Aspire Senior Living Jonesburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Jonesburg, Missouri.
- Location
- 308 Cedar Avenue, Jonesburg, Missouri 63351
- CMS Provider Number
- 265333
- Inspections on file
- 23
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Aspire Senior Living Jonesburg during CMS and state inspections, most recent first.
Staff failed to complete and document ordered weekly skin assessments for a resident with moderate cognitive impairment and identified risk for skin breakdown. Facility policies required weekly head-to-to-toe skin observations and documentation in the medical record, and physician orders specified weekly skin assessments on designated shifts. Review of records showed multiple weeks with no documented assessments, during which time a DTI on the sacrum and a pressure ulcer on the left heel, both described as facility-acquired, were present. Interviews with the MDS nurse, RN, DON, and Administrator confirmed that the charge nurse was responsible for these assessments, that the EHR would have prompted them, and that all physician orders were expected to be followed, yet leadership was unaware the assessments had not been completed or documented.
A resident with severe cognitive and physical impairments developed an open area on the knee that progressed to bone protrusion and significant drainage. Nursing staff documented the change and notified the physician, but failed to promptly inform the resident's legal representative of the condition change, resulting in delayed communication about the resident's health status.
Staff did not report a resident-to-resident altercation involving two residents with dementia to DHSS within the required two-hour timeframe. The incident was only brought to the administrator's attention through an anonymous note days later, and documentation and interviews confirmed that the required reporting procedures were not followed.
A resident with Parkinson's disease and impaired mobility was subjected to verbal and physical abuse by a CNA, who threatened rough treatment and handled the resident aggressively during care. The incident was witnessed by a social worker, and the resident reported distress and pain. The CNA admitted to inappropriate behavior, leading to their suspension and termination.
A resident was issued an immediate discharge from a facility without proper notice or a specified new location, following an incident where the resident allegedly hit someone. The facility's discharge notice lacked required information, and the resident was left in a hospital ER without a clear relocation plan. The facility administrator confirmed the resident would not be readmitted.
The facility failed to maintain a homelike environment for residents, with observations of disrepair such as gaps in flooring, missing tiles, stains, and non-functional lighting in several rooms. Staff interviews revealed a lack of awareness and communication regarding needed repairs, despite a system for reporting issues. The Maintenance Supervisor was unaware of specific repairs needed, and the administrator acknowledged responsibility for ensuring repairs are completed.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon hospital transfer, as required by their policy. This issue was identified for three residents, with staff interviews revealing inconsistent practices in handling bed hold notifications. The administrator was unaware that bed holds were not being signed or copied for the medical record.
The facility failed to develop comprehensive care plans for three residents, neglecting to address their medical, nursing, mental, and psychosocial needs. One resident with severe cognitive impairment and hospice care had behaviors not reflected in the care plan. Another resident with moderate cognitive impairment had a care plan lacking directions for wound care and swelling. A newly admitted resident's care plan did not address elopement and psychosocial concerns. Lack of communication and oversight in updating care plans was evident.
The facility did not maintain the required RN coverage for at least eight hours daily, seven days a week. Staffing records showed gaps in RN coverage on specific dates, and interviews with staff confirmed the challenge in maintaining consistent RN presence. The facility has been advertising for the position and hired an RN for weekend coverage.
A survey revealed deficiencies in medication management at an LTC facility, including failure to destroy discontinued medications for several residents and the presence of expired and loose medications on medication carts. Interviews with staff, including an LPN, DON, and administrator, indicated a lack of awareness and responsibility for maintaining medication storage and carts, leading to oversight and non-compliance with facility policies.
The facility did not have a qualified Director of Food and Nutrition Services, as the Dietary Supervisor (DS) had not completed the required Certified Dietary Manager (CDM) course. The DS quit without notice during the survey, and the facility's registered dietitian only worked part-time as a consultant. This deficiency could impact all 60 residents.
Facility staff failed to protect resident privacy by leaving computer screens unattended and visible, displaying personal and medical information. An RN and an LPN admitted to not locking screens on treatment and medication carts, acknowledging the privacy violation. The DON and administrator confirmed the requirement to lock screens when unattended.
The facility failed to post required nurse staffing information daily, as mandated by policy. Reviews of staff hour postings for July and August 2024 showed missing census and actual hours worked for most days. Observations and interviews confirmed that postings lacked total hours and were not updated as required. The DON and an LPN acknowledged the issue, with the night shift nurse responsible for completing the postings, but this was not consistently done.
Facility staff failed to follow infection control procedures during wound care for four residents, leading to a risk of spreading bacteria. An LPN did not perform hand hygiene between glove changes and did not use gloves appropriately, as confirmed by the DON and the facility administrator.
Failure to Complete and Document Ordered Weekly Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not completing ordered weekly skin assessments for one resident. Facility policies on Skin Integrity and Skin Observation required that the medical record contain all documentation regarding skin assessments and that a full head-to-toe skin observation be conducted by an RN or LPN upon admission/re-admission and weekly thereafter. The resident’s care plan identified impaired cognition and risk for skin breakdown and pressure ulcers, and the Quarterly MDS documented moderate cognitive impairment. Physician’s orders directed weekly skin assessments on specific days and shifts. Review of the resident’s December weekly skin assessment documentation showed no recorded assessments on 12/05/25, 12/12/25, and 12/19/25, and the MDS nurse confirmed that no weekly skin assessments were documented from 11/28/25 through 12/21/25 despite existing orders. Nursing documentation showed that on 12/21/25 a deep tissue injury (DTI) was identified on the resident’s sacrum, and the resident also had a pressure ulcer on the left heel, both described by RN A as facility-acquired and expected to be documented on the weekly skin assessments. Additional physician’s orders on 01/02/26 included topical treatments to the buttocks and left heel. Interviews with the MDS nurse, RN A, the DON, and the Administrator confirmed that the charge nurse was responsible for completing and documenting weekly skin assessments, that the electronic system would have prompted these assessments, and that all physician’s orders were expected to be followed. The DON and Administrator stated they were not aware that the weekly skin assessments had not been documented during the identified period and acknowledged that if it is not documented, it is considered not completed.
Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's legal representative in a timely manner following a significant change in the resident's condition. The resident, who had severe cognitive impairment, lower extremity impairment on both sides, and was dependent on staff for transfers, toileting, and hygiene, was assessed with an open area on the right knee. Nurse notes documented the presence of a 0.5 cm open area with a white center, which progressed to a pinpoint hole with a large amount of pink-tinged drainage and bone protruding under the skin. Despite these significant findings, there was no documentation that the resident's representative was notified of the change in condition at the time it was identified. Further review showed that while the physician was notified and new orders were received for pain management and antibiotics, the resident's representative was not informed until later, after the wound had worsened and infection was suspected. Interviews with facility leadership confirmed that staff are expected to notify the resident's representative promptly after a change in condition, but in this case, notification was delayed without a valid reason. The deficiency centers on the lack of timely communication to the resident's representative regarding a significant change in the resident's health status.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report a resident-to-resident altercation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. According to the facility's policy, all alleged violations of abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made. The incident involved one resident with severe cognitive impairment and dementia who slapped another resident with mild cognitive impairment and dementia. Documentation showed that after the noon meal, the altercation occurred, but there was no evidence that it was reported to DHSS within the mandated timeframe. The incident came to the attention of the facility administrator via an anonymous note left under her door two days after the event. Interviews revealed that a CNA witnessed the altercation and reported it to the charge nurse, who assumed that social services had reported the incident to the administrator. The charge nurse did not follow up or ensure the incident was reported, and the administrator only became aware of the situation upon reading the anonymous note. Review of progress notes and investigation forms confirmed the lack of timely reporting to DHSS.
Resident Subjected to Verbal and Physical Abuse by CNA
Penalty
Summary
The facility staff failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact but had a diagnosis of Parkinson's disease, compression fractures, and impaired mobility. The resident required moderate assistance for transfers and had a care plan indicating a risk of falls due to weakness and impaired balance. On the day of the incident, the CNA threatened the resident with rough treatment if they did not cooperate with care, which was witnessed by a social worker. The social worker observed the CNA handling the resident aggressively, including grabbing the resident's legs, sitting them up on the bed, and moving them abruptly to a wheelchair. The CNA then pushed the resident to the bathroom and attempted to have them hold the grab bars, but when the resident was unable to do so, the CNA lifted the resident by yanking their pants and placed them on the toilet without allowing them to pivot their feet. The resident reported feeling hurt and was crying during the incident. Interviews with the CNA and the resident confirmed the aggressive handling and verbal threat. The CNA admitted to using the term "manhandle" and acknowledged that it was inappropriate. The resident expressed distress and did not recall all the details due to crying. The facility's investigation documented the social worker's observations and the resident's account of the incident, leading to the CNA's suspension and eventual termination.
Failure to Provide Proper Discharge Notice and Refusal to Readmit Resident
Penalty
Summary
The facility staff failed to provide an appropriate emergency discharge notice for a resident and did not allow the resident to return to the facility after being discharged from the hospital. The facility's Transfer and Discharge policy requires that residents be notified at least thirty days prior to an anticipated transfer, except in cases where the safety of individuals in the facility is endangered. The policy also mandates that the notice include specific information such as the location to which the resident is being transferred, the right to appeal, and contact information for the State Long-Term Care Ombudsman. However, the Immediate Discharge Notice for the resident did not include this required information. The resident was issued an immediate discharge due to the facility's claim of being unable to provide adequate care and ensure the safety of others, following an incident where the resident allegedly hit someone. The discharge notice was given without specifying a new location for the resident, and the resident's family was informed by phone. The resident was left in a hospital emergency room without a clear plan for relocation, and the facility administrator confirmed that they would not be taking the resident back. This situation left the resident without a proper discharge plan or location, violating the facility's own policies and regulatory requirements.
Facility Fails to Maintain Homelike Environment Due to Disrepair
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents, as evidenced by multiple observations of disrepair in resident rooms. Observations included gaps in flooring between rooms and hallways, missing tiles in bathrooms, brown stains on floors and toilet bowls, peeled baseboards, frayed and cracked fall mats, and a damaged sink vanity top with exposed particle board. Additionally, a bathroom light was found to be non-functional. These issues were noted in several occupied resident rooms over a span of three days. Interviews with facility staff revealed a lack of awareness and communication regarding the needed repairs. Although staff were instructed to write repair requests in a maintenance log book located at the nurses' desk, the Maintenance Supervisor was unaware of the specific repairs needed in the resident rooms despite conducting daily rounds. The administrator confirmed that maintenance is responsible for repairs, but ultimately, the administrator is accountable for ensuring repairs are completed. Despite a system in place for reporting and addressing maintenance issues, the deficiencies persisted, indicating a breakdown in the process.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for three residents who were discharged to the hospital. The facility's policy mandates that residents or their representatives be informed of the bed hold policy upon admission, at the time of transfer, and during non-covered therapeutic leave. Additionally, a signed authorization for bed hold must be obtained within 48 hours of transfer or by the next business day if the transfer occurs on a weekend or holiday. However, the medical records for the three residents did not contain documentation of such notifications. Interviews with facility staff revealed a lack of consistent practice in handling bed hold notifications. The administrator believed that bed hold paperwork was sent with residents upon discharge but acknowledged that copies were not made for the medical record. A registered nurse expressed uncertainty about whether bed holds were being completed, and the Director of Nursing mentioned a bed hold book at the nurse station but was unsure if the forms were being sent with residents. The administrator admitted responsibility for ensuring bed holds were completed but was unaware that they were not being signed or copied for the medical record.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #41, who had severe cognitive impairment and was on hospice care, exhibited disruptive behaviors such as clapping and yelling, but the care plan lacked guidance for these behaviors and hospice services. Despite observations of the resident's behaviors and interviews indicating a decline in condition, the care plan was not updated due to a lack of communication between staff and the MDS Coordinator. Resident #44, with moderate cognitive impairment and a diagnosis of dementia, had a care plan that did not address the resident's lower extremity swelling or wound care needs. The resident had an order for wound care on the right shin, but the care plan failed to include directions for managing the swelling or wound. Observations showed the resident with swollen legs and a bandage, and interviews revealed that the resident often refused to lay down, which could have benefited the healing process. Resident #164, newly admitted to the facility, had a baseline care plan that did not address risks of elopement, wandering, or psychosocial concerns. The resident was documented as exit-seeking and displaying aggressive behavior towards staff, yet these issues were not reflected in the care plan. Interviews with the MDS Coordinator, DON, and administrator highlighted a lack of communication and oversight in updating care plans, which are essential for directing staff in providing appropriate care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's assessment indicated that an RN should be present for at least 8 hours daily, but a review of the nurse staffing records from August 1 to August 22, 2024, revealed that there was no RN coverage for the required hours on August 3, 4, and 17. Interviews with RN K, the Director of Nursing (DON), and the Administrator confirmed the lack of consistent RN coverage. RN K mentioned that there are times when no RN is present in the building, and the DON acknowledged the difficulty in maintaining RN coverage, especially on weekends. The Administrator stated that while they attempt to have RN coverage daily, they sometimes rely on phone availability when an RN is not physically present. The facility has been actively advertising for the position, and a new RN has been hired to work every other weekend.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to destroy medications in a timely manner for several residents, as observed during a survey. Medications for seven residents were found in a storage room cabinet labeled 'To be destroyed,' including antipsychotics, antispasmodics, opioids, antihistamines, antiemetics, antidepressants, and antidiabetics. These medications had been discontinued but were not returned to the issuing pharmacy or destroyed as per the facility's policy. Interviews with the LPN and DON revealed a lack of awareness and responsibility regarding the medications' prolonged presence in the cabinet. Additionally, the survey identified expired medications and improperly stored medications on the facility's medication carts. An expired bottle of gas relief pills was found on the evening shift medication cart, and loose pills were observed on both the day and evening shift carts. The RN and DON acknowledged that maintaining the medication carts is a shared responsibility among staff, but there were no set days for checking the carts, leading to oversight and the presence of expired and loose medications. Interviews with the DON and the administrator highlighted a lack of consistent oversight and accountability for maintaining medication storage and carts. The DON stated that any CMT or nurse on the medication cart is responsible for its maintenance, while the administrator emphasized that the DON and charge nurses should ensure daily checks. However, both were unaware of the deficiencies found, indicating a gap in communication and adherence to the facility's medication management policies.
Lack of Qualified Nutrition Services Director
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Supervisor (DS), who had been in the position for about three years, had not completed the Certified Dietary Manager (CDM) course or any other dietary management training, despite being aware of the requirement. The DS quit without notice during the survey, leaving the housekeeping supervisor to assist in the kitchen. The facility's registered dietitian only worked as a consultant on a part-time basis, and there were no certified or clinically qualified nutritional staff employed full-time. This deficiency has the potential to affect all 60 residents of the facility.
Failure to Protect Resident Privacy
Penalty
Summary
Facility staff failed to maintain the confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to the public. Specifically, a registered nurse (RN) did not minimize or lock the computer screens on treatment carts when entering the rooms of two residents, resulting in their medical information being displayed. The RN acknowledged the oversight, attributing it to nervousness and a lapse in judgment. Additionally, medication carts on two different halls were observed unattended with computer screens open, displaying resident medication information. A licensed practical nurse (LPN) admitted to forgetting to close the screen, recognizing it as a privacy violation. The Director of Nursing (DON) and the facility administrator confirmed that computer screens should be locked when unattended to protect resident privacy, and they were unaware of staff leaving screens open.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a manner that is easily accessible to residents and visitors. The facility's policy mandates that the nurse staffing information should include the facility name, current date, total number, and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) per shift, along with the resident census. This information must be posted at the beginning of each shift in a prominent place. However, a review of the facility's Staff Hour Posting for July and August 2024 revealed significant omissions. In July, the census and actual hours worked were not documented for 28 out of 31 days, and in August, the census was missing for 19 out of 22 days, with actual hours not documented for all 22 days reviewed. Observations and interviews further highlighted the deficiency. On August 22, 2024, the nurse staff posting was observed to lack the total number of hours. Interviews with an LPN and the Director of Nursing (DON) confirmed that the postings were incomplete and not updated as required. The LPN acknowledged that the postings should include the total number of workers and actual hours worked, while the DON admitted awareness of the issue and stated that the night shift nurse is responsible for completing the staff hour posting. The administrator also confirmed that the charge nurse should update the staff posting at the beginning of each shift, but this was not being done consistently, leading to incomplete and inaccurate postings.
Infection Control Deficiency During Wound Care
Penalty
Summary
Facility staff failed to use appropriate infection control procedures during wound care for four residents, leading to a risk of spreading bacteria. The facility's policy on wound care and treatment, dated 03/2015, requires staff to wash their hands between glove changes and before and after wound care tasks. However, observations showed that an LPN did not follow these procedures. For Resident #1, the LPN did not perform hand hygiene between glove changes while providing wound care to the resident's left foot toe. Similarly, for Resident #2, the LPN did not wash hands between glove changes while treating a pressure ulcer on the resident's left heel. The same pattern was observed with Resident #3, where the LPN did not perform hand hygiene while treating a pressure ulcer on the resident's right ankle. For Resident #4, the LPN failed to wash hands before and after handling wound packing sponge and did not use gloves appropriately, leading to potential contamination of the wound care supplies. Interviews with the LPN and the Director of Nursing (DON) confirmed that the staff did not adhere to the facility's infection control policies. The LPN admitted to not performing hand hygiene due to nervousness and acknowledged the risk of spreading germs and infection. The DON and the facility administrator both stated that it is their expectation for staff to perform hand hygiene when entering and exiting a resident's room and between tasks during wound care. They also emphasized the importance of using gloves when handling wound care supplies to prevent infection control concerns.
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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