Arbor Hills Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ferguson, Missouri.
- Location
- 800 Chambers Road, Ferguson, Missouri 63135
- CMS Provider Number
- 265883
- Inspections on file
- 26
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Arbor Hills Care & Rehab Center during CMS and state inspections, most recent first.
Staff failed to follow infection control practices when an LPN repeatedly used non-medical-grade, lemon-scented wipes to clean a shared glucometer between blood glucose checks on three residents with diabetes, despite leadership later stating that only germicidal wipes should be used on multi-use medical equipment. In addition, a resident receiving nebulized medications for COPD exacerbation was observed with a nebulizer mask on the lap while the machine was running, and later with soiled clothing placed over nebulizer tubing, mask, and machine balled up on a chair, contrary to the DON’s expectation that such equipment be stored on a clean surface in a dated plastic bag. The corporate nurse confirmed there was no facility policy specifying best practices for cleaning and storing glucometers or nebulizer masks.
A resident with dementia, moderate cognitive impairment, psoriasis, and a moderate fall risk was placed into a filled whirlpool using a bathtub Hoyer lift by a CNA who had not gathered all needed supplies in advance. The CNA left the room to obtain special soap, asking a non-nursing manager to "watch" the resident, during which time the resident slid down in the water, reported water entering the mouth, and later expressed fear and refusal to use the whirlpool again. The lift chair in use lacked the manufacturer-indicated lap belt, and the resident’s ongoing fear and related interventions were not fully documented in the care plan. Separately, during supervised smoke breaks, multiple residents with lung disease, neurologic and psychiatric conditions, and care plans requiring supervised, safe smoking and use of smoking aprons were observed discarding lit or smoldering cigarettes into a plastic flowerpot/planter and onto the ground, while staff passed and lit cigarettes but did not redirect residents to use the fireproof ash receptacles or educate them on proper disposal, and the smoking area remained littered with cigarette butts and trash.
Staff failed to consistently complete and document wound care treatments and weekly skin assessments for several residents at risk for or with pressure ulcers. For one resident with advanced wounds and complex medical needs, daily wound care was not documented as completed on multiple occasions. Additionally, weekly skin assessments were missed for four residents, with facility leadership unaware of these lapses until the survey. The DON attributed missed assessments to the absence of the wound nurse during the period in question.
Two residents experienced deficiencies in medication management, including missed doses of anti-anxiety and pain medications due to failure to reorder and unauthorized discontinuation. One resident's change in condition after missing multiple doses was not properly documented or communicated, and pain assessments were missed for another resident. Staff interviews confirmed that medication reordering and communication protocols were not followed.
A resident with heart failure and other complex conditions did not receive several ordered medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, due to delays in ordering, lack of follow-up with pharmacy or hospice, and failure to use available E-Kit medications. Documentation was incomplete, and there was no evidence of timely communication with providers. Additionally, side rails were used after a fall without required assessment or documentation, contrary to facility policy.
Surveyors found that lorazepam (Ativan) liquid, a controlled medication requiring refrigeration, was stored in narcotic lockboxes on three medication carts instead of in a secured refrigerator as labeled. Staff interviews revealed the medication room refrigerator was not locked due to a lost key fob, leading to unauthorized access and improper storage. The DON and pharmacist confirmed the medication should have been refrigerated, and the facility's policy requires such medications to be stored securely and separately from food.
Two residents experienced abuse when CNAs yelled at, physically handled, and spoke disrespectfully to them, causing emotional distress. One resident with cognitive impairment was pulled by the arm and made to cry in the dining room, while another resident with quadriplegia was scolded and insulted after calling for help without a call light. Staff present did not intervene or promptly report the incidents, and the affected residents felt afraid and disrespected.
Two residents with severe cognitive impairment and high risk for skin breakdown experienced failures in pressure ulcer care, including lack of timely physician notification, missing or incomplete treatment orders, and inconsistent wound documentation. Wounds were often not staged or specified, treatments were not administered as ordered, and communication between nursing and hospice staff was unclear, resulting in undated and unsigned bandages and missed documentation in the TAR.
A resident with severe malnutrition, renal disease, and cognitive impairment did not receive increased fluids as ordered by the PCP and RD. Orders to push fluids were not timely entered into the POS or MAR, and when eventually implemented, were not consistently followed, as shown by incomplete documentation. The resident was later hospitalized with renal failure, hypernatremia, and altered mental status.
Staff failed to treat residents with dignity and respect when an activity aide spoke loudly and rudely to a resident with severe cognitive impairment, and when direct care staff argued and cursed at the nurses' station in front of several residents with cognitive impairments. The incidents were witnessed by other staff who did not intervene or report the events, and residents present were exposed to loud, confrontational behavior that was inconsistent with facility policy and resident rights.
The facility did not complete a thorough investigation into an alleged abuse incident involving a non-verbal, cognitively impaired resident receiving hospice care. The allegation was made by a roommate with a history of behavioral issues, but the Administrator and Social Worker failed to obtain required written statements from staff or residents, and the DON did not participate in the process, resulting in noncompliance with the facility's abuse prevention policy.
A resident with severe cognitive impairment and multiple diagnoses experienced an eight-day delay in urine specimen collection after a physician order, leading to delayed lab processing and antibiotic treatment. Staff were unclear about responsibilities for obtaining and documenting the specimen, and there was confusion and inconsistency in the administration and documentation of the prescribed antibiotic due to concerns about drug allergy and pharmacy communication.
A resident with severe cognitive impairment and total dependence on staff for ADLs did not receive required feeding assistance during a meal. Multiple CNAs failed to deliver the meal tray or provide feeding, each assuming the other was responsible, and did not communicate with the nurse. The resident's meal remained on the cart, and documentation inaccurately reflected meal consumption, despite no food or fluids being provided.
A resident with a Foley catheter and recent UTI was observed with improper catheter care, including a catheter tube not secured to the leg, compression of the tube by a limb, visible dried matter on the tube, and the catheter bag placed on the bed and near the floor. Staff did not follow infection control protocols or facility policy, and the resident reported pain and lack of catheter cleaning.
The facility did not act on a report that the Business Office Manager was placed on the Employee Disqualification List, resulting in the individual continuing to work while ineligible. Both the HR Director and Administrator were unaware of the disqualification, and required EDL checks were not performed as scheduled.
A resident with diabetes and Parkinson's disease continued to receive Metformin after hospital discharge orders directed it to be stopped. Facility staff administered the medication for several weeks, during which the resident experienced multiple hypoglycemic episodes requiring interventions. The DON later confirmed the medication was not discontinued as ordered.
The facility failed to maintain its resident transport van in a safe and sanitary condition, with exposed wires, debris, and unsanitary items present during use. Additionally, after falls involving two residents with cognitive and mobility impairments, the facility did not complete thorough investigations or documentation, omitting required witness statements and neuro checks, and failed to update care plans with new interventions as needed. Staff interviews confirmed gaps in post-fall procedures and lack of adherence to policy.
The facility did not remove a Business Office Manager who had been placed on the Employee Disqualification List (EDL), allowing the individual to continue working for over two weeks after notification from the Department of Health and Senior Services. Both the HR Director and Administrator were unaware of the EDL placement due to missed notifications and a lack of regular EDL checks.
A resident with diabetes and other chronic conditions continued to receive Metformin after hospital discharge orders directed its discontinuation. Facility staff administered the medication for several weeks, leading to repeated episodes of hypoglycemia that required emergency interventions. The DON was unaware of the ongoing administration, and there was no documentation of the medication's discontinuation in the resident's records.
A resident with documented dietary preferences and physician orders did not consistently receive meals in accordance with their stated dislikes and required portion sizes. Despite clear instructions to avoid certain foods and receive double portions, staff served meals with non-preferred items and incorrect portions, and the resident's concerns were communicated to facility leadership without resolution.
The facility failed to protect two residents from verbal and physical abuse, resulting in multiple altercations. One resident with paranoid schizophrenia exhibited disruptive behavior, leading to physical fights with another resident who has vascular dementia. Despite interventions, the incidents caused significant psychosocial harm to the second resident, who reported ongoing fear and anxiety.
A resident with severe cognitive decline and a recent hip surgery developed unstageable pressure ulcers due to the facility's failure to implement timely interventions and follow physician's treatment orders. The care plan was updated late, and multiple treatment orders were not documented as completed. The resident was also observed without the prescribed low-air-loss mattress.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week for 22 of 92 days reviewed. The DON confirmed the lack of RN coverage and stated that licensed nurses were aware she was on-call if needed. CMTs also knew how to notify the DON, especially on weekends.
The facility failed to develop, initiate, or revise a facility assessment to determine necessary resources for resident care. The DON could not provide the assessment during the entrance conference, and the Administrator was unfamiliar with it. A document was later provided but was undated and unapproved by the Quality Assurance committee. The DON admitted it was only initiated in January 2024 and revised on the day of the surveyor's request.
The facility failed to develop a QAPI program, affecting all 78 residents. Despite having a Quality Assurance Improvement Plan, the facility did not have a QAPI plan, did not keep minutes for QAPI meetings, and had not developed any PIPs or benchmarks for measuring improvement. The DON relied on daily meetings and EMR reviews to identify concerns.
The QA committee failed to identify quality deficiencies, develop or implement corrective actions, track and measure effectiveness, or develop new interventions based on discussions. The DON admitted that the facility did not have a QAPI plan and that no specific quality deficiencies or performance improvement programs (PIPs) had been identified or conducted.
The QA committee at the facility failed to meet at least quarterly with the required members, missing opportunities to identify and measure quality deficiencies. Only two meetings were documented since January 2022, and key members like the DON, IP, and Medical Director were absent. The Medical Director refused to attend until compensated, affecting the facility's ability to monitor and improve care for all 78 residents.
The facility failed to ensure resident funds were placed in a separate account from the facility operating account, did not obtain written authorization for withdrawals, and failed to provide timely Social Security/Medicaid allowances. Additionally, the facility used resident funds for checking account fees and did not allow residents ongoing access to their funds, affecting all residents whose funds were managed by the facility.
The facility failed to maintain an accurate accounting of resident trust fund accounts by not performing monthly reconciliations. The Business Office Manager admitted to not starting reconciliations until a specific month and could not provide documentation to support that reconciliations were performed.
The facility failed to provide a final accounting of resident fund balances within thirty days for one discharged and four expired residents. Funds were either delayed in being refunded, mismanaged, or not properly reported to the Department of Social Services, Third Party Liability Unit.
The facility failed to maintain an adequate surety bond for the resident trust fund account, which should have been $39,000.00 based on the average monthly balance. The current bond was only $4,000.00. The Business Office Manager and Administrator were unaware of the correct bond amount and lacked a policy for reviewing the surety bond.
The facility failed to post the location of the state survey results and provide unrestricted access to residents and visitors. The Survey Results binder was kept behind the front desk, and a review revealed incomplete documentation. The Administrator and DON confirmed the binder's location and stated that complete survey results and POC were kept in the Administrator's office.
The facility failed to issue accurate Notices of Medicare Non-Coverage (NOMNC) for three residents, using the incorrect CMS-10095 form instead of the required CMS-10123. This resulted in missing information about the type of services ending and necessary QIO contact details, potentially affecting the residents' ability to request an expedited appeal.
The facility failed to protect three residents from misappropriation of their property when the Business Office Manager used resident funds for personal use. The manager manipulated documents, issued checks and cash withdrawals without proper documentation, and instructed family members to return portions of the money in cash.
The facility failed to screen new hires for Federal Indicators, CNA registry, and nursing licenses, affecting three staff members and four nurses. The HR Manager was unaware of the correct procedures, and the Administrator was not informed of the oversight.
The facility failed to post daily nurse staffing information in a timely and accessible manner as required by policy. Observations on multiple days and times revealed no postings, and the ADON admitted that the postings were not completed due to the survey process.
The facility failed to maintain complete and accurate PASRR documentation for three residents with mental illness or intellectual disabilities, increasing the risk of not receiving necessary specialized services. This was confirmed through record reviews and staff interviews.
A resident with paranoid schizophrenia and a history of traumatic brain injury made a verbal threat to shoot residents and staff after a physical altercation. Despite the severity of the threat, the DON did not report it to the State Survey Agency, as required by the facility's policy. The resident had a documented history of violent outbursts and was often allowed to smoke to prevent further escalation.
The facility failed to thoroughly investigate a resident's threat to shoot staff and other residents, and did not properly investigate an allegation of misappropriation involving the Business Office Manager. The DON did not consider the threat credible and did not search for weapons, while the Administrator allowed the BOM to return to work before completing the investigation and speaking with all witnesses.
A resident with Type 2 diabetes and dementia was sent to the emergency room for a hypoglycemic event without receiving the required written transfer notice. Interviews confirmed the absence of the notice, and the facility lacked a policy for issuing such notices.
The facility failed to issue a bed hold notice to a resident with Type 2 diabetes and dementia when transferred to the hospital for a hypoglycemic event. The social worker confirmed no notice was given, and the facility lacked a policy for issuing bed hold forms.
A resident was inaccurately coded for restraints in the MDS, despite observations and confirmation from the MDS Coordinator that no restraints were used during her stay. The error was acknowledged by the MDS Coordinator.
The facility failed to reassess and adjust interventions for a resident with paranoid schizophrenia and a history of traumatic brain injury, who exhibited verbally and physically abusive behaviors. Despite nonpharmacologic interventions and mood-stabilizing medications, the resident's disruptive behavior continued, impacting other residents and staff. Staff interviews and observations revealed the ineffectiveness of current measures, and the DON acknowledged the challenges in managing the resident's behavior.
The facility failed to ensure monthly medication regimen reviews were completed by the consulting pharmacy for two residents, leading to potential adverse side effects from unnecessary or duplicate medications. The DON confirmed that physicians were not made aware of pharmacy recommendations, and the Pharmacy Consultant admitted to incomplete reviews.
The facility failed to ensure that PRN medications for two residents included a stop date no later than 14 days after the order was received, resulting in the potential for adverse side effects from unnecessary medications. Despite recommendations from the consultant pharmacist, there was no documentation indicating that the physicians had been made aware to discontinue the PRN Haldol orders.
The facility failed to notify a resident's responsible party about new skin conditions requiring treatment, despite policy requirements. The resident had multiple medical diagnoses, and staff did not document any notification to the responsible party regarding these new conditions.
Improper Disinfection of Glucometer and Storage of Nebulizer Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper disinfection of a shared glucometer and improper storage of nebulizer equipment. The facility’s Communicable Disease Management Policy stated that infection prevention and control guidelines would be established to prevent transmission of infections and that employees would utilize barriers and implement isolation barriers beyond standard precautions per CDC guidelines. However, the facility lacked specific policies detailing best practices for cleaning and storing glucometers and nebulizer masks, as confirmed by the corporate nurse. For three residents with diabetes, staff used non-medical-grade, lemon-scented disinfecting wipes to clean a multi-use glucometer between blood glucose checks. One resident with moderately impaired cognition and diabetes had a physician’s order for Novolog insulin via sliding scale, and an LPN was observed cleaning the glucometer with a lemon-scented wipe and placing it on a barrier on the medication cart before and after performing the blood sugar test. The same glucometer was then used on two cognitively intact residents with diabetes, one with an order for insulin lispro via sliding scale and another with orders for blood glucose monitoring and physician notification for out-of-range values. In each instance, the LPN cleaned the glucometer only with the lemon-scented disinfecting wipe and placed it back on the barrier on the medication cart. The DON, administrator, and corporate nurse later stated that staff should not use lemon-scented wipes on multi-use medical equipment and that the facility did not purchase such wipes for that purpose, indicating that purple-top Sani Wipes with germicidal content were the expected product for cleaning medical equipment. For a resident with dysphagia following stroke, chronic systolic heart failure, muscle weakness, moderate depression, and COPD exacerbation, the facility failed to ensure proper storage of nebulizer equipment. The resident had orders for budesonide and arformoterol nebulizer treatments for COPD exacerbation. During observation, the resident was in bed with the head of bed elevated and a nebulizer mask lying across the lap while the nebulizer machine was turned on. On a subsequent observation period, soiled clothing was seen on top of the nebulizer tubing, machine, and mask, which were balled up on a chair. An LPN described that the CMT or nurse should remove the nebulizer mask from a protective pad, place medication in the cup, apply the mask, turn on the machine, and remain nearby to observe for nosebleeds or excessive coughing, with no formal monitoring required. The DON stated she expected the nebulizer to be stored on a clean surface with the mask and tubing in a dated plastic bag changed weekly, but this practice was not followed for the observed resident.
Resident Left Unattended in Whirlpool and Unsafe Smoking Supervision
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from accident hazards and to provide adequate supervision during whirlpool bathing. A resident with moderate cognitive impairment, dementia, diabetes, hypertension, psoriasis, and a moderate fall risk was ordered to receive whirlpool baths three times weekly for chronic psoriasis. The resident’s care plan noted a history of resistance to bathing and the need for substantial assistance with showering and supervision for tub/shower transfers. During a scheduled whirlpool bath, the CNA responsible for the bath did not have all required supplies, including the resident’s special soap, before placing the resident into the filled whirlpool using a bathtub Hoyer lift. After lowering the resident into the water, the CNA left the spa room to obtain the special soap and asked the Environmental Services Director (ESD), who was not nursing staff, to watch the resident. The resident remained in the filled whirlpool while the CNA exited. As the CNA left and the ESD entered, the resident began to slide down in the water. The ESD reported seeing the resident slipping under the water and pulled the resident up by the arms; the resident stated that water went into his/her mouth and that he/she was scared and felt like he/she was going under. The resident reported to staff afterward that a CNA had tried to kill him/her and refused further whirlpool use, stating he/she was too scared to go back into the whirlpool. The resident also reported not being belted into the chair, while the CNA stated the strap was under the resident’s armpits and acknowledged that residents without good trunk control could slide down in the chair. The facility’s bathing policy required staff to stay with residents throughout the bath, not leave them unattended, use the call signal for assistance, and place supplies within reach, but the CNA left the resident alone in the filled whirlpool and did not use the call light to obtain help from nursing staff. The bathtub Hoyer lift in the spa had only an upper torso belt and lacked a lower lap belt, despite manufacturer instructions indicating the chair should have both a torso and lap belt. The DON was not aware that the chair should have had a lap belt and the lift chair was not assessed for safety concerns after the incident. Documentation showed brief monitoring for fearfulness after the slip, but there was no further documentation of the resident’s ongoing fear of the whirlpool or care plan interventions addressing that fear. A separate deficiency involved the facility’s failure to ensure safe smoking practices and proper disposal of cigarettes in the designated smoking area. Observations showed the smoking area littered with numerous cigarette butts on the ground, in the grass, and on walkways, as well as cigarette butts and trash in a plastic flowerpot/planter and in trash cans. Fireproof metal containers and smokeless ashtrays were present, but residents repeatedly placed lit or smoldering cigarettes into the flowerpot/planter and onto the ground. During supervised smoke breaks, staff passed out cigarettes and assisted with lighting but did not intervene or educate residents when cigarettes were placed in the planter or dropped on the ground, including when a cigarette bounced under a resident’s Broda chair and when cigarettes in the planter continued to smoke. Multiple residents with diagnoses such as lung disease, hemiplegia, schizoaffective disorder, and cognitive communication deficits were care planned as smokers who required supervision, smoking aprons, and instruction on facility smoking policies, including location, times, and safety concerns. Despite these care plan directives and the facility’s smoking protocol requiring use of fireproof ashtrays and prohibiting disposal of smoking materials in inappropriate areas, staff supervising smoke breaks did not redirect residents to use the proper self-closing ash receptacles and did not address the accumulation of cigarette butts and trash in non-approved containers and on the ground. The Administrator stated that staff monitoring smoke breaks were responsible for supervising residents, passing cigarettes, ensuring safety, and educating residents on proper disposal, and acknowledged that cigarettes should not be disposed of in the flowerpot/planter, trash cans, or on the ground.
Failure to Provide and Document Pressure Ulcer Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident with significant medical conditions, including peripheral vascular disease, hemiplegia, and cognitive communication deficit, staff did not complete daily wound care as ordered. Documentation in the Treatment Administration Record (TAR) showed that wound care treatments for both sacral and left lower extremity pressure ulcers were not consistently documented as completed on numerous days across July and August. The Wound Care Physician and facility leadership confirmed that if treatments were not marked as completed on the TAR, it indicated they were not performed, although they believed the care may have been provided but not documented. The resident was on hospice care, and the focus was on comfort, but the expectation remained that wound care orders would be followed and documented. Additionally, the facility failed to ensure that four residents identified as at risk for pressure ulcers received weekly skin assessments as ordered. Review of medical records and electronic Physician Order Sheets revealed that weekly skin assessments were missed on multiple occasions for these residents. The Director of Nursing (DON) stated that weekly skin assessments should be completed for all residents, regardless of hospice status, and that these assessments are typically performed by a nurse or wound nurse. The DON was unaware that these assessments had not been completed during the specified months and attributed the missed assessments to the departure of the wound nurse during that period. Interviews with facility leadership, including the Administrator and DON, confirmed that they expected nursing staff to follow physician orders and document completion of treatments and assessments. They were not aware of the missing documentation until it was brought to their attention during the survey. The lack of documentation for wound care and skin assessments was acknowledged as a failure to follow established protocols and physician orders, with the potential to negatively impact resident care and wound healing.
Failure to Document and Treat Change in Condition and Follow Physician Orders for Medication
Penalty
Summary
The facility failed to ensure that a resident's change in condition was appropriately documented and treated after the resident missed multiple doses of a prescribed medication. One resident with moderately impaired cognition and diagnoses including dementia and anxiety had an order for Lorazepam (Ativan) to be administered every 12 hours for anxiety. The resident missed several consecutive doses of Ativan due to the medication not being reordered in a timely manner, despite facility policy requiring medications to be reordered before running out. After receiving Ativan following a 48-hour lapse, the resident became unresponsive to questions, with low blood pressure and pulse, prompting a call to emergency services. The nurse involved did not communicate the change in condition to the oncoming shift or the DON, and no follow-up assessments were completed, contrary to facility policy requiring prompt notification and documentation of changes in condition. Additionally, the facility failed to follow physician orders regarding pain medication for another resident with multiple diagnoses, including peripheral vascular disease, hemiplegia, and pressure ulcers. This resident had orders for both scheduled and as-needed Hydrocodone-Acetaminophen (Norco) for pain management, as well as regular pain assessments. The resident did not receive the prescribed Norco doses for an extended period after coming off hospice care, and the medication was discontinued by a nurse without a physician order. Pain assessments were also missed on several shifts, and the DON was not aware of the discontinuation or the missed doses until after the fact. Facility policy requires medications to be administered as prescribed and prohibits discontinuation without a physician's order. Interviews with staff and the residents' physician confirmed expectations that medications should be reordered in advance and that changes in condition or medication status should be communicated promptly to ensure continuity of care. The failures identified included lack of timely medication reordering, inadequate communication between staff, failure to document and assess changes in condition, and unauthorized discontinuation of prescribed medications.
Failure to Administer Medications and Assess Side Rail Use per Orders and Policy
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and accepted clinical standards for a resident with multiple complex medical diagnoses, including congestive heart failure, atrial fibrillation, and kidney failure. The resident had orders for several critical medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, but these medications were not administered as ordered for an extended period. Documentation in the medication administration record (MAR) and progress notes repeatedly indicated that medications were on hold, waiting on prescription, or not available, with no evidence of timely follow-up with the pharmacy, physician, or hospice to resolve the issue. Additionally, there was no documentation of pharmacy contact, physician contact, or hospice notification regarding the missed or refused medications. The resident's care plan included interventions to administer medications as ordered and monitor for side effects and effectiveness, but these interventions were not consistently implemented. The MAR showed multiple days where medications were not given, and staff notes often lacked specific details about which medications were affected. The facility's own policies required timely ordering and administration of medications, as well as clear documentation and communication with the pharmacy and prescribers, but these procedures were not followed. The facility also failed to utilize available emergency medication kits (E-Kits) to obtain necessary medications, despite having relevant drugs in stock. In addition to medication administration failures, the facility did not assess or document the use of side rails for the resident, despite their use following a fall. The facility's policy required a side rail assessment, documentation of rationale, and consideration of less restrictive alternatives, but there was no evidence of such assessment or documentation in the resident's record. The resident was found on the floor after a fall and later found in another resident's room, having climbed over side rails, yet there was no order or care plan documentation regarding side rail use. Interviews with staff revealed inconsistent recollections about the resident's cognitive status and the events surrounding the use of side rails.
Improper Storage of Refrigerated Controlled Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically lorazepam (Ativan) liquid, were labeled and stored according to accepted professional standards. Observations revealed that lorazepam, which is labeled to be stored in a refrigerator, was instead kept in the narcotic lockboxes of three nurse medication carts. The medication was not stored in the refrigerator as required, and staff interviews confirmed that this was due to concerns about the security of the medication room refrigerator, which did not have a functioning lock. The facility's policy requires medications needing refrigeration to be stored in a secured refrigerator, separate from food, and accessible only to authorized personnel. Interviews with staff, including LPNs, RNs, and the DON, indicated that the medication room behind the charting break room did not lock because the key fob had been lost for approximately six months. This allowed unauthorized access by CNAs, who would enter the room to retrieve nutritional supplements from the refrigerator. As a result, lorazepam was kept in the medication cart's narcotic lockbox to maintain double-lock security, despite the medication's requirement for refrigeration. The pharmacist confirmed that lorazepam liquid should always be refrigerated to maintain its effectiveness and stability. Further observations and interviews with the DON confirmed that multiple boxes of lorazepam labeled for refrigeration were found in the narcotic lockboxes of medication carts across different halls. The DON acknowledged that these medications should have been refrigerated and that the current storage practice did not comply with labeling instructions or facility policy. The issue was identified on all three medication carts checked, affecting the facility's compliance with safe medication storage standards.
Failure to Protect Residents from Abuse and Ensure Timely Reporting
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by direct staff actions and inactions observed and reported. In one incident, a resident with moderately impaired cognitive skills, traumatic brain dysfunction, depression, and psychotic disorder experienced an episode where a CNA yelled at them in the dining room, pulled on their arm, and insisted they leave to eat in their room due to wet shoes. This interaction caused the resident to cry and feel afraid. Witnesses, including another resident and a visitor, confirmed that the staff member physically handled the resident and that the event was distressing to both the affected resident and others present. The staff member continued to work with residents after the incident until being suspended later. In another case, a resident with muscle weakness, functional quadriplegia, and end-stage kidney disease, who had intact cognitive response, was left without a call light within reach and had to yell for assistance with incontinence care. The CNA who responded scolded the resident for yelling, told them it would be the last time they would provide care in bed, and later made a derogatory comment while passing the resident in the hallway. The resident reported feeling hurt, disrespected, and reluctant to report the incident due to fear that staff would not help them. The CNA involved denied any complaints and claimed to have a good relationship with the resident. The facility's abuse prevention policy outlines clear expectations for staff conduct, including prohibiting mistreatment, requiring prompt reporting and investigation of abuse, and providing training on abuse prevention. Despite these policies, staff failed to intervene or report the incidents in a timely manner, and other staff present during the events did not take action to protect the residents. The incidents were only reported after delays, and the affected residents experienced emotional distress as a result of the staff's actions and the lack of immediate support.
Failure to Notify Physician, Obtain Orders, and Administer Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to notify the Primary Care Physician (PCP) and obtain orders for pressure ulcers when they were first identified for two residents, and also failed to administer treatments as ordered and maintain consistent documentation of wounds. For one resident with severe cognitive impairment, total dependence for activities of daily living, and multiple comorbidities, there were multiple instances where wounds were present but not properly documented, staged, or reported to the PCP or responsible party. The facility's weekly wound reports repeatedly listed wounds as 'not specified' in terms of stage, and there was inconsistent documentation between the wound reports, skin assessments, and progress notes. Orders for wound care were not always obtained or followed, and documentation in the Treatment Administration Record (TAR) showed that treatments were not completed as ordered on numerous occasions. Additionally, there was no documentation of a Braden score to assess the resident's risk for pressure ulcers. For another resident with severe cognitive impairment and high risk for skin breakdown, the facility's documentation was inconsistent regarding the presence and treatment of pressure ulcers and calluses. Weekly wound reports and skin assessments often failed to specify the stage of wounds or omitted documentation of certain wounds altogether. There were discrepancies between shower sheets, wound reports, and skin assessments, with some documents noting open areas or treatments in place while others did not mention any skin issues. Treatment orders were not always present or followed, and there was a lack of consistent communication and documentation regarding changes in the resident's skin integrity. Interviews with facility staff, including the Wound Nurse, Registered Nurse, and Director of Nursing, revealed confusion and lack of clarity regarding responsibilities for wound care, documentation, and communication with hospice staff. The Wound Nurse was responsible for wound reports, assessments, and treatments, but there was a lack of coordination and documentation when hospice nurses were involved. Bandages were found undated and unsigned, and staff were unsure who had changed them. There was also a lack of timely notification to the PCP and responsible party when new wounds were identified, and the facility did not have a policy to ensure physician orders were followed.
Failure to Implement and Follow Fluid Orders for Resident with Renal Disease and Malnutrition
Penalty
Summary
A deficiency occurred when the facility failed to implement and follow physician and registered dietitian (RD) orders to increase fluid intake for a resident with severe malnutrition, renal disease, and abnormal laboratory values. Despite a primary care physician's handwritten order on 9/10/24 to "push fluids" and a subsequent RD recommendation on 11/22/24 specifying fluid amounts at meals and between meals, these orders were not entered into the resident's physician order sheet (POS) or medication administration record (MAR) in a timely manner. The facility's own policy required individualized assessment and implementation of nutritional and hydration interventions, but the necessary orders were either delayed or not documented, and when eventually entered, were not consistently followed as evidenced by gaps in MAR documentation. The resident's medical records showed persistently abnormal lab values, including elevated creatinine and BUN, indicating ongoing kidney dysfunction and possible dehydration. The care plan was updated to include the RD's fluid recommendations, but the MAR showed that the facility only documented compliance with the fluid order 15 out of 65 opportunities, with multiple missed opportunities on specific dates. There was also a lack of documentation for discontinuation of medications and for follow-up lab orders as recommended by the RD and PCP. The resident, who had severe cognitive impairment and required moderate assistance with eating, was ultimately hospitalized with diagnoses of renal failure, hypernatremia, and altered mental status. Interviews with the DON confirmed expectations for timely entry and implementation of orders, as well as the risks to resident health if orders were not followed. The hospital charge nurse confirmed the resident was admitted with significant renal failure and hypernatremia, consistent with the facility's failure to provide adequate hydration as ordered.
Failure to Ensure Resident Dignity and Respect Due to Staff Conduct
Penalty
Summary
The facility failed to ensure that residents were treated with kindness, dignity, and respect, as required by their own policies and federal regulations. One incident involved an activity aide speaking loudly and rudely to a resident with severe cognitive impairment after the resident dropped a plastic wrapper on the floor. The aide stated, in a loud voice, that they did not like giving the resident anything because the resident was always dropping things. This interaction was witnessed by two staff members at the nurses' station, neither of whom intervened at the time. The resident in question had severe cognitive impairment, dementia, malnutrition, end-stage renal disease, and a history of stroke, and was care planned for psychosocial wellbeing concerns. Another deficiency occurred when direct care staff openly argued and cursed at the nurses' station in front of several residents. The argument began when a CNA refused to give a shower to a resident at the request of an LPN, leading to a loud and confrontational exchange between multiple CNAs. The argument included shouting, cursing, and physical gestures such as hitting the nurses' station tabletop. Several residents with moderate to severe cognitive impairment and various diagnoses, including dementia and depression, were present in the living room area within earshot and eyesight of the incident. Staff interviews confirmed that the argument was loud and could have been intimidating or distressing to the residents who witnessed it. Staff interviews revealed a lack of immediate intervention or reporting of the incidents by those present. Some staff expressed that the behavior was inappropriate and could have made residents feel unsafe or fearful, but did not take action to remove residents from the area or report the events to management at the time. The facility's policy required staff to treat residents with dignity and respect, to report violations of resident rights, and to ensure residents' psychosocial wellbeing, but these expectations were not met during the incidents described.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of abuse involving a resident with severe cognitive impairment, who was non-verbal, required total staff assistance for daily care, and was receiving hospice services. The allegation originated from the resident's roommate, who reported to an outpatient counselor that inappropriate sexual behavior may have occurred. The roommate had a documented history of attention-seeking behavior, previous issues with roommates, and was unable to provide specific details about the alleged incident or identify any individuals involved. Upon notification of the allegation, the facility Administrator initiated an investigation but did not obtain written statements from staff, residents, or the reporting party, as required by facility policy. The Social Worker attempted to interview the non-verbal resident and conducted a skin assessment, which revealed no abnormal findings. The Social Worker also interviewed several residents but did not collect or have any written or signed statements from staff or residents. The Director of Nursing did not participate in the investigation process. Facility policy required that investigations into alleged abuse be thorough and include witness statements from staff, residents, and family members who may have relevant information. The investigation should also include interviews with those involved and a review of all circumstances surrounding the incident. In this case, the investigation lacked the required documentation and statements, resulting in a failure to meet the facility's own abuse prevention policy standards.
Failure to Follow Physician Orders and Delayed Antibiotic Administration
Penalty
Summary
Facility staff failed to follow physician orders as written for one resident, resulting in a significant delay in both the collection of a urine specimen and the initiation of antibiotic treatment. The physician ordered a complete blood count, basic metabolic panel, and urinalysis with culture and sensitivity. While blood samples were collected and processed promptly, the urine specimen was not collected until eight days after the order was given. This delay was not documented in a way that would alert subsequent staff, and there was confusion among nursing staff regarding responsibility for obtaining and documenting the urine sample. The resident involved was severely cognitively impaired, required moderate assistance with personal care, and had multiple diagnoses including dementia, seizure disorder, and myasthenia gravis. The delay in collecting the urine specimen led to a subsequent delay in laboratory processing and in notifying the primary care physician of the results. Once the results were available, there were further delays and confusion regarding the administration of the prescribed antibiotic, Levaquin, due to concerns about a possible drug allergy and issues with pharmacy communication and delivery. Documentation in the Medication Administration Record (MAR) was inconsistent, with conflicting notes about whether the antibiotic was administered as ordered. Nursing staff and the Director of Nursing both acknowledged that orders should be entered and acted upon promptly, and that delays in lab work and medication administration could negatively impact resident care. However, the facility failed to ensure timely collection of the urine specimen, prompt notification of the physician, and accurate documentation of medication administration, resulting in services that did not meet professional standards of quality.
Failure to Provide Feeding Assistance to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for all activities of daily living, including eating and drinking, did not receive necessary feeding assistance during a scheduled mealtime. The resident had severe cognitive impairment, contractures of both hands, and was on hospice care with multiple diagnoses including heart failure, diabetes, dementia, chronic kidney disease, and dysphagia. The resident's care plan and dietary orders specified a pureed diet, nutritional supplements, and total staff assistance for feeding. On the day of the incident, observations showed the resident remained in bed, unable to access fluids placed out of reach, and did not receive a meal tray during lunch. Multiple CNAs assigned to the hall failed to deliver the meal tray or provide feeding assistance, each assuming the other had completed the task. Neither CNA communicated with each other or with the nurse to confirm the resident had been fed, and the meal tray remained on the dining cart. Documentation later reflected that the resident ate 0 to 25% of the meal, despite not having received any food or fluids. Interviews with staff revealed a lack of clear communication and accountability regarding which CNA was responsible for feeding the resident. The assigned nurse was unaware the resident had not been fed and did not verify with CNAs whether all dependent residents received their meals. Facility policy required staff to provide individualized meal assistance and accurate documentation, but these procedures were not followed, resulting in the resident missing a meal and necessary hydration.
Failure to Maintain Infection Control and Proper Catheter Care
Penalty
Summary
Staff failed to maintain infection control and proper catheter care for a resident with an indwelling Foley catheter and a recent history of urinary tract infection. The resident was observed with the catheter tube compressed under a limb, not secured to the leg, and with visible dried dark matter on the tube. The catheter bag was repeatedly placed on the bed, allowed to dangle near the floor, and was kicked by staff during transfers, contrary to facility policy requiring the bag to be kept below the bladder and off the floor. The catheter tube was also observed to be cloudy with visible urinary sediment, and the resident's perineal area had dark brown, foul-smelling matter, identified as stool, in contact with the catheter. The resident reported pain in the genitalia, lower abdomen, and groin, and stated that nursing staff were not cleaning the catheter or addressing the pain. During care, staff did not secure the catheter tubing to the resident's leg, resulting in visible pulling at the insertion site. The catheter tube was repeatedly compressed by the resident's limb, and urine was seen backing up in the tube. Staff cleaned the catheter and perineal area but did not follow proper infection control practices, as the catheter bag was placed on the bed and handled in a manner that risked contamination. Facility policy required staff to keep the catheter and tubing free of kinks, secure the tubing to the resident's leg, keep the drainage bag below the bladder, and ensure the catheter and perineal area were clean. The Director of Nursing confirmed expectations for staff to follow these protocols, including cleaning the catheter and perineal area regularly, securing the tubing, and maintaining the drainage bag in the correct position. However, observations and interviews confirmed that these procedures were not followed for this resident, leading to the identified deficiency.
Failure to Remove Disqualified Employee from Duty
Penalty
Summary
The facility failed to respond appropriately to a report that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL), which made the individual ineligible to work in a certified long-term care facility. The Department of Health and Senior Services (DHSS) notified the facility that the BOM was permanently placed on the EDL, but the BOM continued to work at the facility for over two weeks after the placement. The EDL Active Report confirmed the BOM's name and Social Security Number were added to the list with a permanent order. Interviews revealed that both the Human Resources (HR) Director and the Administrator were unaware of the BOM's placement on the EDL until surveyors began their investigation. The HR Director, who had only been in the position since August, had not performed quarterly EDL checks and stated that no one notified him of the BOM's status. The Administrator also confirmed he was not informed and only became aware shortly before the surveyors' arrival. The BOM had worked at the facility as recently as the day before the investigation began, despite being ineligible for employment.
Failure to Discontinue Blood Sugar Medication as Ordered
Penalty
Summary
Staff failed to discontinue a blood sugar-lowering medication, Metformin, as ordered for a resident with a history of diabetes, hypertension, and Parkinson's disease. The resident had been hospitalized for hypoglycemia, and upon discharge, hospital orders specified to stop Metformin. However, upon the resident's return to the facility, there was no documentation regarding the discontinuation of Metformin, and the medication continued to be administered as per the previous schedule. The resident's Medication Administration Record (MAR) showed that Metformin was administered twice daily for several weeks following the hospital discharge, despite the stop order. During this period, the resident experienced multiple episodes of low blood sugar, including documented blood glucose readings as low as 40 and 51, requiring interventions such as administration of orange juice, glucose tablets, fudge brownies, and Glucagon. Progress notes and direct observations indicated the resident was slow to respond, held food in their mouth, and required staff assistance for blood sugar management. The facility's policies required medications to be administered according to prescriber orders and for all medication changes to be documented and followed. Despite these policies, the failure to discontinue Metformin as ordered resulted in ongoing administration of the medication, contributing to repeated hypoglycemic events for the resident. The Director of Nursing confirmed that the medication was not discontinued as ordered and was unaware of the error until after the fact.
Failure to Maintain Safe Transportation and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure that the vehicle used for resident transportation was maintained in a safe and sanitary condition. Observations revealed the van had exposed wires, missing panels, debris, soiled linen, a used urinal with urine, water leaking from the roof, and a black substance on the wall. The van was used to transport residents, including those in wheelchairs, and there was no formal tracking for preventative maintenance or services performed on the vehicle. The Administrator was unaware of the van's condition, and the issues persisted over multiple days without being addressed. Additionally, the facility did not conduct thorough investigations or maintain complete documentation following resident falls. For two residents with significant cognitive and physical impairments, fall incident reports lacked witness statements and neuro checks, despite requests from surveyors. Progress notes and care plans showed repeated falls, but interventions were not consistently updated after each incident. In some cases, new interventions discussed in interdisciplinary team meetings were not added to the care plan, and there was no evidence of follow-up assessments or documentation as required by facility policy. Interviews with staff revealed a lack of understanding and adherence to post-fall investigation protocols. CNAs reported never being asked to provide statements after witnessing falls, and LPNs considered their progress notes sufficient as statements. The DON acknowledged that a complete investigation should include incident reports, statements, assessments, and neuro checks, but these elements were missing. The DON also did not have access to facility policies and was unaware of their specific requirements.
Failure to Remove Disqualified Employee from Facility Staff
Penalty
Summary
The facility failed to respond appropriately after being notified that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL), which disqualifies individuals from working in certified nursing homes. The Department of Health and Senior Services (DHSS) notified the facility that the BOM was permanently placed on the EDL, but the BOM continued to work at the facility for over two weeks after the placement. Both the Human Resources (HR) Director and the Administrator were unaware of the BOM's EDL status until surveyors began their investigation. The HR Director stated that no one had notified him of the placement and that he had not yet performed quarterly EDL checks since starting in the position a few months prior. The Administrator also confirmed he had not received any notification and was unsure how often EDL checks were being conducted. The EDL Active Report confirmed the BOM's name and Social Security Number had been added to the list with a permanent order. Interviews revealed that the BOM had worked at the facility as recently as the day before the surveyors' arrival and was only absent due to a personal emergency. The lack of timely EDL checks and communication breakdowns within the facility allowed the BOM to remain employed despite being ineligible, as required screenings and ongoing monitoring were not performed as mandated.
Failure to Discontinue Diabetes Medication as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not discontinuing a blood sugar-lowering medication, Metformin, as ordered by the hospital upon the resident's discharge. The resident, who had diagnoses of diabetes, hypertension, and Parkinson's disease, was dependent on staff for all activities of daily living and had a history of both insulin and oral diabetes medication administration. Despite hospital discharge instructions to stop Metformin following an episode of hypoglycemia, the medication continued to be administered by facility staff for several weeks after the resident's return. The resident experienced multiple episodes of low blood sugar (hypoglycemia) after readmission, with documented blood glucose levels as low as 40 and 51, requiring interventions such as administration of glucagon, orange juice, and glucose tablets. Progress notes and medication administration records showed that Metformin was given twice daily from the date of readmission until it was finally discontinued, despite the hospital's explicit order to stop the medication. There was no documentation in the resident's chart regarding the discontinuation of Metformin upon return from the hospital, and the care plan continued to list diabetes medications as ordered by the physician. Staff interviews revealed that the DON was unaware that Metformin had not been discontinued as ordered, and the nurse responsible for the error was no longer employed at the facility. The ongoing administration of Metformin, contrary to the hospital's discharge orders, directly contributed to repeated hypoglycemic events in the resident, as evidenced by clinical documentation and staff observations.
Failure to Honor Resident Food Preferences and Dietary Orders
Penalty
Summary
The facility failed to provide a resident with meals that met their documented food preferences and dietary needs. The resident, who was cognitively intact and able to communicate their preferences, had clear instructions in their care plan and physician's orders to avoid pork, cooked tomatoes, and carrots, and to receive double portions at each meal. Despite these documented requirements, the resident reported that staff continued to serve meals with gravy, foods they disliked, and did not provide the required double portions. The resident had communicated these concerns to both the DON and the Administrator. Observations confirmed that the resident received single portions and was served foods specifically listed as dislikes, such as cooked carrots and stewed tomatoes. Meal trays were not consistently prepared according to the resident's preferences, as evidenced by the presence of non-preferred items and incorrect portion sizes. The Dietary Director acknowledged that resident preferences are documented in the electronic medical record and should be followed when preparing meal trays, but this was not consistently done for this resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse, resulting in multiple altercations between them. Resident 54, diagnosed with paranoid schizophrenia and a history of traumatic brain injury, exhibited disruptive and verbally abusive behavior towards staff and other residents. Despite being placed on 15-minute checks, Resident 54 was observed yelling and shouting vulgarities, primarily focused on his desire to go outside to smoke. On two occasions, Resident 54 engaged in physical altercations with Resident 45, who has vascular dementia and osteoarthritis, leading to kicking and hitting each other. These incidents were not effectively prevented or managed by the facility staff. The first incident occurred when Resident 54 entered Resident 45's room and made a vulgar comment, leading to a physical fight where both residents kicked and hit each other until separated by staff. Despite being transferred to the hospital for a psychiatric evaluation, Resident 54 returned with no new orders to manage his behaviors. The second incident happened when Resident 54 was found hitting Resident 45 near her room, and she retaliated by hitting him with her reacher/grabber tool. Both residents were assessed and found to have no physical injuries, but the incidents caused significant psychosocial harm to Resident 45. Resident 45 reported feeling fearful and unable to sleep well due to concerns about Resident 54 entering her room. Despite being moved to a different part of the building, she continued to express anxiety about her safety. The facility's Director of Nursing acknowledged the challenges in managing Resident 54's behaviors and the impact on other residents. The Medical Director provided situational orders to manage Resident 54's behaviors but did not have specific information about the incidents. The facility's failure to effectively prevent and manage these altercations resulted in a deficiency in protecting residents from abuse.
Failure to Implement Pressure Ulcer Interventions and Follow Treatment Orders
Penalty
Summary
The facility failed to implement pressure ulcer interventions and follow physician's treatment orders for a resident who had undergone left hip surgery. The resident, who was readmitted to the facility with a diagnosis of surgical repair of the left hip, had a severe cognitive decline and was at risk for pressure ulcers as indicated by the Braden Scale scores. Despite this, no pressure ulcer prevention measures were initiated post-surgery until the resident developed unstageable pressure ulcers on the left foot. The care plan was only updated after the ulcers had developed, and interventions such as bilateral heel protectors and monitoring were implemented late. The resident's medical records revealed multiple instances where physician orders for pressure ulcer treatment were not followed. Orders to apply skin prep, Medi-honey, and foam dressing, as well as to cleanse the area with normal saline and apply collagen, were frequently not documented as completed. Additionally, the resident was observed without the prescribed low-air-loss mattress, which the Director of Nursing admitted was not ordered due to cost concerns. Interviews with the Director of Nursing confirmed that the care plan should have been updated post-surgery and that physician orders should always be followed. The failure to implement timely interventions and adhere to treatment orders resulted in the resident's pressure ulcers deteriorating to an unstageable and later a Stage 4 condition, causing actual harm to the resident.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 22 of the 92 days reviewed. This deficiency was identified through interviews, review of the Payroll Based Journal (PBJ) staffing report, and nursing schedules from October 1, 2023, to December 31, 2023. Specifically, there was no RN coverage on multiple days in October, November, and December 2023. The Director of Nursing (DON) confirmed the lack of RN coverage on these dates and acknowledged the requirement for an RN to be scheduled for at least eight hours in a 24-hour period, seven days a week. The facility did not have any RN coverage waivers, and the DON was unable to find a policy stating the RN requirement. During interviews, the DON stated that licensed nurses on shift were aware that she was on-call and would notify her if an RN was needed, at which point she would come to the facility. Certified Medication Technicians (CMTs) also confirmed their awareness of how to notify the DON if needed, especially on weekends. Despite this, the facility's failure to have an RN on duty for the required hours has the potential to affect the care provided to residents and the supervision of the unit.
Failure to Develop and Maintain Facility Assessment
Penalty
Summary
The facility failed to develop, initiate, or revise a facility assessment to determine the necessary resources to care for its residents competently during day-to-day operations. During the entrance conference, the Director of Nursing (DON) was unable to provide the Facility Assessment. The Administrator was unfamiliar with the concept of a Facility Assessment and confirmed that one had not been created since the facility's initial certification in January 2022. A document titled Facility Assessment Tool was later provided but was undated and had not been reviewed or approved by the facility's Quality Assurance committee. The DON admitted that the document was only initiated in January 2024 and revised on the day of the surveyor's request.
Failure to Develop QAPI Program
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) program, which had the potential to affect all 78 residents. The facility's Quality Assurance Improvement Plan, dated February 2020, outlined a process for identifying and correcting quality deficiencies, including tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing causes, implementing corrective actions, and monitoring effectiveness. However, during an interview, the Director of Nursing (DON) stated that the facility did not have a QAPI plan in place. Further interviews revealed that the facility had conducted two QAPI meetings but did not keep minutes for these meetings. The DON mentioned that information was gathered from daily morning meetings, nursing 24-hour reports, and incident/accident reports to identify concerns, which were then reviewed during meetings and communicated to floor staff. However, the facility had not developed any Performance Improvement Plans (PIPs) or benchmarks for measuring improvement. The DON confirmed that there were no benchmarks or regular meetings to identify potential problem areas, relying instead on discussions at morning meetings and reviews of residents' electronic medical records (EMR).
QA Committee Fails to Identify and Address Quality Deficiencies
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to identify quality deficiencies, develop or implement corrective actions, track and measure effectiveness, or develop new interventions based on QA committee discussions. This failure had the potential to affect all 78 residents residing at the facility. The facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, mandates the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on care outcomes and quality of life for residents. However, during interviews, the Director of Nursing (DON) admitted that the facility did not have a QAPI plan and that the QA committee had not identified any specific quality deficiencies or conducted any performance improvement programs (PIPs).
QA Committee Fails to Meet Quarterly with Required Members
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to meet at least quarterly with the required members, resulting in potential missed opportunities for identifying, tracking, and measuring quality deficiencies. The facility's policy stated that the QA committee should meet monthly, but only two meetings were documented since January 2022. The meetings on 11/18/22 and 09/28/23 were missing key members such as the Director of Nursing (DON), Infection Preventionist (IP), Medical Director, and Administrator. The DON confirmed that no QA meetings had been held in 2024, nor were any planned. During interviews, the DON and Administrator acknowledged the lack of regular QA meetings and the absence of key members. The Medical Director stated he would not attend any QA meetings until he was compensated by the facility. This failure to hold regular QA meetings with the required members had the potential to affect all 78 residents at the facility, as it hindered the facility's ability to effectively monitor and improve quality of care.
Failure to Properly Manage Resident Funds
Penalty
Summary
The facility failed to ensure resident funds were placed in an account separate from the facility operating account, resulting in delayed refunds for six residents. Additionally, the facility staff did not obtain written authorization for money withdrawals for 19 residents, and failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner for seven residents. This lack of proper financial management did not allow residents or their financial guardians the right to manage their financial affairs effectively. The facility also failed to withdraw the correct monthly surplus for room and board for one resident, and used resident funds for checking account fees deducted from the resident trust account. Furthermore, the facility did not provide a statement explaining the facility's policies and resident's rights regarding resident funds, and did not allow residents access to their funds on an ongoing basis. Resident petty cash funds were not kept separate from facility funds, affecting all residents whose funds were managed by the facility. Interviews with residents, their guardians, and family members revealed that many were unaware of the withdrawals or did not sign any paperwork authorizing them. The Business Office Manager admitted to not obtaining written authorization for withdrawals if the resident could talk, and was unsure about the reasons for certain credits and debits in the accounts. The facility census was 80, indicating that these deficiencies had the potential to affect a significant number of residents.
Failure to Reconcile Resident Trust Fund Accounts Monthly
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. The facility managed funds for 21 residents, with a census of 80. Record review of the facility-maintained bank statements for account ending in #5015 for several months showed no documentation of reconciliations. Additionally, attempted reconciliation forms for two specific months did not reconcile to the residents' current balance at the time of reconciliation. During an interview, the Business Office Manager admitted to not starting reconciliations until a specific month and could not provide any other documentation to support that reconciliations were performed.
Failure to Provide Timely Final Accounting of Resident Funds
Penalty
Summary
The facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for one discharged resident and four expired residents. Specifically, Resident #1020 had a $30.00 balance that was not refunded within 33 days after discharge. Resident #1019 had a $50.00 balance that was refunded 81 days after expiration, with no documentation showing where the funds went. Resident #1023 had a balance of $929.88, which was not reported to the Department of Social Services, Third Party Liability Unit, and was instead used for back surplus and transferred to the facility operating account. Resident #1025 had a balance of $277.84 that was not reported to the Department of Social Services, Third Party Liability Unit, and there was no documentation showing where the funds went. Resident #1026 had a balance of $402.17 that was transferred to the facility operating account instead of being reported to the Department of Social Services, Third Party Liability Unit. During interviews, the Business Office Manager was unable to provide explanations for the delays and mismanagement of the funds. The manager admitted to not knowing the proper procedures for handling and reporting the funds to the Department of Social Services, Third Party Liability Unit. The facility's failure to properly manage and report resident funds resulted in non-compliance with regulatory requirements, as evidenced by the delayed refunds and lack of documentation for the transactions.
Inadequate Surety Bond for Resident Trust Fund
Penalty
Summary
The facility failed to maintain an adequate surety bond for the resident trust fund account, which should have been one and one half times the average monthly balance for the past 11 months. The average monthly balance was $26,000.00, requiring a bond of $39,000.00. However, the facility only had an approved bond of $4,000.00, dated 8/23/21. The current balance in the resident trust account for February 2024 was $13,782.56. During interviews, the Business Office Manager (BOM) indicated that the Administrator was responsible for ensuring the surety bond was appropriate, but the BOM did not know how often the Administrator reviewed the bond and mentioned there was no policy for the surety bond. The Administrator admitted he was unaware of the need for a $39,000.00 bond and stated he would get it increased.
Failure to Post Survey Results and Provide Access
Penalty
Summary
The facility failed to post the location of the state survey results and provide unrestricted access to residents and visitors. Observations conducted throughout the facility revealed no notices posted to notify residents or visitors where the survey results binder was located. The binder labeled Survey Results was found behind the front desk, and a review of the binder revealed incomplete documentation, missing the facility's plans of correction (POC). During an interview, the Administrator and Director of Nursing (DON) confirmed that the binder was kept behind the receptionist's desk due to a previous incident where the binder was taken when placed in the lobby area. The Administrator also stated that the complete survey results and POC were kept in his office.
Failure to Issue Accurate Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue an accurate Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A service was ending for three residents. The facility used the directions for completion of the NOMNC from the Centers for Medicaid and Medicare Services (CMS) form number CMS-10123 as their policy. However, the facility issued a CMS-10095 to all three residents, which was the incorrect form. This error resulted in the NOMNCs lacking the type of current services that were ending and the necessary information about potential liability for services received after the last covered day (LCD). Additionally, the notices did not include the name, phone number, and TTY number of the Quality Improvement Organization (QIO). The MDS Coordinator, who was responsible for completing and issuing the NOMNCs, revealed that she was provided the CMS-10095 form by an advisor from Missouri University School of Nursing. She was unaware that she was using the incorrect form to notify residents and their representatives. This oversight could have led the residents or their responsible parties to miss the deadline to request an expedited appeal and review.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to ensure that three residents were free from misappropriation of their property when the Business Office Manager used resident funds for personal use. For Resident #1019, the Business Office Manager manipulated funeral home documents and instructed the resident's family member to cash a check and return a portion of the money in cash. The family member confirmed that the Business Office Manager received $2,000 in cash without providing a receipt. The funeral home and bank confirmed that the documents were altered and did not pertain to Resident #1019. For Resident #1010, the Business Office Manager issued checks and cash withdrawals without proper documentation or receipts. The resident and their Financial Power of Attorney (FPOA) confirmed receiving only a $1,000 check and no additional cash. The Business Office Manager attempted to have the FPOA falsely confirm receiving $1,000 in cash. The Activity Director also confirmed that no large cash withdrawals were requested or received for Resident #1010. For Resident #1008, the Business Office Manager issued checks to the resident's family member and instructed them to return a portion of the money in cash. The family member confirmed giving $2,000 in cash to the Business Office Manager and later receiving it back after questioning the transaction. The Activity Director confirmed that no large cash withdrawals were requested for Resident #1008, and the Business Office Manager's explanation for the withdrawal was inconsistent with the family member's account.
Failure to Screen New Hires for CNA Registry and Nursing Licenses
Penalty
Summary
The facility failed to ensure newly hired employees were properly screened for Federal Indicators, CNA registry, and nursing licenses. Specifically, three staff members were hired without a CNA registry check, and one RN and three LPNs were hired without their nursing licenses being verified. This deficiency was identified during a review of a sample of 10 employee files out of 200 new hires since the last survey. The facility's policy on abuse, neglect, exploitation, or misappropriation did not include procedures for employee background checks, licensing, or CNA registry verification. During interviews, the Business Office Manager/Human Resource Manager admitted to not knowing the correct website to use for these checks, and the Administrator was unaware that these checks were not being performed. This lack of proper screening could potentially lead to unqualified or unsuitable individuals being employed, posing a risk to resident safety and care quality.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure daily staffing information was posted timely and in a manner accessible to residents and visitors. The facility's policy required that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed personnel directly responsible for resident care be posted in a prominent location. However, observations on multiple days and times revealed no daily staff posting of nursing hours anywhere in the building. During an interview, the Assistant Director of Nursing (ADON) admitted that neither she nor the Director of Nursing (DON) had completed or posted the daily nurse staffing hours for the week due to the survey process occurring.
Failure to Maintain Complete PASRR Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records, specifically the required Preadmission Screening and Resident Review (PASRR) Level I and Level II evaluations for mental illness or intellectual disabilities for three of 24 sampled residents. This deficiency was identified through record reviews and staff interviews. For instance, one resident with paranoid schizophrenia and a history of traumatic brain injury did not have a PASRR in their medical record, despite exhibiting disruptive and verbally abusive behavior. The social worker confirmed the absence of the PASRR documentation, although a Level II evaluation had been conducted previously without recommendations for specialized services. Another resident with bipolar disorder and dementia was found to have no PASRR documentation in their electronic medical record, despite being cognitively intact according to their quarterly Minimum Data Set (MDS) assessment. Similarly, a third resident with dementia and idiopathic psychosis also lacked a documented PASRR in their medical record. The social worker confirmed the absence of PASRR documentation for these residents as well, even though Level I and Level II evaluations had been conducted previously. These lapses in documentation increased the risk that residents with mental illness or intellectual disabilities would not receive the necessary specialized services.
Failure to Report Verbal Threat to State Survey Agency
Penalty
Summary
The facility failed to report to the State Survey Agency (SA) a verbal threat to shoot residents and staff made by a resident diagnosed with paranoid schizophrenia and a history of traumatic brain injury. The resident, who exhibited moderate cognitive impairment and was known for disruptive and verbally abusive behavior, made the threat after a physical altercation with another resident. Despite the severity of the threat, the Director of Nursing (DON) did not consider it credible and did not report it to the SA, as the resident did not have access to a gun. The facility's policy requires all reports of abuse, neglect, and mistreatment to be promptly reported to local, state, and federal agencies, but this protocol was not followed in this instance. The resident in question, who was admitted with a history of paranoid schizophrenia and traumatic brain injury, had a documented pattern of violent outbursts and verbal abuse. On two separate occasions, the resident was observed cursing and demanding cigarettes near the nurse's station. The staff, including a Certified Nurse Aid (CNA) and a Certified Medication Tech (CMT), confirmed that they struggled to manage the resident's behavior and often allowed him to smoke to prevent further escalation. The facility's electronic medical record (EMR) showed intermittent 15-minute checks as a care plan intervention to deescalate the resident's violent behavior. However, after the resident made a verbal threat to shoot everyone in the building following a physical altercation, the threat was not reported to the SA, contrary to the facility's abuse investigation and reporting policy.
Failure to Investigate Threats and Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate a verbal threat made by a resident (R54) to shoot staff and other residents. Despite R54's history of paranoid schizophrenia and traumatic brain injury, and his observed disruptive and verbally abusive behavior, the Director of Nursing (DON) did not consider the threat credible because R54 did not have access to a gun. No search of R54's person or room was conducted to rule out the presence of weapons, which the DON confirmed should have been part of a thorough investigation. Additionally, the facility failed to properly investigate an allegation of misappropriation involving the Business Office Manager (BOM). The Administrator did not immediately suspend the BOM upon receiving the complaint and allowed the BOM to return to work before speaking with all potential witnesses. The BOM made contact with one of the residents involved in the allegation multiple times, including in person, which is against the facility's policy. The investigation into the misappropriation was incomplete and poorly documented. The Administrator did not speak with all relevant family members and relied on incomplete statements. The BOM and other staff provided statements that did not address all allegations, and there were discrepancies in the financial records. The Administrator's actions and the facility's investigation did not adhere to their own policies, leading to an inadequate response to the serious allegations of misappropriation.
Failure to Issue Transfer Notice
Penalty
Summary
The facility failed to issue a notice of transfer to a resident or their responsible party when the resident was sent to the emergency room for a hypoglycemic event. The resident, who was initially admitted for long-term care and had diagnoses including Type 2 diabetes mellitus and dementia, was transferred to the hospital without receiving the required written notice. Interviews with the resident were unsuccessful, and the social worker confirmed that no written transfer notice was provided. Additionally, the facility was unable to provide a policy for issuing such notices.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to one of three residents when the resident was sent to the emergency room. The resident, who was initially admitted for long-term care and had diagnoses including Type 2 diabetes mellitus and dementia, was transferred to the hospital for a hypoglycemic event. A review of the electronic medical record revealed no documents indicating that a bed hold form was provided. Interviews with the resident were unsuccessful, and the social worker confirmed that no bed hold notice was given. Additionally, the facility could not provide a policy for issuing a bed hold form upon transferring a resident to the emergency room.
Inaccurate Coding for Restraints
Penalty
Summary
The facility failed to accurately code a resident for restraints, as required by the Resident Assessment Instrument (RAI) manual. During an observation, the resident was seen transferring herself to a wheelchair without any restraints on the wheelchair or bed. An interview with the MDS Coordinator confirmed that the resident did not have any restraints at any time during her stay, and the coding error was acknowledged. A review of the quarterly Minimum Data Set (MDS) indicated that the resident was incorrectly coded for the use of restraints in a section titled 'Used in chair or out of bed.' This discrepancy was identified as an error by the MDS Coordinator.
Failure to Reassess Behavior Management Interventions
Penalty
Summary
The facility failed to reassess and adjust interventions for a resident diagnosed with paranoid schizophrenia and a history of traumatic brain injury, who exhibited verbally and physically abusive behaviors towards other residents and staff. Despite the resident's disruptive and vulgar behavior, which included screaming sexually vulgar statements and demanding to go outside or call his sister, the facility did not effectively modify the behavior management plan. Staff interviews revealed that they were unable to predict or redirect the resident's behaviors, often resorting to allowing him to smoke to prevent escalation. The resident's care plan included nonpharmacologic interventions and mood-stabilizing medications, but these measures were not reassessed for efficacy when they proved ineffective. Observations during the survey showed the resident's behavior remained disruptive and abusive, impacting the well-being of other residents. The Director of Nursing (DON) acknowledged the difficulty in managing the resident's behavior and the unsuccessful attempts to find alternate placement. The Medical Director deferred to psychiatric specialists for treatment management, and situational orders were provided intermittently. The facility's failure to reassess and adjust the behavior management interventions increased the risk of ongoing abusive behaviors by the resident towards others.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were completed by the consulting pharmacy for two residents, resulting in the potential for adverse side effects from unnecessary or duplicate medications. Resident 22, who was severely cognitively impaired, had an order for Haldol 5 mg PRN for agitation. Despite the consultant pharmacist recommending discontinuation of the PRN Haldol on two occasions, there was no documentation indicating that the physician had been made aware of these recommendations. The order for PRN Haldol remained on Resident 22's MAR, and the resident received doses in January and March 2024. Additionally, there were no pharmacy reviews or recommendations documented for March and April 2024 for Resident 22. Resident 25, who was cognitively intact, had an order for Haldol 0.5 ml PRN for agitation. The consultant pharmacist did not provide any recommendations to the facility in March or April 2024, and Resident 25 had not received any doses of Haldol. During interviews, the DON confirmed that the physicians for both residents had not been made aware of the pharmacy recommendations regarding the Haldol orders. The Pharmacy Consultant admitted that the March 2024 reviews were not yet loaded in the EMR and that the April 2024 reviews had not been completed. The facility was unable to provide any policies related to pharmacy reviews or expectations prior to the survey exit.
Failure to Include Stop Dates for PRN Medications
Penalty
Summary
The facility failed to ensure that PRN (as needed) medications for two residents included a stop date no later than 14 days after the order was received. This resulted in the potential for adverse side effects from unnecessary medications. Resident 22, who was admitted with diagnoses of dementia with agitation, major depressive disorder, and cognitive communication deficit, had an order for Haldol without an end date. Despite recommendations from the consultant pharmacist to discontinue the PRN Haldol, there was no documentation indicating that the physician had been made aware of these recommendations, and the order remained active for several months. Similarly, Resident 25, who was admitted with diagnoses of dementia without agitation and depression, also had an order for Haldol without an end date. The resident did not receive any doses, but the order remained active without reevaluation. Interviews with the Director of Nursing and the consultant pharmacist confirmed that there was no documentation in the residents' electronic medical records indicating that the physicians had been informed to continue or discontinue the Haldol orders. This oversight highlights a failure in the facility's medication management and communication processes.
Failure to Notify Responsible Party of New Skin Conditions
Penalty
Summary
The facility failed to notify a resident's responsible party after new skin conditions requiring treatment were identified. Specifically, for one resident, the facility did not inform the responsible party about a reddened area on the right great toe noted on 12/1/23 and a reddened area with three small openings on the coccyx noted on 2/15/24. Although the facility's policy mandates notifying the responsible party within 24 hours of any change in condition, this was not done in either instance. The facility's Wound Nurse and other staff did not document any notification to the responsible party regarding these new skin conditions. The resident involved had multiple medical diagnoses, including diabetes, stroke, cognitive communication deficit, anemia, and a urinary tract infection. The facility's administration confirmed that staff are expected to notify a resident's responsible party of any change in condition, including new wounds or skin issues, and to document such notifications. However, in this case, the responsible party was not informed about the new skin conditions, contrary to the facility's policy and expectations.
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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