F0689

E

Failure to Provide Adequate Supervision, Fall Investigation, and Smoking Safety Management

Milwaukee, Wisconsin Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents, including falls and smoking-related hazards, for multiple residents. One resident with encephalopathy, vertigo, mild neurocognitive disorder, chronic pain syndrome, and moderately impaired cognition (BIMS score 11) had been assessed as high risk for falls and was recommended by therapy to use a two-wheeled walker (2WW) with supervision for all mobility due to vertigo and cognitive impairment. The resident’s care plans referenced use of a 2WW with staff assistance for toileting and short distances and a wheelchair for long distances, but the care plan was not revised after the ADL evaluation and therapy discharge to clearly reflect the current level of assistance and supervision required. Surveyors repeatedly observed this resident ambulating in the hallway without a walker, and staff reported that the resident sometimes used a walker and sometimes did not, depending on how the resident felt, without consistent staff supervision or redirection to use the walker.

Another deficiency involved a resident who smoked and had COPD, depression, and a cognitive communication deficit, with intact cognition (BIMS 14) and minimal assistance needs for ADLs. The facility’s smoking policy required evaluation of safe smoking status on admission and quarterly, including whether the resident could smoke safely with or without supervision and whether the resident could retain smoking materials. For this resident, only an admission smoking assessment and one quarterly assessment were located, and there were no documented quarterly smoking assessments for other quarters. Both available assessments and the smoking care plan lacked documentation specifying whether the resident was to smoke supervised or unsupervised and whether the resident or the facility should hold the smoking materials. Staff interviews indicated the resident typically went outside to smoke alone and retained personal smoking materials, and staff were unsure how often smoking assessments were to be completed or who was responsible for them.

The facility also failed to thoroughly investigate falls for two other residents at high risk for falls. One resident with paraplegia, morbid obesity, and severe cognitive impairment (BIMS 4) had a documented fall in the room that was unwitnessed, resulting in a bruised left eye and nosebleed. The post-fall evaluation documented that the resident was reaching for items at the time of the fall, was wearing socks, and was not using prescribed assistive devices or oxygen, but the fall investigation form stated the resident was unable to describe the event, listed no predisposing environmental, physiological, or situational factors, and contained only a brief second-hand statement without clear identification of witnesses or staff involved. The investigation did not document when the resident was last seen, whether the fall was from bed, wheelchair, or chair, what fall-prevention interventions were in place at the time, or any root cause or new interventions.

Another resident, in a comatose state with impaired range of motion in all extremities, dependent for all ADLs, and assessed as at risk for falls, was found face down on the floor next to the bed with an abraded area on the right forehead after an unwitnessed fall. Documentation later described the resident on the floor on the left side of the bed in a supine position with all equipment intact and no apparent injuries, and the resident was transported to the ER. The post-fall evaluation and fall investigation forms indicated no identified environmental, physiological, or situational predisposing factors and did not identify a root cause. Staff statements documented that two agency CNAs and a respiratory therapist had repositioned the resident shortly before the fall and then found the resident on the floor minutes later, with adaptive devices such as a low bed, wedges, and boots in use. The DON later described a possible mechanism involving coughing, air mattress positioning, and a loose sheet, but this explanation and a clear root cause were not documented in the formal fall investigation, and the facility could not provide additional information explaining how a resident without bed mobility fell from the bed.