Inspection Reports for
Lakeview Post Acute
1201 GARDEN PLAZA DR, FLORISSANT, MO, 63033-2230
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
24.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
79% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 95
Deficiencies: 1
Date: Jun 4, 2025
Visit Reason
The inspection was conducted to investigate the facility's compliance with proper foot and wound care for a resident who had a wound to the great toe and a blister on the second toe.
Findings
The facility failed to ensure proper foot and wound care was performed for one resident, resulting in an infected great toe wound and failure to document a blister on the second toe in skin assessments. The wound was left uncovered until the wound management company assessed it, and treatment orders were delayed.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals for foot/wound care.
Report Facts
Sample size: 10
Resident wound size: 0.2
Resident wound size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Created late entry note about resident's wound and communicated with physician and wound care company |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding awareness of resident's wounds and skin assessments |
| Physician | Physician | Interviewed regarding awareness and orders for resident's wounds |
| Wound Nurse | Wound Nurse | Performed first wound care appointment and debridement on resident's infected wound |
Inspection Report
Routine
Census: 92
Deficiencies: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing a safe, clean, comfortable, and homelike environment, specifically focusing on hot water availability for bathing and personal care.
Findings
The facility failed to provide adequate hot water temperatures for bathing and personal care in multiple resident rooms and shower rooms, with temperatures consistently below the facility's policy and state regulations. Several residents reported dissatisfaction with the water temperature being too cold or taking too long to warm up.
Deficiencies (1)
Failure to provide hot water at appropriate temperatures for bathing and personal care, affecting multiple resident rooms and shower rooms.
Report Facts
Census: 92
Hot water temperature measurements: 88.9
Hot water temperature measurements: 92.4
Hot water temperature measurements: 92.2
Hot water temperature measurements: 84.5
Hot water temperature measurements: 95.5
Hot water temperature measurements: 84
Hot water temperature measurements: 85.5
Hot water temperature measurements: 77
Hot water temperature measurements: 86.6
Hot water temperature measurements: 88.1
Hot water temperature measurements: 104.5
Hot water temperature measurements: 94.6
Hot water temperature measurements: 94.6
Hot water temperature measurements: 82.7
Hot water temperature measurements: 103.8
Hot water temperature measurements: 94.4
Hot water temperature measurements: 91.2
Hot water temperature measurements: 84
Hot water temperature measurements: 87.2
Hot water temperature measurements below 105 degrees F: 4
Water heaters replaced: 8
Mixing valves replaced: 3
Inspection Report
Routine
Census: 77
Deficiencies: 5
Date: Jan 3, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, wound care, activities of daily living assistance, medication administration, pest control, and documentation accuracy in a nursing facility.
Findings
The facility failed to ensure proper wound care and medication administration, including failure to apply leg wraps as ordered, failure to provide showers and incontinence care, failure to maintain wound vac supplies and follow wound care orders, inaccurate documentation of treatments, and inadequate pest control resulting in gnats in resident rooms. These deficiencies affected multiple residents and posed risks of harm.
Deficiencies (5)
Failure to apply leg wraps as ordered for Resident #13, resulting in swollen legs and potential harm due to CHF.
Failure to provide adequate personal hygiene and incontinence care for Residents #25 and #64, including failure to provide showers at least twice weekly.
Failure to obtain and administer medication for rheumatoid arthritis and failure to follow wound vac and wound care orders for Residents #24 and #87, including lack of wound vac supplies and inaccurate documentation.
Failure to maintain accurate and complete resident records, including documenting treatments as provided when they were not for Residents #24, #87, and #13.
Failure to maintain an effective pest control program resulting in gnats infestation in resident rooms (#87, #25, #64).
Report Facts
Census: 77
Wound vac pressure: 125
Wound vac dressing measurements: 18.5
Wound vac dressing measurements: 9
Wound vac dressing measurements: 0.3
Pain level: 11
Medication dosage: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Named in relation to leg wrap application for Resident #13 |
| Nurse Practitioner | Nurse Practitioner | Provided information about Resident #13's compliance with leg wraps and Resident #24's medication hold |
| Director of Nursing | Director of Nursing | Interviewed regarding documentation and wound care practices |
| Licensed Practical Nurse B | Licensed Practical Nurse | Applied wet to dry dressing for Resident #24 and reported wound vac issues |
| Central Supply I | Central Supply | Provided information about ordering wound care supplies |
| Physical Therapist L | Physical Therapist | Observed urine puddle incident for Resident #64 |
| Certified Nurse Aide H | Certified Nurse Aide | Reported Resident #64's shower refusal and assisted with cleanup |
| Registered Nurse M | Registered Nurse | Responded to urine puddle incident for Resident #64 |
| Maintenance Director | Maintenance Director | Interviewed about pest control and gnats |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Dec 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the diversion of Schedule II controlled medications by a licensed practical nurse at the facility.
Complaint Details
The complaint investigation was substantiated with findings of drug diversion by LPN A on 11/12/24. The nurse was terminated and arrested. The police report identified felony stealing of controlled substances. Witnesses included LPN B and the former Administrator.
Findings
The facility failed to prevent the unauthorized removal of controlled medications for one resident, resulting in the termination of the responsible nurse and police involvement. Additionally, the facility failed to ensure working call lights in residents' bathrooms and bathing areas for four sampled residents.
Deficiencies (2)
Failed to prevent diversion of Schedule II controlled medications by a licensed practical nurse for one resident.
Failed to ensure call lights were in working order, including visible notification at the nurses station for four residents.
Report Facts
Residents affected: 1
Residents affected: 4
Census: 89
Call lights not working: 10
Medication administration times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication diversion finding and termination |
| LPN B | Licensed Practical Nurse | Witness to medication diversion and reported missing medication |
| Director of Nursing | Director of Nursing | Notified of diversion, conducted investigation, and terminated LPN A |
| Former Administrator | Administrator | Provided investigation information and was reporter in police report |
Inspection Report
Routine
Census: 99
Deficiencies: 10
Date: Oct 21, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, notification of changes, abuse reporting, wound care, safety, nutrition, staffing, and medication administration.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity, failure to notify responsible parties of significant changes or incidents, failure to report abuse allegations, inadequate wound care and treatment documentation, failure to prevent resident elopement, insufficient staffing levels and supervision, failure to provide appropriate training and competency for tracheostomy care and equipment use, medication administration errors, and malfunctioning call light systems.
Deficiencies (10)
Failure to ensure dignity of a resident with exposed brief in common area.
Failure to immediately notify responsible parties of resident elopement, changes in condition, and hospital transfers.
Failure to timely report suspected abuse and neglect to appropriate authorities.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing; delayed wound treatment orders and incomplete wound care documentation.
Failure to ensure safety and adequate supervision to prevent resident elopement; inadequate investigation and documentation of elopement incident.
Failure to provide appropriate administration of enteral nutrition; resident's tube feeding was off for approximately five hours without infusion.
Failure to provide sufficient nursing staff 24/7 to meet resident care needs; inadequate monitoring and delayed response to call lights; staff sleeping during shifts.
Failure to ensure nurses and nurse aides have appropriate competencies and training for tracheostomy care, suctioning, and use of oxygen monitoring and suction equipment.
Failure to ensure residents are free from significant medication errors; missed medication doses due to unavailable medications and lack of documentation or physician notification.
Failure to ensure all call lights in the facility were in working order including audible notification at the nurse station on the 100 and 200 halls.
Report Facts
Sample size: 33
Census: 99
Residents with pressure ulcers: 29
Residents with tube feedings: 19
Residents with tracheostomy: 15
Residents receiving dialysis: 10
Residents requiring IV antibiotics: 6
Residents using ventilator: 2
Residents using CPAP: 2
Licensed nurses on night shift: 3
Certified Nursing Assistants on night shift: 6
Residents per CNA on night shift: 15
Residents per CNA on day shift: 15
Call light duration: 108
Tube feeding off duration: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN R | Licensed Practical Nurse | Named in relation to failure to report resident elopement and abuse allegation, and staffing concerns |
| CNA B | Certified Nurse Aide | Named in relation to abuse allegation |
| RN W | Registered Nurse | Named in relation to abuse allegation and medication administration |
| LPN BB | Licensed Practical Nurse | Named in relation to tracheostomy care deficiency |
| RRT Z | Registered Respiratory Therapist | Named in relation to tracheostomy care and equipment training deficiency |
| LPN D | Licensed Practical Nurse | Named in relation to tube feeding administration deficiency |
| LPN F | Licensed Practical Nurse | Named in relation to tube feeding administration and notification deficiency |
| Administrator | Named in relation to expectations for dignity, notification, staffing, training, and medication administration | |
| DON | Director of Nursing | Named in relation to notification, abuse reporting, staffing, and medication administration |
| ADON | Assistant Director of Nursing | Named in relation to staffing and medication administration |
| Pharmacist SS | Pharmacist | Named in relation to medication availability and prior authorization |
Inspection Report
Routine
Census: 99
Capacity: 120
Deficiencies: 20
Date: Oct 21, 2024
Visit Reason
Routine state inspection of Lakeview Post Acute to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, inadequate call light response, failure to notify responsible parties of significant incidents, incomplete care plans, medication administration errors, insufficient staffing, inadequate infection control practices, and failure to maintain safe bed rails and call light systems.
Deficiencies (20)
Failure to ensure dignity of resident by staff not intervening when resident was exposed in common area.
Failure to ensure call lights were within reach and answered timely for residents with limited mobility and preferences.
Failure to notify responsible parties timely after resident elopement, change in condition, or hospital transfer.
Failure to notify Department of Health and Senior Services of resident elopement and abuse allegations.
Failure to investigate an allegation of staff to resident abuse and document findings.
Failure to maintain complete, accurate, and individualized care plans addressing resident needs including elopement risk, side rail use, tracheostomy, gastrostomy, and behaviors.
Failure to complete ordered labs timely and failure to complete neurological checks after resident fall.
Failure to initiate wound treatment timely per physician orders and failure to document wound care treatments.
Failure to administer tube feeding continuously as ordered, resulting in resident going approximately five hours without feeding.
Failure to have complete and accurate physician orders for tracheostomy and ventilation machines, and failure to train staff on use of respiratory equipment and continuous oxygen monitoring.
Failure to ensure timely medication administration and failure to notify physician and document when medications were unavailable or required prior authorization.
Failure to follow pharmacist recommendations for medication regimen review including gradual dose reductions and side effect monitoring for psychotropic medications.
Failure to ensure medication administration per physician orders for multiple residents including missed doses and lack of documentation.
Failure to secure medication carts, date opened medications, and properly store insulin and PPD solution.
Failure to complete a thorough facility-wide assessment addressing staffing needs, competencies, and resources for resident care including respiratory therapy and restorative services.
Failure to follow infection control standards including hand hygiene and use of appropriate PPE for residents on Enhanced Barrier Precautions and failure to keep Foley catheter bag off the floor.
Failure to ensure residents received influenza, pneumococcal, COVID-19 vaccinations and PPD skin tests or documented refusals.
Failure to routinely inspect and document bed rails and mattresses for safety and entrapment risks for residents.
Failure to ensure call lights were audible and answered timely on 100 and 200 halls, resulting in residents waiting extended periods for assistance.
Failure to provide sufficient nursing staff on all shifts to meet resident care needs, including residents with tracheostomies and ventilators.
Report Facts
Residents affected by dignity deficiency: 1
Residents affected by call light deficiency: 3
Residents affected by notification deficiency: 4
Residents affected by abuse reporting deficiency: 3
Residents affected by care plan deficiency: 5
Residents affected by medication lab delay: 1
Residents affected by neuro-check deficiency: 1
Residents affected by wound care delay: 1
Residents affected by tube feeding delay: 1
Residents affected by respiratory care deficiency: 3
Residents affected by medication administration errors: 3
Residents affected by psychotropic medication monitoring deficiency: 2
Residents affected by medication administration documentation deficiency: 3
Residents affected by medication cart security deficiency: 3
Residents affected by infection control deficiency: 4
Residents affected by vaccination deficiency: 4
Residents affected by bed rail safety deficiency: 3
Residents affected by call light malfunction: 1
Residents affected by staffing deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN R | Licensed Practical Nurse | Named in abuse allegation and staffing concerns |
| RN W | Registered Nurse | Named in abuse allegation and medication administration |
| LPN NN | Licensed Practical Nurse | Named in abuse allegation and medication administration |
| CNA B | Certified Nurse Aide | Named in abuse allegation |
| LPN F | Licensed Practical Nurse | Named in wound care and tube feeding deficiencies |
| RRT Z | Registered Respiratory Therapist | Named in respiratory care deficiencies |
| LPN D | Licensed Practical Nurse | Named in tube feeding deficiency |
| CNA C | Certified Nurse Aide | Named in infection control deficiency |
| CNA V | Certified Nurse Aide | Named in infection control deficiency |
| CNA O | Certified Nurse Aide | Named in infection control deficiency |
| ICP Nurse | Infection Control Preventionist Nurse | Named in infection control and vaccination deficiencies |
| LPN Q | Licensed Practical Nurse | Named in call light deficiencies |
| CNA S | Certified Nurse Aide | Named in call light deficiencies |
| CMT OO | Certified Medication Technician | Named in elopement incident |
| CNA PP | Certified Nurse Aide | Named in elopement incident |
| LPN UU | Licensed Practical Nurse | Named in elopement incident |
| Administrator | Named in multiple deficiencies and expectations | |
| DON | Director of Nursing | Named in multiple deficiencies and expectations |
| ADON | Assistant Director of Nursing | Named in multiple deficiencies and expectations |
| LPN BB | Licensed Practical Nurse | Named in respiratory care deficiency |
| LPN GG | Licensed Practical Nurse | Named in respiratory care deficiency |
| RRT EE | Registered Respiratory Therapist | Named in respiratory care deficiency |
| RRT EE | Registered Respiratory Therapist | Named in respiratory care deficiency |
| LPN X | Licensed Practical Nurse | Named in emergency response deficiency |
| CNA KK | Certified Nurse Aide | Named in emergency response deficiency |
| CNA DD | Certified Nurse Aide | Named in emergency response deficiency |
| CNA L | Certified Nurse Aide | Named in call light deficiency |
| CNA M | Certified Nurse Aide | Named in call light deficiency |
| CMT N | Certified Medication Technician | Named in call light deficiency |
| LPN W | Licensed Practical Nurse | Named in medication cart security deficiency |
| LPN E | Licensed Practical Nurse | Named in medication storage deficiency |
| LPN F | Licensed Practical Nurse | Named in medication storage deficiency |
| Maintenance Director | Named in bed rail safety deficiency | |
| CNA J | Certified Nurse Aide | Named in infection control deficiency |
| CNA A | Certified Nurse Aide | Named in infection control deficiency |
| CNA HH | Certified Nurse Aide | Named in staffing deficiency |
| SC | Staffing Coordinator | Named in staffing deficiency |
| CNA QQ | Certified Nurse Aide | Named in elopement incident |
| CMT OO | Certified Medication Technician | Named in elopement incident |
| CNA PP | Certified Nurse Aide | Named in elopement incident |
| LPN UU | Licensed Practical Nurse | Named in elopement incident |
| Family member | Named in elopement incident | |
| RRT CC | Registered Respiratory Therapist | Named in infection control deficiency |
| CNA V | Certified Nurse Aide | Named in infection control deficiency |
| CNA O | Certified Nurse Aide | Named in infection control deficiency |
| ICP Nurse | Infection Control Preventionist Nurse | Named in infection control and vaccination deficiencies |
| LPN Q | Licensed Practical Nurse | Named in call light deficiencies |
| CNA S | Certified Nurse Aide | Named in call light deficiencies |
| Administrator | Named in multiple deficiencies and expectations | |
| DON | Director of Nursing | Named in multiple deficiencies and expectations |
| ADON | Assistant Director of Nursing | Named in multiple deficiencies and expectations |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to obtain physician orders and complete tracheostomy treatment orders for a resident requiring tracheostomy care and maintenance.
Complaint Details
The investigation was complaint-related, focusing on the failure to obtain and follow physician orders for tracheostomy care. The report indicates the deficiency was substantiated with findings of inadequate orders and documentation.
Findings
The facility failed to have physician orders and documentation for routine tracheostomy care, including suctioning and changing equipment, for Resident #12. Multiple instances showed lack of documentation and orders for tracheostomy care from April through July 2024, resulting in inadequate respiratory care and several emergency hospital transfers due to low oxygen saturation.
Deficiencies (1)
Failure to obtain physician orders and complete tracheostomy treatment orders for Resident #12 requiring tracheostomy care and maintenance.
Report Facts
Census: 106
Dates of documented orders: Apr 11, 2024
Dates of resident hospital transfers: Apr 20, 2024
Dates of resident hospital transfers: Jun 22, 2024
Dates of resident hospital transfers: Jul 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Agency Nurse | Interviewed regarding nursing staff following orders and documentation for tracheostomy care |
| Assistant Director of Nursing | ADON | Interviewed about nursing staff licensure and expectations for tracheostomy care |
| Director of Therapy Services | Interviewed about respiratory staff responsibilities and order audits for tracheostomy care | |
| Director of Nursing | DON | Interviewed about respiratory care team responsibilities and documentation expectations |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 6
Date: May 10, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided at the facility.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive, person-centered care plans, inadequate assistance with activities of daily living, incomplete wound and pressure ulcer treatments, failure to implement dietary recommendations for residents with severe weight loss, and failure to provide adaptive eating equipment as ordered. All deficiencies were cited with minimal harm or potential for actual harm.
Deficiencies (6)
Failed to develop comprehensive, person-centered care plans addressing nutritional needs and adaptive devices for residents with significant weight loss.
Failed to ensure staff checked residents for incontinence at least every two to three hours, resulting in residents left urine saturated for extended periods.
Failed to ensure wound treatments were completed as ordered for residents with wounds.
Failed to ensure residents received pressure ulcer treatments as ordered and failed to update care plans accordingly.
Failed to implement Registered Dietician's dietary recommendations for residents with severe weight loss and failed to provide adaptive utensils and cups as ordered.
Failed to ensure residents received adaptive eating equipment at meals as ordered to assist with eating independence and increase food/fluid intake.
Report Facts
Residents sampled: 11
Residents sampled: 7
Residents sampled: 2
Residents sampled: 5
Residents sampled: 4
Census: 94
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
The inspection was conducted following a complaint related to the facility's failure to develop an adequate care plan to prevent falls for a high-risk resident.
Complaint Details
The investigation was complaint-related, focusing on the failure to prevent falls for a resident who was identified as high risk and subsequently died after a fall and cardiac arrest.
Findings
The facility failed to develop a care plan with interventions to prevent falls for a resident identified as high risk. The resident fell from a wheelchair, suffered a seizure, went into cardiac arrest, and was pronounced dead at the hospital.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, including fall prevention interventions.
Report Facts
Census: 85
Inspection Report
Routine
Census: 90
Deficiencies: 7
Date: Mar 8, 2024
Visit Reason
The inspection visit was conducted to assess compliance with regulatory requirements including resident care, staffing, safety, and facility conditions.
Findings
The facility failed to ensure residents consistently received scheduled showers due to inadequate staffing, failed to develop care plans addressing fall risks leading to a resident fall and death, failed to complete wound treatments as ordered especially on weekends, failed to implement dietary recommendations for residents with severe weight loss, failed to provide adaptive eating equipment as ordered, failed to maintain safe water temperatures for resident bathing, and failed to ensure nurses were trained and aware of ventilator alarms and backup equipment.
Deficiencies (7)
Failure to provide residents with scheduled showers due to inadequate CNA staffing.
Failure to develop and implement a care plan addressing fall risk leading to a resident fall, seizure, cardiac arrest, and death.
Failure to complete wound treatments as ordered, especially on weekends, resulting in untreated wounds.
Failure to follow dietary recommendations for residents with severe weight loss including failure to provide fortified foods, double portions, and appetite stimulants.
Failure to provide residents with ordered adaptive eating equipment such as plate guards, built-up utensils, and two-handled cups during meals.
Failure to maintain safe and comfortable water temperatures for resident bathing; water temperatures were consistently below acceptable thresholds.
Failure to ensure nurses were trained on non-invasive mechanical ventilator alarms and unaware of backup ventilators available.
Report Facts
Census: 90
Scheduled showers missed: 6
Scheduled showers missed: 2
Scheduled showers missed: 1
Scheduled showers missed: 2
Scheduled showers missed: 1
Scheduled showers missed: 1
Scheduled showers missed: 1
Scheduled showers missed: 1
Weight loss: 7
Weight loss: 21.2
Weight loss: 10.3
Weight loss: 18.3
Weight loss: 23.4
Water temperature: 54
Water temperature: 61
Water temperature: 75
Water temperature: 78
Water temperature: 80
Water temperature: 82
Water temperature: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Assigned nurse who was unaware of ventilator alarms and backup ventilators |
| CNA A | Certified Nursing Assistant | Reported inadequate staffing leading to missed showers and care |
| Staffing Coordinator | Staffing Coordinator/CNA | Reported frequent CNA call-offs and staffing shortages impacting care |
| DON | Director of Nurses | Provided statements on staffing, care expectations, and ventilator training |
| DM | Dietary Manager | Reported issues with dietary staff not providing adaptive equipment or fortified foods |
| RD | Registered Dietician | Provided dietary recommendations that were not fully implemented |
| WN | Wound Nurse | Reported wound treatments often missed on weekends |
| NP | Nurse Practitioner | Provided wound care orders and assessments |
| MD | Maintenance Director | Tested and reported cold water temperatures |
| RT E | Respiratory Therapist | Reported ventilator alarm parameters and training gaps |
| COTA K | Certified Occupational Therapy Assistant | Reported adaptive utensils not being provided consistently |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Dec 19, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide residents with showers as scheduled, failure to ensure timely and accurate wound treatment orders and documentation, inadequate pressure ulcer care and prevention, and unsafe resident transfers resulting in falls.
Complaint Details
The complaint investigation was triggered by allegations that residents did not receive showers as scheduled, wound treatments were not properly managed, pressure ulcers were not prevented or treated appropriately, and a resident fell due to improper use of transfer lifts. The investigation confirmed these issues with multiple residents.
Findings
The facility failed to provide showers according to resident preferences and schedules, failed to ensure wound treatment orders were timely and accurately implemented, failed to prevent pressure ulcers and provide appropriate care, and failed to ensure safe resident transfers, resulting in falls. Deficiencies included missing shower documentation, incomplete wound treatment documentation, inconsistent use of heel protectors, and improper use of mechanical lifts.
Deficiencies (4)
Failure to provide showers to residents as scheduled and according to preferences.
Failure to ensure timely and accurate wound treatment orders and documentation, including missed treatments and incorrect treatment plans on TAR and POS.
Failure to provide appropriate pressure ulcer care and prevention, including inconsistent use of heel protectors and failure to assess and notify physician of skin changes.
Failure to ensure safe resident transfers, resulting in falls due to improper use of sit-to-stand lift instead of Hoyer lift and lack of staff competency verification.
Report Facts
Residents sampled for shower preference and provision: 9
Scheduled showers vs received showers for Resident #25: 13
Scheduled showers vs received showers for Resident #27: 13
Scheduled showers vs received showers for Resident #28: 13
Scheduled showers vs received showers for Resident #29: 13
Scheduled showers vs received showers for Resident #14: 10
Number of residents with wounds identified: 5
Falls for Resident #1: 2
Braden Scale score for Resident #2: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Involved in resident fall due to improper use of sit-to-stand lift; competency checklist showed previous experience but no return demonstration. |
| PT N | Physical Therapist | Noted resident's heels were boggy and red, recommended heel protectors, and reported concerns to nursing. |
| Nurse O | Nurse | Did not recall being informed of resident's heel issues; failed to assess and notify physician. |
| DON | Director of Nursing | Oversaw investigations, expected staff to follow policies, and acknowledged gaps in staff competency verification. |
| WM NP | Wound Management Nurse Practitioner | Provided wound care orders and expected timely implementation and documentation. |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 7
Date: Nov 14, 2023
Visit Reason
The inspection was conducted as part of an annual survey of the nursing home to assess compliance with regulatory requirements, including resident care, abuse reporting, wound care, and enteral feeding practices.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of resident condition changes, failure to timely report suspected abuse, failure to inform residents of bed hold policies, failure to administer prescribed wound care and antibiotics leading to resident harm and death, failure to complete wound assessments and treatments, failure to turn and reposition residents with pressure ulcers, and failure to follow physician orders for enteral feeding and document accurately.
Deficiencies (7)
Failed to notify a resident's responsible party after a change of condition.
Failed to timely report suspected abuse or injury of unknown origin to proper authorities.
Failed to inform residents or their representatives of the facility's bed hold policy at time of transfer or therapeutic leave.
Failed to administer prescribed antibiotics and monitor for bleeding after wound debridement on a resident receiving anticoagulant medication, resulting in resident's death.
Failed to complete wound assessments and treatments as ordered, resulting in wound deterioration.
Failed to turn and reposition a resident with pressure ulcers, failed to enter new orders, and failed to provide appropriate pressure relieving mattress.
Failed to provide appropriate care and follow physician orders for residents receiving enteral feeding, including failure to document accurately in the medication administration record.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager J | Witnessed tracheostomy tube reinsertion and failed to notify resident's POA | |
| Nurse K | Replaced resident's tracheostomy tube but failed to notify POA | |
| Nurse G | Assessed resident with rib fracture but failed to report injury | |
| Wound Nurse A | Wound Nurse | Failed to notify PCP of bruising, failed to ensure antibiotic orders were placed, incomplete wound documentation |
| Wound Nurse B | Wound Nurse | Responsible for wound care orders and assessments, noted issues with wound vac orders |
| Nurse F | Nurse on duty when resident was found bleeding profusely | |
| Nurse H | Responsible for hanging and monitoring enteral feeding pump | |
| Administrator | Expected staff to follow policies and procedures for wound care, feeding, and reporting | |
| Director of Nursing | Oversaw wound care program and expected compliance with policies | |
| Primary Care Physician | PCP | Expected to be consulted before wound debridement and for feeding orders |
| Specialty Wound Physician | Expected consultation and monitoring of wound care |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Oct 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to promote and facilitate resident self-determination through support of resident choice, specifically related to staff not responding to a resident's call for help and not leaving the call light within the resident's reach.
Complaint Details
The complaint investigation found that staff did not respond when Resident #4 cried out for help and the call light was not within the resident's reach. Staff were observed talking in the hallway instead of responding. Interviews with staff and the Director of Nursing confirmed expectations that call lights be accessible and staff respond promptly. The resident reported not knowing how to get help and mentioned facility rules about going back to bed.
Findings
The facility failed to ensure that a resident's call light was accessible and that staff responded promptly when the resident cried out for help. Observations and interviews confirmed that the call light was out of reach and staff did not respond timely, violating the resident's rights to self-determination and dignity.
Deficiencies (1)
Failed to promote and facilitate resident self-determination through support of resident choice by not responding to a resident's call for help and not leaving the call light within reach.
Report Facts
Residents Affected: 1
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Assistant | Observed not responding to resident's call for help and placing call light on resident's bed |
| Nurse E | Interviewed regarding call light accessibility and staff response expectations | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff expectations for call light placement and response to resident calls |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Aug 24, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide residents with showers as scheduled and concerns about wound care and pressure ulcer management.
Complaint Details
The complaint investigation was triggered by reports that residents were not receiving showers as scheduled, wound care treatments were not timely or properly documented, pressure ulcer care was inadequate, and a resident eloped from the facility without staff knowledge or supervision.
Findings
The facility failed to ensure residents received showers according to their preferences and schedules, failed to timely and accurately update wound treatment orders and documentation, and failed to provide appropriate pressure ulcer care including consistent use of heel protectors. Additionally, the facility failed to provide adequate supervision for a resident who eloped from the facility.
Deficiencies (4)
Failure to provide scheduled showers to residents preferring showers, with incomplete shower documentation.
Failure to ensure timely and accurate wound treatment order updates and documentation, resulting in missed or delayed treatments.
Failure to provide appropriate pressure ulcer care and prevent new ulcers, including inconsistent use of heel protectors and delayed treatment order updates.
Failure to provide adequate supervision and follow elopement policy for a resident who eloped from the facility and walked approximately 7.6 miles to his/her family home.
Report Facts
Residents affected by shower deficiency: 5
Scheduled showers missed: 10
Pressure ulcer measurements: 1.5
Distance walked by eloped resident: 7.6
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Nurse | Assigned to resident's hall during elopement incident; failed to perform routine checks and initial behavior log correctly. |
| Nurse H | Nurse | Last saw eloped resident at 1:45 A.M. on bench outside; did not alert staff or redirect resident inside. |
| PT N | Physical Therapist | Noted resident's heels were boggy and red on 11/30/23 and 12/1/23; reported to nursing but no action taken; ordered podus boots on 12/5/23. |
| DON | Director of Nursing | Expected staff to follow shower and wound care policies; acknowledged failure to ensure heel protectors were used consistently. |
| Administrator | Facility Administrator | Investigated elopement incident; lacked access to video footage; did not interview involved staff. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Jul 11, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that a Certified Nursing Assistant (CNA A) treated a resident disrespectfully, ignored the resident's request not to have personal care provided by that staff member, and left the resident exposed and unattended on the toilet, causing distress and fear of retaliation.
Complaint Details
The complaint involved allegations that CNA A was rude, forced a resident to transfer beyond their ability, removed the resident's wheelchair out of reach while on the commode, ripped the resident's briefs off without consent, and left the resident exposed and unattended on the toilet. The resident reported nightmares and fear of retaliation. The facility investigation was unable to substantiate willful abuse but found failures in care and reporting. CNA A was suspended.
Findings
The facility failed to ensure residents were treated with dignity and respect, as CNA A ignored the resident's request and left the resident exposed on the toilet. The facility also failed to substantiate allegations of willful abuse but acknowledged deficiencies in care and reporting. Additionally, the facility failed to provide appropriate pressure ulcer care and consistent skin assessments for two residents, resulting in untreated or inadequately treated pressure ulcers.
Deficiencies (2)
Failure to honor resident's right to dignified care and self-determination, including ignoring resident's request not to have a specific staff member provide care and leaving resident exposed on toilet.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including inconsistent skin assessments and missed wound treatments for residents with pressure ulcers.
Report Facts
Sample size: 14
Census: 60
Number of unstageable pressure ulcers upon admission: 3
Braden score: 18
Wound measurements: 3
Wound measurements: 3.5
Wound measurements: 2.9
Wound measurements: 18.6
Wound measurements: 4.8
Wound measurements: 4.4
Wound measurements: 5.1
Wound measurements: 5.8
Wound measurements: 3.6
Wound measurements: 2.8
Wound measurements: 4
Wound measurements: 4.3
Wound measurements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in resident mistreatment and neglect findings; suspended after investigation |
| Nurse B | Nurse | Reported initial resident concerns to administrator; interviewed about incident |
| Nurse C | Nurse | Overnight nurse who documented resident concerns and spoke with CNA A |
| Social Services Director (SSD) | Social Services Director | Notified of incident by family; contacted administrator to initiate investigation |
| Administrator | Administrator | Interviewed regarding incident and facility response |
| Administrator in Training | Administrator in Training | Interviewed regarding incident and facility response |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding incident and wound care deficiencies |
| Wound Care Nurse | Wound Care Nurse | New to facility; responsible for wound care treatments |
| Nurse F | Nurse | Responsible for wound treatment for Resident #8 |
| Clinical Nurse Manager G | Clinical Nurse Manager | Performed wound care for Resident #8 during observation |
| Certified Nursing Assistant (CNA) D | Certified Nursing Assistant | Reported obligation to notify nurse if wound treatment missing |
| Certified Nursing Assistant (CNA) E | Certified Nursing Assistant | Reported obligation to notify nurse if wound treatment missing |
Inspection Report
Routine
Census: 73
Deficiencies: 3
Date: Jun 13, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including grievance procedures, medication administration, wound care, and food service.
Findings
The facility failed to promptly resolve grievances and properly inform residents about grievance procedures. Medication administration was often delayed or undocumented, wound treatments were frequently not documented as completed, and food temperatures were not consistently taken or maintained at safe levels.
Deficiencies (3)
Failure to make prompt efforts to resolve grievances and failure to establish and maintain grievance policies and documentation.
Routine pain medication given outside of administration parameters and failure to document wound treatments as completed for four residents.
Failure to take food temperatures to ensure hot food was served at or above 120 degrees Fahrenheit.
Report Facts
Census: 73
Sample size: 20
Medication administration delays: 7
Undocumented wound treatments: 30
Food temperature documentation gaps: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Supervisor F | Licensed Practical Nurse Supervisor | Spoke with Resident #123 about concerns and reported to Administrator |
| Director of Nursing | Director of Nursing (DON) | Responsible for medication administration oversight and grievance follow-up |
| Social Service Director | Social Service Director | Identified as Grievance Official responsible for grievance management |
| Administrator | Facility Administrator | Involved in grievance and medication administration issues |
| Dietary Manager | Dietary Manager | Acknowledged food temperature monitoring lapses |
Inspection Report
Abbreviated Survey
Census: 73
Deficiencies: 9
Date: Jun 13, 2023
Visit Reason
The inspection was conducted to investigate multiple areas of compliance including grievance procedures, employee screening, medication administration, infection control, and resident care.
Findings
The facility failed to promptly resolve grievances, maintain grievance policies, and notify residents of grievance procedures. Employee background screening was incomplete. Medication administration errors and documentation deficiencies were noted. Insulin storage and labeling were improper. Food temperatures were not consistently monitored or maintained. Infection control practices were deficient, including catheter care. Code status documentation was inconsistent and incomplete for many residents.
Deficiencies (9)
Failure to make prompt efforts to resolve grievances and failure to establish and maintain grievance policies.
Failure to follow abuse and neglect policy for employee screening, including incomplete criminal background and nurse aide registry checks.
Failure to follow professional standards in medication administration and documentation of wound treatments.
Failure to ensure basic life support and accurate code status documentation for residents.
Failure to count controlled substances inventory at each shift change as required.
Medication error rate exceeded 5%, including missed medication without documentation.
Failure to date insulin flexpens when opened and failure to properly label and store insulin.
Failure to take and document food temperatures to ensure hot food served at appropriate temperatures.
Failure to follow tuberculosis screening policy for employees and failure to maintain proper infection control practices for residents with indwelling urinary catheters.
Report Facts
Census: 73
Medication error rate: 6.06
Controlled substance count missing initials: 8
Controlled substance count missing initials: 11
Controlled substance count missing initials: 18
Controlled substance count missing initials: 22
Controlled substance count missing initials: 3
Controlled substance count missing initials: 3
Food temperature: 88.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Supervisor F | Licensed Practical Nurse Supervisor | Named in medication administration error and resident grievance findings |
| Administrator | Named in grievance and code status findings and interviews | |
| DON | Director of Nursing | Named in medication administration, insulin storage, grievance, and code status findings |
| Human Resources Director | Named in employee screening findings | |
| LPN E | Licensed Practical Nurse | Named in code status findings and interviews |
| Nurse Z | Named in code status findings and interviews | |
| LPN M | Licensed Practical Nurse | Named in controlled substance count and insulin storage findings |
| CMT D | Certified Medication Technician | Named in code status findings |
| Dietary Manager | Named in food temperature findings | |
| Nurse BB | Named in catheter care infection control findings | |
| Social Service Designee | Named in grievance and code status findings |
Inspection Report
Routine
Census: 77
Deficiencies: 14
Date: Nov 22, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident food preferences and adaptive equipment, improper management of resident trust accounts, failure to provide required Medicare notices, lack of timely transfer/discharge notices and bed hold policy notifications, failure to meet professional standards in medication administration and care, inadequate perineal and oral care, insufficient treatment of pain, wounds and eye irritation, unsafe resident transfers, improper storage of potentially hazardous items, improper use and monitoring of bed rails, food service safety violations, and lapses in infection control practices.
Deficiencies (14)
Failed to provide reasonable accommodations of individual needs and preferences by not honoring food preferences and failing to provide adaptive plateware and utensils for residents to eat independently.
Failed to ensure resident trust was reconciled monthly for 12 of 12 months, affecting all residents with money in the trust account.
Failed to maintain a bond equal to or greater than one and one-half times the average monthly balance for residents' personal funds for 12 consecutive months.
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter at initiation, reduction, or termination of Medicare Part A benefits for three residents.
Failed to provide timely written transfer/discharge notice to residents or representatives when transferred to hospital for nine sampled residents.
Failed to notify residents or representatives in writing of the facility's bed hold policy at time of hospital transfers for nine sampled residents.
Failed to meet professional standards of quality in medication administration, documentation of urinary output, clarification of medication diagnosis, administration of nutritional supplements, and use of hand splints for seven residents.
Failed to provide proper perineal care for two residents and appropriate oral care for one resident.
Failed to ensure residents received treatment and care according to orders, preferences and goals, including pain management, wound care, and eye irritation treatment for three residents.
Failed to ensure safe transfer techniques during resident transfers and failed to secure potentially hazardous items such as razors, iodine, and nail clippers in common areas and resident rooms.
Failed to properly assess, monitor, obtain physician orders, attempt alternatives, and address use of bed/side rails on care plans for 12 residents.
Failed to regularly inspect bed frames, mattresses, and bed rails for safety and entrapment risks for one resident.
Failed to serve food in accordance with professional food service safety standards by not covering plates and desserts during service, failing to cover food in walk-in cooler, and improper storage of dishes.
Failed to follow infection control practices during blood sugar testing by not properly disinfecting glucometers and placing them on unclean surfaces; failed to document tuberculosis testing and assessments for several residents.
Report Facts
Residents affected: 2
Residents affected: 12
Residents affected: 12
Residents affected: 3
Residents affected: 9
Residents affected: 9
Residents affected: 7
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 4
Razors in unlocked cabinet: 10
Razors in unlocked cabinet: 30
Residents affected: 12
Residents affected: 3
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Observed improper glucometer placement and cleaning during blood sugar testing | |
| LPN B | Uncertain about urinary output documentation location | |
| CNA C | Reported inability to record urinary output amount | |
| Dietary Manager | Responsible for ensuring residents receive adaptive equipment | |
| Director of Nursing | Provided multiple interviews regarding deficiencies in care and procedures | |
| Business Office Manager | Explained trust account reconciliation issues | |
| Wound Nurse N | Discussed wound care documentation and coordination with family | |
| CNA D | Observed using Hoyer lift with legs closed during transfer | |
| CNA E | Observed using Hoyer lift with legs closed during transfer | |
| CNA F | Observed using Hoyer lift with legs closed during transfer | |
| CNA G | Observed using Hoyer lift with legs closed during transfer | |
| CNA I | Observed using Hoyer lift with legs closed during transfer | |
| CNA H | Observed using Hoyer lift with legs closed during transfer |
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