Inspection Reports for
Avenir at Mark Twain
11988 MARK TWAIN LN, BRIDGETON, MO, 63044-2825
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
75 residents
Based on a December 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 75
Deficiencies: 3
Date: Dec 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, including notification after falls, adherence to physician orders for diabetes management, and proper wound assessment and documentation.
Findings
The facility was found deficient in notifying a resident's representative after a fall, failing to follow physician orders and obtain notification parameters for blood glucose levels for diabetic residents, and inadequately assessing and documenting a resident's surgical wound upon admission and weekly thereafter.
Deficiencies (3)
Failed to notify the resident's representative after a fall for one resident.
Failed to ensure services met professional standards by not following physician orders to notify the physician for out-of-range blood sugar levels and lacking physician notification parameters for blood glucose for three residents.
Failed to thoroughly and accurately assess and document a resident's surgical wound upon admission and weekly as per facility policy.
Report Facts
Census: 75
Blood sugar measurement occurrences above 300: 14
Wound size: 0.8
Wound size: 2.5
Wound size: 0.5
Wound size: 0.6
Wound size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding fall notification procedures and blood sugar notification practices |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding fall notification procedures, blood sugar notification practices, and wound assessment procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding fall notification, blood sugar notification, and wound assessment expectations |
| Director of Nursing | Director of Nursing | Interviewed regarding fall notification and blood sugar incident reporting |
| Administrator | Administrator | Interviewed regarding expectations for fall notification, blood sugar management, and wound documentation |
| Wound Nurse | Wound Nurse | Interviewed regarding wound assessment and documentation procedures |
Inspection Report
Routine
Census: 72
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to treatment and skin integrity management, focusing on wound care and skin assessments for residents, including Resident #54.
Findings
The facility failed to ensure appropriate treatment and care according to orders and standards, specifically failing to administer treatments as ordered for non-pressure wounds, complete comprehensive skin assessments routinely, and reassess treatment efficacy for skin integrity issues for one resident. Observations included missed skin assessments, improper application and documentation of wound care treatments, and inadequate monitoring of skin conditions.
Deficiencies (1)
Failure to administer treatments as ordered for non-pressure wounds and to complete comprehensive skin assessments routinely.
Report Facts
Residents in sample: 6
Census: 72
Wound dressing frequency: 3
Skin assessment frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Documented wound care and heel protector administration; interviewed regarding wound dressing and skin assessments |
| CNA B | Certified Nursing Assistant | Assisted resident with turning and bathing; applied lotion; interviewed about skin care practices |
| RN A | Registered Nurse | Interviewed regarding nurse responsibilities for compression wraps and skin assessments |
| Regional Director of Operations | Interviewed about expectations for wound care and skin assessments | |
| Wound Nurse | Provided wound care and interviewed about dressing changes and skin assessments |
Inspection Report
Routine
Census: 75
Capacity: 75
Deficiencies: 22
Date: Aug 20, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, self-determination, resident rights, care and assistance with activities of daily living, infection control, medication administration, food service, environmental cleanliness, staff training, and quality assurance. Specific issues included staff disrespectful behavior, failure to assist residents timely, improper handling of resident funds, inaccurate assessments, failure to provide ordered therapies and diets, inadequate infection prevention practices, and lack of proper documentation and policies.
Deficiencies (22)
Staff failed to treat residents with dignity and respect, including verbal disrespect and neglecting assistance needs.
Failure to assist residents with self-determined preferences such as timely transfers and showers.
Failure to complete third party liability forms for deceased residents with funds in their accounts.
Resident rooms and shower rooms were not maintained in a clean, homelike, and safe environment; temperature control issues noted.
Failure to complete criminal background checks and Nurse Aide Registry checks for new hires.
Facility admission policy required residents to waive liability for lost personal property; inventory sheets were not maintained or updated.
Residents' assessments inaccurately coded side rails as restraints when used for repositioning without restriction.
Resident did not receive prescribed anti-anxiety medication for over two weeks; weights not accurately documented; resident outings not documented.
Failure to provide adequate assistance with activities of daily living including hygiene and feeding.
Failure to provide appropriate foot care including toenail trimming and lotion application.
Fall prevention interventions were incomplete or inconsistently implemented including improper bed positioning and call light placement.
Failure to ensure resident was positioned upright during meals as ordered to prevent aspiration.
Failure to provide or maintain respiratory equipment properly; oxygen orders not followed accurately.
Failure to assess residents for safety and obtain consent for use of side rails; no policy guidance for non-restraint side rails.
Food served at unsafe temperatures, food quality and portion issues, and failure to accommodate allergies and preferences.
Failure to maintain kitchen cleanliness, pest control, and proper functioning of kitchen appliances including oven and dishwasher.
Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program with regular meetings and documentation.
Failure to maintain infection prevention and control program including incomplete employee TB testing, failure to implement Enhanced Barrier Precautions, and improper hand hygiene.
Failure to ensure resident immunizations including influenza and COVID-19 vaccines were offered, documented, and tracked.
Failure to ensure therapeutic diets were provided as ordered including nectar-thick liquids and double portions.
Failure to provide and document COVID-19 vaccination education and status for residents and staff.
Failure to provide ongoing CNA education and training with documentation of required hours.
Report Facts
Residents affected: 5
Residents affected: 75
Deficiencies cited: 22
Temperature: 80.2
Temperature: 83.8
Temperature: 125
Temperature: 90
Temperature: 95
Temperature: 31.1
Temperature: 20.9
Temperature: 20.1
Temperature: 20.2
Temperature: 43
Temperature: 2
Temperature: 4
Temperature: 2
Temperature: 4
Temperature: 1
Temperature: 2
Temperature: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Restorative Aide W | Restorative Aide | Named in undignified treatment and improper hand hygiene findings |
| Director of Nurses | Director of Nurses | Interviewed regarding staff behavior, infection control, and facility policies |
| Administrator | Administrator | Interviewed regarding staff behavior, infection control, and facility policies |
| Dietary Manager | Dietary Manager | Named in food service and dietary deficiencies |
| Certified Nursing Assistant I | Certified Nursing Assistant | Named in resident assistance and dietary findings |
| Licensed Practical Nurse J | Licensed Practical Nurse | Named in medication and dietary findings |
| Certified Nurse Aide B | Certified Nurse Aide | Named in resident assistance and dietary findings |
| Certified Nurse Aide M | Certified Nurse Aide | Named in dietary and hygiene findings |
| Certified Nurse Aide T | Certified Nurse Aide | Named in dietary and oxygen therapy findings |
| Certified Nurse Aide S | Certified Nurse Aide | Named in dietary and infection control findings |
| Registered Nurse A | Registered Nurse | Named in medication, oxygen, and dietary findings |
| Certified Medication Technician O | Certified Medication Technician | Named in oxygen therapy findings |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Named in infection control and vaccination findings |
| Licensed Practical Nurse R | Licensed Practical Nurse | Named in infection control and vaccination findings |
| Certified Nurse Assistant HH | Certified Nurse Assistant | Named in food service findings |
| Dietary Aide OO | Dietary Aide | Named in food service findings |
Inspection Report
Routine
Census: 75
Capacity: 75
Deficiencies: 6
Date: Aug 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, quality of care, activities of daily living, dietary services, medication administration, and staff training at the nursing home.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, failure to provide medications timely, inadequate documentation of resident weights and appointments, failure to meet residents' activities of daily living needs, serving food at inappropriate temperatures and not accommodating dietary preferences and allergies, and insufficient ongoing education documentation for certified nursing aides.
Deficiencies (6)
Failure to ensure residents were treated in a dignified manner affecting 5 of 18 sampled residents.
Failure to ensure services met professional standards when one resident did not receive routine anti-anxiety medication for over two weeks and failure to document weights and appointments accurately.
Failure to ensure activities of daily living needs were met for three residents including hygiene and feeding assistance.
Failure to ensure residents were served food at palatable, safe, and appetizing temperatures affecting 10 of 18 sampled residents.
Failure to provide food that accommodates resident allergies, intolerances, preferences, and alternative meal options for 8 residents.
Failure to provide documentation of ongoing educational training totaling no less than 12 hours per year for four of six sampled CNAs.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 10
Residents affected: 8
Sample size: 18
Census: 75
Deficiencies cited: 6
Medication not received: 16
Weights recorded: 5
Inservice hours missing: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Restorative Aide W | Restorative Aide | Named in undignified treatment of Resident #1 and failure to assist Resident #28 |
| Housekeeping Aide M | Housekeeping Aide | Named in undignified treatment of Resident #1 |
| Dietary Manager (DM) | Dietary Manager | Named in rude interactions with residents and issues with food temperature and availability |
| Certified Nursing Assistant (CNA) I | Certified Nursing Assistant | Named in failure to assist Resident #28 and observations of dietary manager behavior |
| Licensed Practical Nurse (LPN) J | Licensed Practical Nurse | Named in medication administration issues and dietary staff behavior |
| Certified Nursing Assistant (CNA) M | Certified Nursing Assistant | Named in expectations for resident hygiene and feeding assistance |
| Administrator | Facility Administrator | Named in expectations for staff behavior and dietary services |
| Director of Nurses (DON) | Director of Nursing | Named in expectations for staff behavior, medication administration, dietary services, and CNA education |
| Certified Nursing Assistant (CNA) B | Certified Nursing Assistant | Named in dietary slip and food preference issues |
| Dietary Aide (DA) OO | Dietary Aide | Named in food availability and alternate menu issues |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 4
Date: Jan 21, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse and neglect, failure to provide care according to professional standards including post-fall care, and failure to provide appropriate basic life support including CPR for a resident.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to report neglect timely, failed to provide appropriate post-fall care and documentation, and failed to provide timely and adequate CPR and emergency response for a resident who expired. Immediate jeopardy was identified related to CPR failures and lack of CPR certified staff.
Findings
The facility failed to timely report suspected neglect involving cessation of CPR before EMS arrival for one resident, failed to provide appropriate post-fall care and documentation for three residents, and failed to ensure CPR certified staff were available on all shifts. CPR was initiated but stopped prematurely, EMS was not notified timely, and staff lacked knowledge of code status and CPR procedures.
Deficiencies (4)
Failure to timely report suspected neglect involving cessation of CPR before EMS arrival for one resident.
Failure to provide care in accordance with professional standards including post-fall assessments, documentation, and notifications for three residents.
Failure to provide appropriate basic life support including CPR for one resident; CPR was stopped before EMS arrival and EMS was not notified timely.
Failure to ensure CPR certified staff were available on all shifts; 14 out of 30 night shifts lacked CPR certified staff.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 54
Census: 71
Days without CPR certified staff on night shift: 14
Duration of CPR performed: 10
Time delay before calling 911: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Performed CPR on Resident #1, called family and physician, delayed calling 911 |
| LPN B | Licensed Practical Nurse | Assisted with CPR on Resident #1 |
| CNA C | Certified Nursing Assistant | Performed chest compressions on Resident #1, not CPR certified |
| CNA D | Certified Nursing Assistant | Assisted during CPR event on Resident #1, not CPR certified |
| Staffing Coordinator | Responsible for ensuring CPR certified staff on shifts, unaware of responsibility until after state notification | |
| Administrator | Expected staff to follow policies and physician orders, notified of immediate jeopardy | |
| Social Worker | Interviewed regarding Resident #1's code status and wishes | |
| Primary Care Physician | Stated CPR should be started immediately and continued until EMS arrival | |
| Medical Director | Stated CPR should be initiated immediately and continued until EMS arrival | |
| Emergency Medical Technician F | First EMS on scene, found no CPR in progress | |
| Emergency Medical Technician E | Second EMS on scene, found no CPR in progress | |
| Assistant Fire Chief | Expressed concern about CPR not in progress upon arrival | |
| Human Resources | Responsible for orientation and CPR card collection | |
| LPN G | Licensed Practical Nurse | Unaware of who is CPR certified |
| LPN H | Licensed Practical Nurse | Facility did not have current CPR certification on file |
Inspection Report
Census: 80
Deficiencies: 1
Date: Sep 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality related to laboratory services and reporting, specifically regarding failure to obtain ordered labs for a resident.
Findings
The facility failed to ensure that one out of three resident's labs were obtained per physician orders. Documentation showed the resident refused some procedures, and the facility did not follow up adequately with the lab or document refusals or notifications to the physician. The lab confirmed the labs were not drawn due to a breakdown in communication.
Deficiencies (1)
Failure to ensure one out of three resident's labs were obtained per physician orders.
Report Facts
Residents Affected: 3
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding lab order entry and follow-up responsibilities |
| Director of Nursing | Director of Nursing | Interviewed regarding lab order process and facility oversight |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse by a Certified Nurse Aide (CNA) towards a resident, which was overheard by another resident.
Complaint Details
The complaint involved an allegation of verbal abuse by CNA A towards Resident #2, overheard by Resident #1 on 4/1/24. Resident #1 reported the incident to the Social Worker on 4/4/24, but the allegation was not reported to the state agency within the required two-hour timeframe nor investigated promptly. The facility was experiencing a respiratory outbreak at the time, which contributed to the delay. The Administrator and nursing leadership were unaware of the allegation until the survey on 4/5/24.
Findings
The facility failed to immediately report the allegation of verbal abuse to the Department of Health of Senior Services within the required two-hour timeframe and failed to investigate the allegation promptly. The Social Worker did not report or investigate the allegation in a timely manner, and management was unaware of the incident until the survey.
Deficiencies (2)
Failed to timely report suspected verbal abuse involving a staff member and resident to the state agency within the required timeframe.
Failed to investigate an allegation of verbal abuse following resident notification.
Report Facts
Census: 82
Sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named as the staff member allegedly involved in verbal abuse |
| Resident #1 | Resident who overheard and reported the verbal abuse allegation | |
| Resident #2 | Resident alleged to be verbally abused | |
| Social Worker | Social Worker (SW) | Received the verbal abuse allegation from Resident #1 but failed to report or investigate timely |
| Administrator | Administrator | Reported unawareness of the allegation until survey and stated staff are expected to report immediately |
| Assistant Director of Nursing | ADON | Identified alleged staff member as CNA A based on resident description |
| Director of Nursing | DON | Unaware of the allegation until survey |
| Licensed Practical Nurse C | LPN | Took Resident #1 to Social Worker to report the allegation |
| CNA B | Certified Nurse Aide | Denied involvement in abuse and was not interviewed regarding the allegation |
Inspection Report
Routine
Census: 69
Deficiencies: 12
Date: Jan 19, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with state and federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident trust fund management, notification of residents regarding account balances, employee abuse screening, discharge summary completion, foot care, restorative nursing services, smoking supervision, physician visits, nurse aide training, nurse staffing postings, food temperature management, and tuberculosis screening for employees.
Deficiencies (12)
Failed to follow up on outstanding resident trust fund checks during monthly reconciliations.
Failed to notify residents or responsible parties timely when resident accounts were within or over the Medicaid spend down limit.
Failed to check federal abuse indicator in the Nurse Aide registry for six of ten employee files reviewed.
Failed to complete a discharge summary for one resident including recapitulation of stay and final status.
Failed to provide timely podiatry follow-up and care for one resident with foot care needs.
Failed to ensure a resident with limited mobility received restorative nursing services and assistance with brace use as recommended by Physical Therapy.
Failed to ensure adequate supervision and safe environment during resident smoking breaks, resulting in residents being locked outside unattended in freezing weather.
Failed to ensure one resident was seen by a physician within the first 30 days of admission; resident was only seen by Nurse Practitioner.
Failed to have a system to ensure Certified Nurse Aides received required 12 hours of annual in-service training.
Failed to post nurse staffing information daily including breakdown of RN and LPN hours.
Failed to provide residents food at safe and appetizing temperatures; multiple residents reported cold meals and observations confirmed food served lukewarm or cold.
Failed to ensure six of ten sampled staff hired since last survey received two-step tuberculin skin test prior to or upon hire as per facility policy.
Report Facts
Residents affected: 20
Census: 69
Outstanding checks: 7
Temperature: 22
Wind speed: 9
Number of CNAs employed more than a year: 13
Food temperature: 82
Food temperature: 93.7
Food temperature: 104.3
Food temperature: 109.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner S | Nurse Practitioner | Provided care to Resident #61 but no physician visits documented |
| Business Office Manager | Responsible for Resident Trust Fund reconciliation and notifications | |
| Interim Administrator | Oversaw smoking policy implementation and resident supervision | |
| Director of Nurses | Director of Nurses | Responsible for in-service training and TB test tracking |
| Staffing Coordinator | Responsible for posting nurse staffing information | |
| Human Resources Manager | Responsible for employee background screenings | |
| Wound Nurse | Reported on foot care and smoking supervision | |
| Licensed Practical Nurse B | Licensed Practical Nurse | Reported on foot care and smoking supervision |
| Certified Nurse Aide A | Certified Nurse Aide | Reported on foot care and smoking supervision |
| Housekeeper E | Observed smoking supervision issues | |
| Activity Director | Reported on smoking supervision | |
| Task Aide H | Reported on smoking supervision | |
| Medical Director | Medical Director | Approved smoking policy and expected supervision |
| Dietary Aide F | Reported on food temperature expectations | |
| Regional Director of Operations | Reported on food temperature expectations |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Jan 19, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide proper foot care for a resident, inadequate supervision of residents during smoking times leading to immediate jeopardy, and failure to provide food at safe and appetizing temperatures.
Complaint Details
The complaint investigation revealed that Resident #7 did not receive timely podiatry care despite documented need and consent. Multiple residents were left unsupervised outside in freezing temperatures during smoking times, with some residents having access to the keypad code to exit but no way to re-enter without staff assistance, creating immediate jeopardy. Additionally, several residents reported and were observed to receive food that was cold or lukewarm, not meeting safe and appetizing standards.
Findings
The facility failed to ensure timely podiatry follow-up for a resident with foot care needs, left multiple residents unsupervised outside in freezing weather during smoking times causing immediate jeopardy, and served food at unsafe and unappetizing temperatures to several residents.
Deficiencies (3)
Failure to provide proper foot care and timely podiatry follow-up for Resident #7.
Failure to ensure resident environment was free from hazards and provide adequate supervision during smoking times, resulting in residents being left unattended outside in freezing weather.
Failure to provide residents food at a safe and appetizing temperature.
Report Facts
Residents affected: 1
Residents affected: 5
Census: 69
Temperature: 22
Wind speed: 9
Food sample size: 17
Food temperature: 82
Food temperature: 93.7
Food temperature: 104.3
Food temperature: 109.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in foot care deficiency finding for Resident #7 |
| LPN B | Licensed Practical Nurse | Named in foot care deficiency finding for Resident #7 |
| Interim Administrator | Provided information on foot care and smoking supervision deficiencies | |
| Wound Nurse | Provided information on foot care and smoking supervision deficiencies | |
| Housekeeper E | Observed leaving residents unattended outside during smoking times | |
| Task Aide H | Assigned to monitor smoking time but did not supervise residents | |
| Activity Director | Provided information on smoking supervision | |
| Admissions Director | Provided information on smoking supervision and resident needs | |
| Medical Director | Provided information on smoking policy and supervision expectations | |
| Dietary Aide F | Dietary Aide | Provided information on food temperature expectations |
| Regional Director of Operations | Provided information on dietary staff expectations for food temperature |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Sep 7, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to follow a resident's do not resuscitate (DNR) code status, resulting in staff performing CPR contrary to the resident's wishes.
Complaint Details
The complaint investigation revealed that CPR was performed on Resident #1 despite a DNR order. The resident's code status was not properly updated in the EMR or code status binders, and staff were unaware of the change. The police department investigated, and the resident was pronounced dead at 5:14 A.M.
Findings
The facility failed to develop and implement adequate policies and procedures to update and communicate residents' code status, leading to CPR being performed on a resident with a DNR order. The code status documentation was inconsistent and not properly updated in the electronic medical record or nurse station binders.
Deficiencies (1)
Failure to develop policies to define the process for updating residents' code status, resulting in staff performing CPR contrary to a resident's DNR wishes.
Report Facts
Residents present during inspection: 72
Time of 911 call: 5.04
Time EMS dispatched: 5.06
Time EMS arrived: 5.13
Time of death declared: 5.14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Found resident unresponsive and initiated CPR |
| CNA G | Certified Nurse Aide | Took over CPR from LPN A, unaware of DNR status |
| Director of Nursing | Director of Nursing (DON) | Conducted internal investigation and updated code status binders |
| Nurse Supervisor | Nurse Supervisor | Witnessed resident's updated DNR request and responsible for code status updates |
| LPN B | Licensed Practical Nurse | Witnessed resident's updated DNR request and involved in documentation |
| Social Worker | Social Worker | In charge of code status updates and unaware of DNR status change |
| Medical Records Staff | Medical Records Staff | Responsible for uploading signed code status documents to EMR |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 4
Date: Apr 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to identify a resident's fall risk and to develop appropriate interventions, following an unwitnessed fall that resulted in a left femur fracture.
Complaint Details
The investigation was complaint-driven due to a resident fall resulting in injury. The fall was unwitnessed, and the facility failed to fully investigate or document the incident properly. The resident was sent to the hospital at the family’s request and was found to have a broken leg. The complaint was substantiated by the findings.
Findings
The facility failed to identify and address the fall risk of Resident #19, who had an unwitnessed fall resulting in a left femur fracture. The facility also failed to complete a full investigation of the fall and did not update the resident's care plan or perform required neuro checks. Staff lacked access to resident care status and did not receive fall-related education after the incident.
Deficiencies (4)
Failed to identify a resident's risk for falls and develop interventions to address potential risk.
Failed to complete a full investigation of the resident's fall.
No care plan, including interventions, for fall risk status or actual falls for the resident.
Neuro checks were not performed or documented after the unwitnessed fall because the resident was sent to the hospital.
Report Facts
Sample size: 20
Census: 66
Date of fall incident: Mar 28, 2023
Date of resident admission: Admission date redacted
Date of quarterly MDS assessment: Jan 13, 2023
Date of Nursing Admission/readmission Data Collection: Mar 9, 2023
Date of care plan initiation: Mar 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Responded to fall incident, performed assessments |
| CNA B | Certified Nursing Assistant | Discovered resident on floor after fall, provided initial care |
| CNA C | Certified Nursing Assistant | Assisted in placing resident back into bed after fall |
| DON | Director of Nursing | Responsible for fall investigations and care plan updates |
Inspection Report
Routine
Census: 84
Deficiencies: 13
Date: Nov 8, 2019
Visit Reason
The inspection was a routine regulatory survey of the nursing home to assess compliance with federal regulations and standards of care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, resident self-determination, transfer/discharge notification, care plan updates, following physician orders, provision of restorative therapy, safe transfer techniques, dietary staffing and food preparation, infection control, and dialysis care. Deficiencies were generally of minimal harm but affected some or few residents.
Deficiencies (13)
Staff failed to treat residents with respect and dignity by leaving a resident exposed during personal care and standing while assisting residents with meals.
Facility failed to promote and facilitate resident self-determination by opening and withholding resident mail without permission and failing to ensure diet texture met resident needs.
Facility failed to provide timely written transfer/discharge notices and bed hold policy notices to residents or representatives for hospital transfers.
Care plans were not updated to reflect new fall interventions, NPO orders, elopement risk and skin condition treatments for sampled residents.
Physician orders were not followed for hand splint, gastrostomy tube care, suprapubic catheter care, and fluid restriction documentation.
Residents who were unable to perform activities of daily living did not consistently receive adequate oral hygiene and nail care.
Facility failed to ensure safe transfer techniques with a stand up lift and failed to secure razors in shower rooms.
Facility failed to provide restorative therapy as recommended for residents with limited range of motion and mobility.
Facility failed to provide thorough dialysis assessments, orders, monitoring and communication with dialysis centers; lacked contract with one dialysis provider.
Facility failed to ensure sufficient dietary staff to carry out food service timely and at appropriate times.
Facility failed to follow recipes for preparation of therapeutic pureed diets resulting in unpalatable food.
Facility failed to prevent frost and ice buildup in walk-in freezer due to broken door, failed to date and cover food items, keep handwashing sink clean, and prevent storage of boxes on freezer floor.
Facility failed to ensure acceptable infection control during blood sugar testing and incontinence care; failed to properly label and store combs and brushes in community shower rooms.
Report Facts
Sample size: 18
Census: 84
Deficiency count: 14
Meal service times: 7
Meal service times: 12
Meal service times: 13
Meal service times: 17
Meal service times: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nurse Aide | Named in dignity and respect deficiency related to leaving resident exposed and improper transfer technique |
| CNA H | Certified Nurse Aide | Assisted CNA G during resident transfer |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding deficiencies in care, policies, and procedures |
| Administrator | Facility Administrator | Provided interviews regarding facility operations and deficiencies |
| LPN C | Licensed Practical Nurse | Observed performing blood sugar testing with infection control deficiencies |
| CNA J | Certified Nurse Aide | Observed providing incontinence care with infection control deficiencies |
| Cook L | Cook | Observed preparing pureed diets not following recipes |
| Cook M | Cook | Observed preparing pureed diets not following recipes |
| Therapy Program Director | Therapy Program Director | Interviewed regarding restorative therapy deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding freezer door repair |
| Dietary Manager | Dietary Manager | On leave during inspection; discussed in dietary staffing deficiency |
| DA N | Dietary Aide | Interviewed regarding dietary staffing and food service |
| DA O | Dietary Aide | Interviewed regarding dietary staffing and food service |
Viewing
Loading inspection reports...
