Windsor Estates Of St Charles
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Charles, Missouri.
- Location
- 2150 West Randolph Street, Saint Charles, Missouri 63301
- CMS Provider Number
- 265518
- Inspections on file
- 39
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Windsor Estates Of St Charles during CMS and state inspections, most recent first.
A resident who was at risk for falls was not assessed or treated after a reported fall, resulting in a fractured wrist that went unaddressed for two days. Staff failed to follow physician orders for x-ray, immobilization, and RICE treatment, and did not document or provide the prescribed brace or sling. Communication lapses and lack of documentation contributed to the resident experiencing ongoing pain and lack of appropriate care.
A resident with significant mobility limitations and a high fall risk experienced multiple falls from bed due to staff failing to keep the bed in the lowest position and not setting the low air loss mattress to the correct weight. The mattress was repeatedly set too high, and new fall prevention interventions were not consistently implemented or documented after each fall, despite the resident's ongoing incidents and injuries.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, leading to the occurrence and worsening of pressure ulcers.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Multiple residents reported receiving meals that were not hot, and observations confirmed that hot foods and beverages were served below required temperatures due to improper temperature monitoring, lack of insulated covers, and malfunctioning equipment. Staff interviews revealed inconsistent temperature checks and inadequate procedures for maintaining food safety and palatability during meal service.
The facility did not maintain the main parking lot, leaving a large, deep area of damaged asphalt in the visitor parking section. This unrepaired damage affected vehicles traveling through the area, and the Administrator was aware of the issue but had not yet addressed it.
A resident who was dependent on staff for bed mobility and care fell from bed and sustained injuries after a CNA turned away to retrieve supplies, leaving the resident unattended on an unsecured air mattress overlay. The CNA had previously noticed the mattress shifting but did not report it, and the facility lacked a policy for monitoring such overlays. The care plan and therapy evaluation did not clearly specify the number of staff needed for bed mobility, contributing to the incident.
The facility did not ensure the Dietary Manager had completed the necessary training or certification to fulfill the role, and lacked a policy for training or competency requirements. The DM was enrolled in a course but had not finished it, and the required food protection manager certification was not posted, resulting in non-compliance.
Surveyors identified multiple deficiencies in food storage and labeling, including unlabeled and expired food items, lack of discard dates, visible spoilage, and improper refrigerator maintenance such as rust, ice buildup, and missing thermometers. Dietary staff were unclear about cleaning responsibilities, and only food from the dietary department was supposed to be stored in the dining room refrigerator.
Staff failed to consistently provide scheduled ADL care, including showers, nail care, shaving, and grooming, to several dependent residents. Documentation was often incomplete or missing, and residents were observed with poor hygiene, long nails, and unkempt hair. Interviews with residents and family members confirmed that care was not provided as scheduled, and staff gave inconsistent explanations about responsibilities for ADL tasks.
A persistent leak from the water pipe under the dishwasher led to pooled water on the kitchen floor, with staff mopping up the water several times daily. Inspection reports and staff interviews confirmed that the plumbing issue had been ongoing, and the facility was cited for non-compliance with plumbing standards.
The facility failed to provide ordered medications for two residents, leading to deficiencies in care. A resident with a joint prosthesis infection and low back pain did not receive Tramadol for pain management due to delays in prescription and delivery. Another resident with cellulitis and osteomyelitis missed doses of IV antibiotics because the medication was not available upon admission. Staff interviews revealed communication lapses in ensuring medication availability, impacting resident care.
The facility's call system failed to provide audible alerts, requiring staff to rely on visual cues to respond to residents' needs. This deficiency affected all residents, with some experiencing significant delays in assistance. Staff interviews confirmed the absence of pagers or phones to receive alerts, and the administrator was unaware of a state requirement for such devices.
A facility failed to ensure the safety of two residents, leading to serious injuries. One resident, dependent on staff for bed mobility, fell from the bed due to the absence of a required fall mat and lack of reassessment for safety. The resident sustained severe injuries, including intracranial hemorrhage and rib fracture. Another resident, with a rotator cuff tear, was unsafely transferred by staff using a gait belt, causing pain in the injured shoulder. The facility's policies for fall management and safe lifting were not effectively implemented, contributing to these incidents.
A resident with a history of heart failure and muscle weakness was left unattended on a mechanical lift mat in a high bed position, resulting in a fall and a fractured left leg. The resident, who was dependent on staff for transfers, was left alone when a CNA left the room to get a nurse. The incident was witnessed by the resident's roommate, who called for help. The resident was assisted off the floor and diagnosed with a fractured tibia.
The facility failed to implement an admission policy, resulting in a resident's admission without a signed agreement. Additionally, several residents and their representatives did not receive the required 30-day written notice of rate increases, leading to confusion and dissatisfaction. The previous administrator claimed to have mailed the notices, but many residents reported not receiving them.
The facility failed to employ a Food Service Director (FSD) with valid credentials. The FSD, who started in October 2023, did not have a current certification in food safety management. The Administrator had planned to enroll the FSD in a certification course, but this did not occur. The FSD confirmed that he had started but not completed the course, and the Regional Director of Operations acknowledged the lack of certification. A review of the FSD's employee file revealed an expired certification.
A facility failed to ensure a resident with nasal and inhaler medications had a self-administration assessment, physician's order, and care plan. The resident, who was cognitively intact, had medications at their bedside without the required documentation, increasing the potential for medication errors.
A resident with Alzheimer's and repeated falls was found with a swollen, discolored knee, but the injury was not reported to the state agency until six days later, violating the facility's policy requiring immediate notification.
A resident with Alzheimer's and repeated falls was found with a swollen and discolored knee, but the injury was not reported or investigated until several days later, violating the facility's policy on immediate reporting and investigation of injuries of unknown origin.
The facility failed to update the care plan for a resident with wandering behaviors after two incidents where the resident left the skilled nursing unit without staff knowledge or supervision. Despite the resident's Alzheimer's disease and repeated falls, no new interventions were added to the care plan following the incidents.
The facility failed to prevent a resident with Alzheimer's and wandering behaviors from leaving the skilled nursing unit without supervision on two occasions. Staff were unclear about specific interventions, and the doors did not have effective alarms. The DON confirmed the lack of an elopement assessment and root cause analysis.
A facility failed to ensure CNAs changed gloves and performed hand hygiene during catheter care for a resident with neuromuscular dysfunction of the bladder. The CNAs did not adhere to the facility's infection control policies, leading to potential cross-contamination.
Failure to Assess and Treat Resident After Fall Resulting in Fracture
Penalty
Summary
Staff failed to assess a resident after a reported fall, did not provide timely treatment, and did not implement or follow physician orders for care following the identification of a fall with injury. The resident, who had diagnoses including heart disease, macular degeneration, muscle weakness, and was at risk for falls, self-reported a fall that occurred two days prior to being evaluated by clinical staff. The fall was not reported by staff at the time it occurred, and no assessment or documentation was completed immediately following the incident. The resident subsequently developed pain, swelling, and bruising to the left arm, which was not addressed until the resident reported these symptoms to a nurse practitioner. Despite clear physician orders to obtain an x-ray, immobilize the arm, and provide RICE (Rest, Ice, Compression, Elevation) treatment, staff did not document or provide these interventions in a timely manner. The x-ray, when eventually performed, revealed an acute distal radial metaphysis fracture. The resident was sent to the emergency room for further evaluation and returned with a splint, but staff continued to fail in documenting assessments, treatments, or the application of the prescribed brace or sling. Interviews with staff and the resident confirmed that the resident was often left without the prescribed immobilization device and continued to experience pain. Multiple staff interviews revealed a lack of communication and failure to follow protocol regarding fall reporting, assessment, and implementation of physician orders. The charge nurse was not informed of the fall, and staff did not provide or document the required treatments. The resident's pain and injury went unaddressed for an extended period, and staff were unaware of the current treatment plan or the location of the prescribed immobilization devices. The facility's own policies required assessment and intervention after any fall, but these were not followed in this case.
Failure to Prevent Falls and Ensure Safe Bed Settings
Penalty
Summary
The facility failed to provide adequate protective oversight and prevent falls for a resident with multiple risk factors, including end stage renal disease, heart failure, muscle weakness, and a right above-the-knee amputation. The resident was assessed as a high fall risk, required extensive assistance with activities of daily living, and was dependent on staff for transfers and mobility. Despite these needs, staff did not consistently ensure that the resident's bed was kept in the lowest position while the resident was in bed, as required by the care plan and facility policy. Additionally, the resident's low air loss mattress was repeatedly set at a weight setting significantly higher than the resident's actual weight, contrary to manufacturer instructions and facility expectations. Observations confirmed that the mattress was set at 340 pounds while the resident weighed 268 pounds, which staff acknowledged could contribute to the resident rolling out of bed. The resident experienced multiple falls from bed, often while reaching for personal items or attempting to reposition, and reported discomfort from frequently sliding down in bed, with feet resting on the footboard. After several falls, there was no documentation that new fall risk interventions were implemented in a timely manner following each incident, as required by the facility's fall policy. Staff interviews revealed inconsistent practices regarding the use of mechanical lift slings, bed positioning, and mattress settings. The resident continued to experience falls, some resulting in skin tears, and staff failed to consistently apply or document new interventions after each event.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages were prepared and served at safe and appetizing temperatures, as required by their own policy. Multiple residents who received meals in their rooms and in the assisted dining room reported that their food was not hot when served. Observations confirmed that during meal service, hot foods such as roast pork, mashed potatoes, and corn were plated, covered with plastic film, and placed on an open metal cart without insulation. The cart also contained beverages, including milk, tea, and juice, which were not kept on ice. The last meal tray was delivered over 30 minutes after plating, and temperature checks of a test tray revealed that hot foods were below the required serving temperatures, and milk was above the safe cold temperature. Interviews with dietary staff and the Dietary Manager revealed that food temperatures were not consistently checked at the steam table, and two wells on the steam table were not functioning to keep food warm. The facility lacked insulated plate covers, and the timing of room tray delivery depended on staff availability. The Dietary Manager and Administrator both acknowledged that food and beverages should be served at proper temperatures, but the observed practices and equipment issues led to food being served at temperatures that did not meet policy or safety standards.
Failure to Maintain Safe and Clean Parking Lot Environment
Penalty
Summary
The facility failed to maintain the main parking lot, resulting in a large area of damaged asphalt at the end of the visitor parking area. Observations revealed that the damaged area was approximately ten feet in diameter and 8-10 inches deep at the center, affecting any vehicle using the area for travel. The Administrator acknowledged awareness of the needed repair and indicated that several projects were in progress, but the area remained unrepaired at the time of the survey.
Resident Fall Due to Unsecured Mattress Overlay and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who required staff assistance for bed mobility and care, fell out of bed while receiving personal care and sustained multiple injuries, including a laceration to the forehead, skin tears, and bruising. The resident was dependent on staff for bed mobility, dressing, and hygiene, and had significant physical limitations due to diagnoses such as respiratory failure, dementia, and stroke. The resident was also on hospice care and used an air mattress overlay on top of a regular mattress, which was reported by staff to shift on the bed. On the day of the incident, a CNA was providing care and rolled the resident onto their side. The CNA then turned away from the resident to retrieve additional supplies from a bedside table, during which time the resident slid off the bed and fell to the floor. The CNA admitted to not having all necessary supplies at the bedside before starting care and did not request additional assistance, despite the mattress overlay shifting and the resident's dependency for mobility. The CNA had previously repositioned the air mattress overlay multiple times during the shift but had not reported the issue to anyone. The facility did not have a policy for monitoring residents using air mattresses or mattress overlays. Interviews with staff and leadership confirmed expectations that supplies should be prepared in advance and that staff should seek help when needed. The physical therapy evaluation did not specify the number of staff required for bed mobility, and the care plan indicated only one staff member was needed for repositioning and turning. The lack of a secure mattress overlay and insufficient supervision during care contributed to the resident's fall and subsequent injuries.
Dietary Manager Lacked Required Competency and Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the appropriate competencies and skill set required to manage the food and nutrition services for all residents. The DM had been in the role since September of the previous year and was enrolled in an online dietary manager course but had not completed it. The DM was unable to specify when the course began or when it would be completed and had not taken any other relevant classes. The DM reviewed some course modules with the Registered Dietician during weekly visits but lacked a completed certification. Additionally, the facility did not have a policy regarding training or competency requirements for the DM position. A review of the Food Establishment Inspection Report from the local county health department indicated that the facility was out of compliance with the requirement for a Certified Food Protection Manager. The required certificate of training was not posted in the food establishment, and the Administrator was unaware of the DM's progress in the course or the expected completion timeline.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to comply with food storage, labeling, and sanitation policies as evidenced by multiple observations in the main dining room and kitchen prep/storage area refrigerators. Surveyors found several food items, such as Jello with fruit, ham sandwiches, potato salad, slaw, thickened lemon water, milk, and cut fruit, that were either not labeled with the date opened, lacked discard dates, or were past their expiration or use-by dates. Some food items showed visible signs of spoilage, such as dried and discolored fruit. Additionally, five pieces of cake in the freezer were not dated, and there was a buildup of food debris in the freezer. Both refrigerators lacked hanging thermometers, and the main dining room refrigerator had rust spots and ice buildup inside. Interviews with dietary staff and the administrator confirmed that only food from the dietary department should be stored in the dining room refrigerator, and that all food should be labeled and discarded according to policy. However, staff were unaware of when the refrigerator was last cleaned or who was responsible for its maintenance. The facility census at the time was 62, and the deficiencies were identified through observation, interview, and record review.
Failure to Provide Scheduled ADL Care and Personal Hygiene Services
Penalty
Summary
Facility staff failed to provide necessary care and services to maintain good personal hygiene and prevent body odor for four residents who were unable to perform their own activities of daily living (ADLs). Multiple instances were documented where residents did not receive scheduled showers, bed baths, nail care, shaving, or haircuts as outlined in their individualized care plans. Documentation was often missing regarding whether care was offered, refused, or provided, and there was a lack of follow-up when residents reportedly refused care. In several cases, there was no resident signature to confirm refusals, and staff did not consistently attempt to reschedule or offer care at a later time. Residents affected by these deficiencies included individuals who were cognitively intact, dependent on staff for bathing and personal hygiene, and in some cases, frequently or always incontinent of urine and/or bowel. Observations revealed that residents had greasy, matted hair, facial hair, long and dirty fingernails, dry and flaky skin, and rooms with noticeable body odor. Interviews with residents confirmed that they had not received showers, shaves, or haircuts for extended periods, despite expressing a desire for such care. Some residents reported that staff told them services like haircuts could not be provided due to regulations, and others stated that staff promised to provide care but did not follow through. Staff interviews revealed inconsistencies in understanding and executing responsibilities for ADL care. CNAs and nurses gave conflicting accounts regarding who was responsible for nail care, shaving, and grooming, particularly for diabetic residents. The facility lacked specific policies for showers, shaving, nail care, or haircuts, and staff assignments for showers and grooming were not always completed as scheduled. Family members and responsible parties also reported concerns about the lack of ADL care, with some having to provide grooming themselves or escalate complaints to facility leadership.
Failure to Maintain Dishwasher Plumbing in Good Repair
Penalty
Summary
The facility failed to maintain the water supply to the dishwasher in good working condition, resulting in a persistent leak from the water pipe under the dishwasher. Observations over multiple days showed water dripping from pipes beneath the dishwashing machine, leading to pooled water under the dishwasher and shelving, which then flowed onto the kitchen floor. The issue was noted during inspections and was observed to have been ongoing for over a year, with kitchen staff mopping up the water several times daily. Inspection reports from the local county public health department documented leaking plumbing and plumbing in disrepair, with the facility being cited for non-compliance. Interviews with staff revealed that while a previous leak under the sink had been repaired, the leak under the dishwasher was considered new by some, though others indicated it had persisted for an extended period. The administrator was not aware of the leak until recently, despite repeated findings by the health department during follow-up visits, where the leak remained uncorrected.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were available for administration to two residents, leading to deficiencies in care. Resident #1 was admitted with a diagnosis of infection of a joint prosthesis and low back pain, with an order for Tramadol to manage pain. However, the medication was not available upon admission, and the resident experienced pain without relief. Despite attempts to contact the physician and pharmacy, the medication was not delivered promptly, resulting in the resident being administered Tylenol instead. The resident's family member expressed concerns about the lack of pain management, and the resident was eventually transferred to another facility. Resident #2 was admitted with cellulitis, diabetes with a foot wound, and osteomyelitis, requiring IV antibiotics. The facility did not have the necessary medication upon the resident's arrival, as the hospital did not send the medication orders in advance. The resident missed several doses of the prescribed IV antibiotic, Cefazolin, due to the delay in medication delivery. The facility's cubex contained the medication, but it was not utilized, leading to a lapse in the resident's treatment. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of communication and coordination in ensuring medications were available and administered as ordered. The pharmacy consultant confirmed delays in receiving prescriptions and medication deliveries. The deficiencies highlight the facility's failure to adhere to professional standards of practice in medication management, impacting the residents' care and well-being.
Deficient Call System Lacks Audible Alerts
Penalty
Summary
The facility failed to maintain an effective call system that adequately alerted staff when residents required assistance. Observations and interviews revealed that the call system did not produce an audible sound to notify staff of activated call lights. Instead, staff had to rely on visual cues, such as a monitor at the nurses' station or a light above the resident's door, to know when a call light was on. This deficiency affected the entire facility, which had a census of 66 residents across three halls. Interviews with staff, including CNAs and an LPN, confirmed that they did not carry pagers or phones to receive alerts, and the system's lack of an audible function meant that staff could miss calls for assistance, especially if they were not near the monitors or the resident's room. Several residents reported significant delays in response times when they activated their call lights. One resident mentioned waiting over 30 minutes for assistance and having to resort to yelling for help. Another resident noted that staff often walked past their room without acknowledging the activated call light. The facility's administrator acknowledged the absence of an audible alert in the call system and was unaware of a state agency exception that required staff to carry pagers. The corporate office was reportedly working with the state agency on updates to the call light system, but the reason for the lack of an audible function remained unclear.
Failure to Ensure Resident Safety and Proper Transfer Techniques
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for bed mobility. During care, the resident was rolled to their side, reached out to the opposite side, and fell from the bed to the floor. The care plan required a fall mat to be in place, but it was not present at the time of the fall. The resident, who often reached out during care, had not been reassessed for safety with bed mobility. As a result of the fall, the resident required hospitalization and sustained serious injuries, including intracranial hemorrhage, epidural hematoma, subdural hematoma, concussion, and a right rib fracture. Another resident, who required staff assistance for transfers, was unsafely transferred by two staff members using a gait belt. The resident, who had a rotator cuff tear, reported pain in the injured shoulder during the transfer. The facility's policy for safe lifting and movement of residents was not adhered to, as staff did not use the appropriate techniques or equipment for the transfer. The resident's care plan indicated a need for two-person assistance, but the staff failed to follow the correct procedures, leading to the resident experiencing pain and discomfort. The facility's policies for fall management and safe lifting were not effectively implemented or followed. Staff did not communicate the resident's resistive behavior during care, which could have prompted a reassessment for safety. Additionally, the facility did not ensure that the necessary equipment, such as fall mats and mechanical lifts, was used as required by the care plans. These failures contributed to the incidents involving both residents, resulting in injuries and hospitalizations.
Resident Left Unattended on Bed Results in Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for transfers and at risk for falls. The resident was left unattended on a mechanical lift mat with the bed in a high position, leading to the resident sliding off the bed and sustaining a fracture of the left leg. This incident occurred when a staff member left the room to get a nurse after noticing the resident had scratched their back and was bleeding. The resident involved had a history of heart failure, stage 5 chronic kidney disease, a below-the-knee amputation of the right leg, and muscle weakness. The resident was assessed as being at risk for falls due to deconditioning and was dependent on staff for bed mobility, transfers, and wheelchair mobility. The resident was alert, oriented, and able to make needs known, as documented in their care plan and Minimum Data Set (MDS). The incident was reported to the administrator, and it was noted that the resident had been left on the side of the bed while the staff member left the room. The resident's roommate witnessed the fall and called for help. The resident was subsequently assisted off the floor by staff and sent to the emergency room, where a fractured left tibia was diagnosed.
Deficiency in Admission Policy and Rate Increase Notification
Penalty
Summary
The facility failed to develop and implement an admission policy and protocol, resulting in a deficiency related to the admission agreement for a resident. The resident, who was cognitively impaired and admitted for rehabilitation, did not have an admission agreement signed by their representative. The representative, who held power of attorney, reported not receiving any admission packet or signing any paperwork upon the resident's admission. Additionally, the representative was informed verbally by the previous administrator about an immediate payment requirement and a future rate increase, but did not receive any written documentation. The facility also failed to provide at least a 30-day written notice of rate increases to several residents and their representatives. Multiple residents and their representatives reported not receiving any notification of rate increases, despite the facility's policy requiring such notice. In some cases, residents were cognitively intact and responsible for their own financial matters, yet they were unaware of the rate changes until they received a bill reflecting the increase. The facility's business office manager was on vacation when the rate increase letters were supposedly sent, and the previous administrator claimed to have mailed the letters, but several residents and their representatives did not receive them. The facility's documentation showed inconsistencies in the communication of rate increases, with some letters lacking addresses and others not being sent at all. The corporate office had approved the rate increase, and the previous administrator signed a memo acknowledging the implementation of the increase. However, the lack of proper notification to residents and their representatives led to confusion and dissatisfaction among those affected. The facility's failure to adhere to its own policies and ensure proper communication contributed to the deficiency identified by the surveyors.
FSD Lacks Valid Certification
Penalty
Summary
The facility failed to employ a Food Service Director (FSD) with valid credentials, as required by their job description. The Director of Nursing (DON) confirmed that the FSD, who started in October 2023, did not have a current certification in food safety management. The Administrator had planned to enroll the FSD in a certification course, but this did not occur. The FSD himself confirmed that he had started but not completed the certification course. The Regional Director of Operations (RDO) also acknowledged that the FSD lacked the necessary certification. A review of the FSD's employee file revealed that his previous certification had expired. This deficiency had the potential to affect all 55 residents in the facility, although there were no residents receiving enteral feeding at the time of the survey.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident with nasal and inhaler medications at their bedside had a self-administration of medication assessment, a physician's order, and a care plan completed. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had Astepro nasal solution, Albuterol sulfate HFA inhalation aerosol solution, and Trilogy inhaler at their bedside. However, there was no evidence of a self-administration assessment, physician's order, or care plan for these medications in the resident's electronic medical record (EMR). During an interview, the resident confirmed using the medications as needed. The facility's policy requires an interdisciplinary team (IDT) assessment and a physician's order for self-administration of medications, but these steps were not documented. The Director of Nursing (DON) acknowledged the oversight and removed the medications until an assessment could be completed. This failure to follow protocol increases the potential for medication errors for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident (R21) to the State of Missouri Department of Health and Senior Services in a timely manner. R21, who had diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls, was found to have a swollen and discolored left knee on 03/12/24. Despite the observation and subsequent X-ray order by RN3, the incident was not reported to the Administrator or Director of Nursing (DON) until 03/18/24, when the DON learned of the fracture and reported it to the state agency the same day. The facility's policy mandates that such injuries be reported within two hours of discovery, which was not adhered to in this case. The deficiency was identified during a review of R21's records and interviews with the staff involved. RN3 noted the injury but failed to report it to the appropriate authorities, and the DON only became aware of the situation six days later. This delay in reporting violated the facility's abuse prevention and prohibition policy, which requires immediate notification to the state agency and law enforcement. The failure to report the injury promptly was confirmed by the DON during the interview, acknowledging that the injury should have been reported on the day it was discovered.
Failure to Immediately Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an investigation was immediately initiated when an allegation of injury of unknown origin was found for a resident. The resident, who had diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls, was found to have a swollen and discolored left knee on 03/12/24. Despite the observation and documentation by a Registered Nurse (RN), the injury was not reported to the Administrator or Director of Nursing (DON) until 03/18/24, when the resident was found to have a fracture. The facility's policy requires that injuries of unknown origin be reported immediately and an investigation initiated, which did not occur in this case. The DON confirmed that she first learned of the injury on 03/18/24 and initiated an investigation on the same day. The delay in reporting and investigating the injury of unknown origin was a clear violation of the facility's abuse prevention and prohibition policy. The policy mandates that nursing staff report such injuries immediately to the Administrator and that an investigation be conducted promptly. The failure to follow these procedures resulted in a significant delay in addressing the resident's injury and ensuring their safety.
Failure to Update Care Plan for Wandering Resident
Penalty
Summary
The facility failed to update the care plan for a resident with wandering behaviors after two incidents where the resident left the skilled nursing unit without staff knowledge or supervision. The resident, diagnosed with Alzheimer's disease, cerebral infarction, and repeated falls, was found in the independent living Bistro and later in the chapel, both times without any changes made to the care plan. The care plan, dated several months prior, only included general interventions such as offering pleasant diversions and redirection, with no updates following the incidents. The Director of Nursing confirmed that there was no incident report for the first incident and acknowledged that the facility did not have a policy related to updating care plans. Despite the resident's wandering behaviors and the incidents, the care plan remained unchanged, and no new interventions were put in place to address the resident's safety and wandering tendencies. The lack of updates to the care plan and the absence of a policy for such updates contributed to the deficiency identified in the report.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a resident with wandering behaviors from leaving the skilled nursing unit without staff's knowledge or supervision. The resident, identified as R21, left the skilled nursing unit and was found in the independent living Bistro and later in the chapel, which was located past two closed double doors at the end of the hall. The resident had a history of Alzheimer's disease, cerebral infarction, and repeated falls, and was known to wander. Despite this, the care plan did not have updated interventions after the incidents, and staff were unsure of the specific interventions in place to supervise the resident. On two separate occasions, R21 was able to leave the skilled nursing unit without staff noticing. On the first occasion, the resident was found in the Bistro, and on the second occasion, the resident was missing for over two hours before being found in the chapel. Interviews with staff revealed that they were aware of the resident's wandering behavior but were unclear about the specific interventions to prevent it. The doors leading to the chapel did not have an effective alarm system, and there was no documentation of hourly monitoring after the resident was found. The Director of Nursing (DON) confirmed that there was no elopement assessment for R21 prior to the incidents and no root cause analysis or investigation into how the resident exited the unit. Additionally, there was no documentation of the 15-minute checks that were supposed to be implemented after the second incident. The facility's policy on elopements stated that all residents should be afforded adequate supervision and assessed for behaviors that put them at risk for elopement, but this was not followed in R21's case.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) changed gloves and performed hand hygiene when transitioning from a contaminated area to a clean area during catheter care for a resident. The facility's policy on Standard Precautions and Prevention of Catheter-Associated Urinary Tract Infections mandates that hand hygiene be performed immediately after any manipulation of or contact with the catheter site, catheter, tubing, drainage bag, or emptying container, even when gloves are worn. Additionally, gloves should be removed before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated. However, during an observation, CNA2 and CNA1 did not adhere to these protocols while providing catheter care to a resident diagnosed with neuromuscular dysfunction of the bladder, who had a recent urinalysis showing mixed pathogen growth. CNA2 and CNA1 failed to change gloves and perform hand hygiene at multiple points during the procedure, including after handling soiled linens and before touching clean items and areas of the resident's body. During the catheter care, CNA2 used the same gloves to remove bowel movement, handle soiled linens, and then touch clean items such as a new incontinence brief and a clean shirt. CNA1 also failed to change gloves after handling soiled linens and before assisting with clean tasks. Furthermore, CNA2 did not perform hand hygiene after removing gloves at the end of the procedure. Interviews with CNA2 and the Director of Nursing (DON) confirmed that gloves should be changed when moving from dirty to clean areas, indicating a clear deviation from the facility's established infection control policies.
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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