. The wound nurse and DON confirmed that staff did not notify them of the wounds upon admission, and the wounds were only addressed after management reviewed hospital paperwork and initiated a skin assessment. Interviews with staff revealed that CNAs and nurses were expected to report and document new skin issues immediately, but this did not occur in either case. The facility's policies required comprehensive skin assessments on admission and weekly thereafter, as well as prompt notification of the physician and responsible parties when new wounds were identified. These procedures were not followed, resulting in delayed identification, documentation, and treatment of pressure ulcers for both residents.
Failure to Provide Adequate Nutritional Support and Mealtime Assistance
Penalty
Summary
The facility failed to provide adequate mealtime assistance to a resident, resulting in a significant weight loss of 9.43% within a 30-day period. The resident, who was cognitively intact and required partial assistance with eating, was observed multiple times lying in bed with an untouched meal tray. Despite the resident's inability to feed themselves due to hand tremors, staff did not assist with meals, leading to the resident only eating when family members visited. The resident's spouse confirmed that staff did not set up the meal tray or feed the resident, and a handwritten sign requesting assistance was placed in the resident's room. Another resident experienced a 6.34% weight loss over three months, and the facility failed to notify the physician and implement the Registered Dietician's (RD) recommendation to increase a nutritional supplement from twice to three times daily. The resident, who had diagnoses including heart failure and diabetes, was not provided with the recommended increased supplement intake, as there was no documentation of a physician's order for the change. Interviews with staff revealed a lack of communication and follow-through on dietary recommendations. A third resident, at risk for weight loss, did not receive the prescribed double portions and fortified shakes. Despite being on a regular diet with double portions and fortified foods, the resident's meal tickets did not reflect these orders, and the resident reported not receiving the fortified shakes. Observations confirmed that the resident's meals did not include double portions, and the Dietary Manager admitted that health shakes were not consistently distributed. The RD expected the resident to receive the prescribed nutritional support, but this was not implemented, contributing to the resident's weight loss.
Failure to Serve Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to provide residents with food that was palatable and at a safe and appetizing temperature, affecting 7 out of 18 sampled residents. Observations and interviews revealed that residents consistently received meals that were cold and unappetizing. For instance, Resident #80, with moderate cognitive impairment and multiple diagnoses including heart failure and malnutrition, reported that lunch was terrible and always served cold. Similarly, Resident #38, who is cognitively intact, stated that meals served in resident rooms were always cold, prompting family members to bring food during visits. Other residents, such as Resident #292 and Resident #81, also expressed dissatisfaction with the temperature and quality of the food served. During meal service observations, food temperatures were recorded well below the safe and appetizing range. For example, on the 200 Hall, sliced ham was measured at 87°F, scrambled eggs at 88.7°F, and hashbrowns at 89°F. On the 500 unit, scrambled eggs were at 108.5°F, sliced ham at 93.0°F, and oatmeal at 92.1°F. The Dietary Manager acknowledged that staff should ensure food is served on time and not cold, while the Administrator confirmed that hot foods should be served hot and cold foods cold, emphasizing the need for timely and palatable meal service.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents or their responsible parties were invited to participate in the development and implementation of person-centered care plans. This deficiency was identified for six out of eighteen sampled residents, despite the facility's policy requiring resident and representative involvement in care planning. The policy mandates that care plans be reviewed and revised by an interdisciplinary team with knowledge of the resident's needs, and that residents and their representatives be given advance notice of care planning conferences. Interviews and record reviews revealed that several residents and their responsible parties were not contacted or invited to participate in care plan meetings. For instance, a resident's responsible party reported not being contacted for a care plan meeting since the resident's admission. Another resident, who was their own responsible party, stated they had not participated in a care plan meeting and were unaware of the facility's plan for them. Similar issues were noted for other residents, with no documentation of care plan meetings or notifications in their medical records. The Social Services Director (SSD) admitted to not holding care plan meetings for long-term residents, while the MDS coordinator confirmed that care plan meetings had not been consistent. The Administrator and Director of Nursing expected care plan meetings to be held quarterly and as needed, with notifications sent to residents and responsible parties. However, this expectation was not met, leading to the deficiency.
Failure to Notify Families of Room Changes for COVID-19 Positive Residents
Penalty
Summary
The facility staff failed to notify the family or resident representatives in a timely manner regarding the change of room assignments for three residents who tested positive for COVID-19. The facility's COVID-19 policy did not include a requirement for notifying the residents' representatives about room changes. Resident #62, who was cognitively intact and diagnosed with heart disease, kidney failure, anxiety, and depression, was moved off the isolation unit without the family being informed. Similarly, Resident #31, also cognitively intact and diagnosed with COVID-19, was transferred back to their original room without family notification. Resident #14, with moderately impaired cognition and a COVID-19 diagnosis, was moved off the isolation unit without the family being informed. Interviews with facility staff revealed inconsistencies in the notification process. LPN D stated that the nurse transferring the resident to or from the isolation unit was responsible for notifying the doctor and family. LPN A mentioned that they would notify the Director of Nursing, Administrator, Medical Records, the doctor, and the family when a resident was moved to or from the isolation unit. The Administrator expected the family to be notified when a resident was moved. However, the lack of documentation in the progress notes indicated that the families were not informed of the room changes for the three residents.
Incomplete and Inaccurate Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. This deficiency was identified for three residents out of a sample of 18. The facility's policy requires that care plans be person-centered, comprehensive, and reviewed by an interdisciplinary team. However, the care plans for these residents did not include critical information such as the use of indwelling catheters, bed rails, and mental health evaluations. For Resident #36, the care plan did not include information about the use of an indwelling catheter or bed rails, despite physician orders and evaluations indicating their necessity. Observations confirmed the presence of these devices, yet they were not documented in the care plan. Similarly, Resident #79's care plan lacked documentation regarding the use of bed rails, which were observed in use, and there was no physician order for them. Resident #292's care plan failed to include the resident's PASRR II evaluation and mental health condition, and the resident reported not being invited to care plan meetings. Interviews with facility staff, including the Social Services Director and MDS Coordinator, revealed inconsistencies in the updating of care plans. The staff acknowledged that care plans should be resident-specific and include necessary information such as side rails, catheters, and mental health evaluations. However, the updates were not consistently performed, leading to incomplete care plans that did not reflect the residents' current needs and conditions.
Failure to Provide Adequate ADL Assistance
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Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal care. One resident, diagnosed with Parkinsonism and diabetes, was observed multiple times in a soiled hospital gown and bed sheets, with red and pink spots from food. Despite the resident's inability to feed themselves due to hand tremors, staff did not assist with meals, leaving the resident hungry and unclean. The resident's call light was out of reach, and they reported yelling for assistance without response. Interviews with staff confirmed the resident required total assistance with meals, yet this was not consistently provided. Another resident, who required supervision and assistance with toileting hygiene, was found soaked in urine during the night shift. The resident's care plan indicated a risk for skin integrity issues, yet staff failed to check on the resident regularly, resulting in a saturated bed pad and wet sheets. The CNAs were unaware of their assignment to the resident, leading to a lack of timely personal care. A third resident, with cognitive impairment and contracted hands, required assistance with eating. Despite a dietician's recommendation for staff to assist the resident during meals, observations showed the resident eating slowly and without help. A CNA removed the resident's meal tray, further hindering their ability to eat. The facility's administrator and DON acknowledged the failures in providing necessary ADL care, including feeding assistance, as required by federal regulations.
Lack of Resident Activities During COVID Outbreak
Penalty
Summary
The facility failed to provide an ongoing activity program based on resident preferences, which led to dissatisfaction among residents. Observations, interviews, and record reviews revealed that the facility did not offer sufficient activities to meet the needs of its residents. The resident council meeting participants reported that activities were insufficient, and several residents expressed concerns about the lack of activities. The facility's activity calendar showed a limited range of activities, and during the survey, no activities were observed taking place. Several residents, including those who were cognitively intact and those with moderate cognitive impairments, reported a lack of activities. Residents were confined to their rooms due to a COVID outbreak, but even before the outbreak, activities were limited. The facility's care plans indicated that residents should receive in-room activities during isolation, but residents reported that these were not provided. Many residents expressed a desire for more engagement, such as puzzles, cards, and one-on-one interactions, which were not offered. Interviews with staff, including CNAs and the Activity Director, confirmed that activities had been suspended for about three weeks due to the COVID outbreak. The Activity Director mentioned that an assistant was supposed to conduct room visits and one-on-one activities, but the assistant was out with COVID. The Administrator and DON acknowledged that activities should have continued even during the outbreak and should have been documented, but this was not done.
Failure to Follow Respiratory Evaluation Orders for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that physicians' orders for respiratory evaluation and treatments were followed for five residents diagnosed with COVID-19. These residents were identified as having various cognitive impairments and medical conditions, including kidney failure, dementia, heart disease, and depression. Despite being placed under respiratory precautions, the facility did not complete the required respiratory evaluations consistently. For instance, Resident #50 had 15 out of 30 evaluation opportunities missed, while Resident #62 had 21 out of 30 evaluations not completed. The care plans for these residents indicated a focus on preventing complications from COVID-19, with goals to avoid hospitalization and interventions that included ongoing respiratory assessments. However, the facility's records showed significant gaps in completing these assessments. Resident #31, for example, had 19 out of 30 evaluations not completed, and similar deficiencies were noted for Residents #14 and #44, with 19 and 13 missed evaluations, respectively. Interviews with facility staff, including LPNs and the Administrator, revealed that respiratory assessments were expected to be completed every shift and documented accordingly. However, the assessments were not consistently performed, as evidenced by the missed evaluation opportunities. The Administrator acknowledged the expectation for staff to follow physician orders and complete the necessary respiratory assessments, highlighting a failure in adherence to these protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12.12% error rate. This was identified through observations, interviews, and record reviews involving four residents. The errors included improper administration of insulin and incorrect dosage of medication. Specifically, insulin pens were not primed before administration for two residents, and a resident received double the prescribed dose of a diuretic medication. Resident #242, diagnosed with endocarditis, experienced an issue with the administration of intravenous fluids. The staff member was unsure if the PICC line was flushed correctly, as there was no clear documentation or communication regarding the procedure. This lack of clarity and adherence to physician orders contributed to the medication error rate. Interviews with staff, including LPNs and the Director of Nursing, revealed inconsistencies in following the facility's medication administration policy. Staff members demonstrated a lack of understanding of the correct procedures for insulin pen priming and medication dosage. The Director of Nursing and the Administrator expressed expectations for staff to adhere to the five rights of medication administration and follow physician orders, which were not consistently met.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not wearing appropriate personal protective equipment (PPE) during high-contact activities with residents on enhanced barrier precautions (EBP). Observations revealed that staff did not wear gowns and failed to change gloves between dirty and clean tasks while providing care to residents with indwelling catheters, feeding tubes, and wounds. This non-compliance was noted in the care of five residents, where staff did not adhere to the facility's policy requiring gown and glove use during high-contact activities such as bathing, transferring, and providing hygiene. Additionally, the facility did not follow its incontinent care policy when providing perineal care to three residents. Staff were observed using improper techniques, such as not changing gloves between dirty and clean tasks and using the same washcloth for different parts of the body. These actions were contrary to the facility's policy, which outlines specific steps for maintaining cleanliness and preventing infection during perineal care. Furthermore, the facility failed to adhere to its Tuberculosis (TB) policy for employees, as six out of ten sampled employees did not have documentation of the required two-step TB skin test. This lack of compliance with TB testing protocols could potentially affect all residents and staff within the facility. Interviews with staff indicated a lack of understanding and adherence to the facility's policies regarding PPE use and TB testing, contributing to the deficiencies observed.
Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge, was completed for two residents. Resident #54, who was cognitively intact and had diagnoses including heart failure, kidney failure, diabetes, and high blood pressure, was discharged to a new facility to be closer to family. Despite the completion of an assessment and the resident's compliance with medication and activities of daily living, the medical record lacked a discharge summary. Similarly, Resident #89, who had diagnoses including kidney failure, quadriplegia, muscle weakness, and cognitive communication deficit, was discharged without a completed discharge summary. The resident had initially planned to cancel discharge plans due to insurance noncoverage but eventually proceeded with the discharge. The Social Services Director and nursing staff documented the discharge process, but no discharge summary was retained in the medical record. Interviews with facility staff, including the Clinical Quality Coordinator and Social Services Director, revealed a lack of recollection or documentation of the discharge summaries.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for a resident with an arterial ischemic ulcer on the left heel and ankle. The resident's care plan included specific interventions for wound care, such as assessing the wound and keeping the feet clean and dry. However, observations revealed that the resident's wound dressing was not changed as ordered, resulting in a dirty and loose dressing. The resident reported having to request wound care and noted that the dressing was not changed over the weekend. Interviews with staff indicated that the assigned nurse was responsible for wound care when the wound nurse was unavailable. Despite this, the resident's wound dressing remained unchanged for several days, contrary to the treatment order. The facility's administrator acknowledged the expectation for staff to follow wound treatment orders and adhere to the wound/skin care policy, highlighting a lapse in the facility's adherence to its own protocols.
Inadequate Wound Care Management
Penalty
Summary
The facility failed to ensure that a resident with wounds received the necessary treatments and services to promote healing. The resident, who was cognitively intact, had multiple diagnoses including heart failure, stroke, calciphylaxis, end-stage renal disease, and a colostomy. The resident had a stage three pressure ulcer and other open lesions. The care plan included specific interventions for wound care, but these were not consistently followed. The resident reported that staff were not changing dressings as ordered, leading to a change in the treatment frequency. The Treatment Administration Record (TAR) revealed multiple instances where wound care treatments were not documented as completed. For example, there were blank entries for orders to cleanse and dress wounds, indicating missed opportunities for care. Progress notes also showed instances where treatments were not completed due to the resident's leave of absence, unavailability of supplies, or the resident's refusal. Observations confirmed that the resident's dressings were not changed as frequently as required, and there was significant drainage from the wounds. Interviews with staff, including LPNs and the Director of Nursing (DON), highlighted inconsistencies in wound care practices. Staff admitted that blanks on the TAR could mean treatments were not done, and there were expectations to change soiled linens and reposition the resident regularly. The DON acknowledged that the resident's heel wounds were not adequately treated, and the administrator expected wound care to be completed per physician orders. The lack of adherence to the care plan and physician orders contributed to the deficiency in wound care management for the resident.
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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