Aspire Senior Living Moberly
Inspection history, citations, penalties and survey trends for this long-term care facility in Moberly, Missouri.
- Location
- 700 East Urbandale Drive, Moberly, Missouri 65270
- CMS Provider Number
- 265407
- Inspections on file
- 16
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Aspire Senior Living Moberly during CMS and state inspections, most recent first.
After being notified by a structural engineer that the middle common area, including the nurses station and resident sitting area, was not structurally sound, the facility failed to restrict access, allowing residents, staff, and visitors to continue using the area. Staff and residents were observed in the unsafe area for several days, and communication lapses among the Administrator, maintenance, and the regional project manager contributed to the delay in implementing safety measures.
The facility did not provide an RN on duty for eight consecutive hours each day as required, with staffing records showing 15 days without RN coverage during a 32-day period. The staffing coordinator and DON were aware of the issue, which was attributed to a shortage of available RNs, and the administrator confirmed the facility was not meeting regulatory requirements.
A resident with severe cognitive impairment and behavioral symptoms was administered an antipsychotic medication by an LPN who was unaware of the medication's contents, after the medication had been prepared by another nurse and unsuccessfully offered by a CNA. The administration was not documented in the MAR, and there was no record of the resident's condition or the medication's effectiveness, contrary to facility policy requiring licensed staff to both administer and document medications.
A resident experienced increased depression due to an uncomfortable wheelchair, which was not addressed by staff, leading to feelings of abandonment and reduced participation in activities. Additionally, call lights were not within reach for three residents with cognitive impairments, preventing them from calling for help. The facility's leadership was unaware of these issues, contributing to the deficiencies.
The facility was found deficient in food safety and hygiene practices, including improper food labeling and storage, inadequate hair and beard restraints, and failure to follow handwashing and glove use protocols. Additionally, the walk-in cooler had debris buildup, and the ice machine lacked an air gap.
The facility failed to identify a disqualifying criminal offense in the background check of an employee, Housekeeper H, who had a previous conviction for first-degree burglary. Despite policies requiring criminal background checks, the Business Office Manager missed the offense, allowing the employee to continue working without a good cause waiver. Interviews revealed a breakdown in the hiring process, with the Director of Housekeeping and Administrator unaware of the disqualifying offense.
The facility failed to provide a meaningful activity program for several residents, including those with dementia and depression, as per their care plans. Residents were not engaged in activities at the required frequency, and observations showed they often remained in their rooms instead of participating in scheduled group activities. The facility did not adequately address barriers to participation, such as discomfort in wheelchairs, leading to a lack of engagement in meaningful activities.
The facility failed to provide adequate staffing in the memory care unit, leading to insufficient supervision and care for residents. Despite having a staffing plan, only one CNA was assigned to the unit, which was inadequate for the needs of the residents. Observations showed residents were left unattended, and there were no activities provided due to reduced staffing. The decision to decrease staffing was based on the overall facility census and budget constraints, resulting in a deficiency.
The facility failed to maintain residents' privacy by opening mail without permission. Two residents reported receiving opened mail, despite the facility's policy requiring mail to be delivered unopened unless requested otherwise. Interviews with staff confirmed the policy, but the mail was still opened, indicating a breach of protocol.
Two residents were subjected to physical restraints without proper documentation or medical justification. One resident was placed in a locked wheelchair against a dining table, preventing movement and left unattended, while another was reclined in a chair with a pommel cushion. Both lacked restraint assessments, consent, or documented interventions for safe use. Staff interviews revealed these measures were used to prevent falls, but no formal restraint policy was followed.
The facility failed to develop comprehensive care plans for two residents, leading to inadequate oral hygiene care. One resident, cognitively intact, required partial assistance but did not receive necessary dental care, resulting in plaque accumulation. Another resident, with moderate cognitive impairment, needed substantial assistance but only received oral care on shower days. The MDS Coordinator and DON acknowledged that care plans lacked specificity, contributing to these deficiencies.
Two residents requiring assistance with ADLs were not provided adequate oral hygiene care. One resident with hemiplegia had poor oral hygiene, with heavy plaque and gingivitis, and reported that staff did not regularly offer to brush his/her teeth. Another resident with dementia had teeth brushed only on shower days, leading to plaque buildup. Interviews with the DON and Administrator revealed that CNAs were expected to provide oral hygiene twice daily, but this was not consistently done.
A facility failed to ensure an approved indication for the use of psychotropic medications for a resident with dementia-related psychosis. The resident was prescribed risperidone, an antipsychotic contraindicated for dementia-related psychosis, without proper documentation of the root cause of behaviors or attempts at non-pharmacological interventions. The resident's dosage was increased after a single day of behavioral issues, without a comprehensive assessment or documentation of non-pharmacological interventions. The facility did not document education or consent from the resident's responsible party regarding the use of antipsychotic medication.
The facility failed to include required components in its arbitration agreements, affecting all residents. The agreements lacked statements that signing was not a condition for admission, did not allow communication with officials, and omitted a 30-day rescission period. Staff were unaware of these requirements.
Failure to Restrict Access to Structurally Unsound Common Area
Penalty
Summary
The facility failed to ensure a safe environment for all residents by not restricting access to a structurally unsound area after being notified by a structural engineer. On 8/22/25, the facility received a report from a structural engineer indicating that the middle common area, including the nurses station, sitting area, and access to multiple hallways and the dining room, was not structurally sound. The engineer explicitly advised that the area below the compromised framing should remain unoccupied until all deficiencies were addressed. Despite this, the facility continued to allow residents, staff, and visitors to access and occupy the area. Observations and interviews revealed that the area remained accessible and in use by residents and staff for several days after the engineer's warning. Staff were present at the nurses station, and residents were observed sitting in the main common area watching television, even though this area had visible cracks and sagging in the ceiling. Multiple staff members, including CNAs, LPNs, and the MDS Coordinator, confirmed that the area was only roped off with caution tape days after the initial warning, and even then, the tape was inconsistently maintained, allowing continued access to the unsafe area. Communication failures contributed to the deficiency. The Administrator did not review the engineer's report or contractor recommendations until several days after they were received, and the regional project manager assumed the Administrator had taken appropriate action without confirming. The maintenance director and other staff were aware of the structural concerns but did not ensure the area was fully restricted. As a result, the facility did not act promptly to protect residents, staff, and visitors from the identified structural hazard, leading to a determination of immediate jeopardy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours a day, seven days a week, as required by regulation and the facility's own policy. Review of posted staffing sheets over a 32-day period revealed that there was no RN coverage on 15 separate days. The facility census during this period was 70 residents. The facility's staffing plan called for eight RN hours per resident day on the day shift, but this was not met on multiple occasions. Interviews with the staffing coordinator, Director of Nursing (DON), and administrator confirmed awareness of the RN coverage issue. The staffing coordinator, responsible for scheduling, reported the lack of RN coverage to the administrator after the previous DON resigned and a new one was hired. The DON acknowledged the ongoing issue and attributed it to a shortage of available RNs. The administrator confirmed that the facility was not meeting the regulatory requirement for RN coverage and was unaware of the extent of the missed days until informed.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medication administration was performed according to professional standards of practice for one resident. Specifically, an LPN administered an antipsychotic medication that had been prepared by another nurse and was unaware of the contents of the medication cup at the time of administration. The medication was initially refused by the resident, and after a CNA was unsuccessful in administering it, the LPN administered the medication without verifying what it was. The LPN also failed to document the administration of the medication on the Medication Administration Record (MAR). The resident involved had severe cognitive impairment, a history of dementia with agitation, and was frequently agitated and resistive to care. The care plan indicated the resident could be forgetful, confused, and sometimes resistive, with behaviors worsening in the late afternoon and evening. The resident had recent medication changes, including as-needed orders for antipsychotic and antianxiety medications. Documentation was lacking regarding the resident's condition, behaviors, and the effectiveness of the medications administered, particularly for the as-needed antipsychotic medication. Facility policy required that medications be administered by licensed nurses or authorized staff, with the nurse who prepared the medication responsible for its administration and documentation. The policy also specified that CNAs were not permitted to administer medications. Despite this, the medication was passed between staff, including a CNA, before being administered by an LPN who did not know what the medication was. There was no documentation in the MAR or nurses' notes regarding the administration, the resident's condition, or the effectiveness of the medication at the relevant time.
Failure to Accommodate Resident Needs and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident who did not have a comfortable wheelchair, leading to increased depression symptoms. The resident, who had a history of osteoarthritis, anxiety disorder, depression, and legal blindness, reported that the wheelchair caused significant discomfort and pain, particularly in the back, hips, and shoulders. Despite expressing these concerns to staff, no action was taken to address the issue, resulting in the resident staying in bed, feeling abandoned, and unable to participate in activities or smoke as desired. Additionally, the facility did not ensure that call lights were within reach for three residents, all of whom had cognitive impairments and required assistance with activities of daily living. Observations showed that the call lights were placed out of reach, preventing these residents from being able to call for help when needed. Interviews with staff confirmed that the call lights were not consistently placed within reach, despite the facility's policy requiring it. The Director of Nursing and the Administrator were unaware of the specific issues related to the resident's wheelchair discomfort and the placement of call lights. The lack of awareness and action from the facility's leadership contributed to the ongoing deficiencies in accommodating the needs and preferences of the residents, as outlined in the facility's policies.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. Several food items in the refrigerator and walk-in cooler were either not dated, improperly sealed, or left open to air. This included containers of macaroni salad, pepper gravy, jelly, green beans, and cheese. Additionally, items such as potato chips and cheese puffs were not dated. These actions were in violation of the facility's policy on labeling and dating foods, which requires all stored foods to be properly labeled and dated. The facility also did not comply with its policy on hair restraints and hand hygiene. Dietary staff were observed not wearing appropriate hair and beard restraints while handling food, and one staff member's hair was not fully covered. Furthermore, staff failed to follow proper handwashing and glove use procedures. Instances were noted where staff did not wash hands before donning gloves, did not change gloves after touching non-food surfaces, and handled food with potentially contaminated gloves. These actions were contrary to the facility's policy, which mandates handwashing before and after glove use and changing gloves when contaminated. Additional deficiencies were noted in the maintenance of kitchen equipment. The walk-in cooler fan shrouds had a significant buildup of debris and rust, and the ice machine lacked an appropriate air gap, which is necessary to prevent contamination. The Maintenance Director was unaware of the requirement for an air gap. The Dietary Manager acknowledged the issues, noting that some container lids did not fit properly and that there was uncertainty about who was responsible for cleaning the fan shrouds.
Failure to Identify Disqualifying Criminal Offense in Employee Background Check
Penalty
Summary
The facility failed to identify a disqualifying criminal offense in the background check of an employee, Housekeeper H, who had a previous conviction for first-degree burglary, a class B felony. This oversight occurred despite the facility's policy requiring criminal background checks for all prospective employees and annual checks thereafter. The Business Office Manager (BOM) was responsible for reviewing these checks and was supposed to alert the administrator and relevant department heads if any disqualifying offenses were found. However, the BOM missed the criminal offense in both the initial and subsequent background checks, allowing the employee to continue working at the facility without a good cause waiver. Interviews with the BOM, Director of Housekeeping, and the Administrator revealed a breakdown in the facility's hiring process. The BOM admitted to seeing the employee's criminal background but could not explain how the offense was overlooked. The Director of Housekeeping relied on the BOM to flag any concerning background checks, and the Administrator was unaware of the employee's disqualifying offense. Despite having a system where at least two people reviewed background checks, the facility failed to prevent the hiring of an individual with a criminal history that should have disqualified them from employment, as per the facility's policy and state regulations.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to design a meaningful activity program to meet the needs and interests of six residents, as observed through a review of 24 sampled residents. The facility did not provide activities at a frequency consistent with the residents' plan of care and activity assessment. Specifically, three residents in the memory care unit did not receive a structured activities program focused on their individualized needs to keep them engaged in meaningful activities. Resident #3, diagnosed with Alzheimer's Disease, vascular dementia, major depressive disorder, and anxiety disorder, was not provided with the required frequency of activities as per their care plan. The resident's activity assessment indicated a preference for one-on-one activities three times a week, yet documentation showed a lack of consistent engagement in such activities. Observations revealed the resident often remained in their room, not participating in scheduled group activities like manicures and yoga. Resident #4, who is legally blind and suffers from anxiety and depression, also did not receive the necessary activities as outlined in their care plan. The resident expressed a preference for audio books and social interaction, yet the activity logs showed minimal engagement in meaningful activities. The resident's reluctance to participate in group activities due to discomfort in their wheelchair was noted, but the facility did not adequately address these barriers to ensure the resident's participation in activities.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to provide adequate staffing to monitor and care for residents in the memory care unit, which led to a deficiency. The facility was licensed for 120 beds, with 14 beds designated for dementia care. At the time of the survey, the facility had a census of 64 residents, with 10 residents in the locked dementia care unit. The staffing plan indicated that there should be five CNAs on both the day and evening shifts, and three CNAs on the night shift. However, only one CNA was assigned to the memory care unit during these shifts, which was insufficient to meet the needs of the residents. Observations and interviews revealed that the single CNA on duty was unable to adequately supervise and assist all residents. For instance, one CNA was observed leaving residents unattended in the dining area while assisting others with toileting and meals. Residents were seen wandering unsupervised, and there were no activities provided for them due to the reduced staffing. The CNA reported feeling overwhelmed and unable to keep up with the residents' needs, as most required assistance with toileting and were at risk of falling. The decision to reduce staffing was made by the facility's administration due to a decrease in the overall census and budget constraints. The Director of Nursing and the Administrator acknowledged the staffing reduction, which was based on the facility's census rather than the specific needs of the memory care unit. This reduction in staffing led to inadequate supervision and care for the residents, contributing to the deficiency identified during the survey.
Failure to Ensure Privacy in Resident Mail Delivery
Penalty
Summary
The facility failed to ensure residents' right to privacy in communication by opening personal mail without permission. Two residents reported receiving opened mail, with one resident mentioning a financial statement and the other personal mail. Neither resident had any restrictions on their mail nor had they given the facility permission to open it. The facility's policy, revised in May 2017, clearly states that residents are allowed to communicate privately and receive mail unopened unless they request assistance, which should be documented in their care plan. Interviews with facility staff, including the Social Services Director, Business Office Manager, and Activity Director, confirmed that mail should be delivered unopened unless requested otherwise by the resident. The staff involved in mail delivery, including activity staff and the business office manager, acknowledged this policy. However, the residents' mail was still opened, indicating a failure to adhere to the established protocol. The administrator also confirmed that the residents should have received their mail unopened and had no restrictions in place.
Failure to Document and Monitor Use of Physical Restraints
Penalty
Summary
The facility failed to provide documentation of a medical diagnosis that warranted the use of physical restraints for two residents, prior to their initiation, assessment, and monitoring. The facility did not document other interventions attempted or the consent of the residents or their representatives. Observations showed that Resident #50 was placed in a wheelchair with brakes locked against a dining table, preventing the resident from moving freely. The resident was left unattended for extended periods, with no staff present to monitor or assist, despite the resident's attempts to move and verbal expressions of discomfort. Resident #50 had a history of severe cognitive impairment, dementia, and unspecified mood disorder, requiring substantial assistance for daily activities. The resident's care plan indicated a high risk for falls and a need for assistance with transfers. However, there was no restraint assessment, consent, or documentation of interventions for the safe use of restraints in the resident's medical record. Staff interviews revealed that the resident's wheelchair was locked to prevent falls, but no formal restraint policy was followed. Similarly, Resident #22, who had severe cognitive impairment, dementia with behaviors, and Parkinson's disease, was observed in a recliner with feet elevated and a pommel cushion in a high-back wheelchair. The resident's medical record lacked a restraint assessment, consent, or documentation of interventions for safe restraint use. Staff interviews indicated that the resident was reclined to manage behaviors and prevent falls, but again, no formal restraint policy was adhered to. The Director of Nursing was unaware of the restraint practices being used and confirmed that the facility did not have any restraints in use at the time.
Deficiency in Person-Centered Care Planning for Oral Hygiene
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan specific to the needs of two residents, leading to deficiencies in oral hygiene care. Resident #42, who is cognitively intact and requires partial assistance for oral hygiene, was not provided with the necessary support for dental care as recommended by their dentist. Despite having a history of poor oral hygiene and dental extractions, the resident's care plan did not include specific interventions for oral hygiene, resulting in moderate plaque and debris accumulation. Similarly, Resident #36, who has moderate cognitive impairment and requires substantial assistance for oral hygiene, was not receiving adequate oral care. The resident's care plan failed to specify the need for assistance with oral hygiene, despite dental notes indicating poor oral hygiene and the need for teeth brushing twice daily. The resident reported that staff only brushed their teeth on shower days, which was insufficient to meet their dental care needs. Interviews with the MDS Coordinator and the Director of Nursing revealed that the care plans were not individualized to address specific ADL needs, such as oral hygiene. The MDS Coordinator was responsible for developing care plans based on brief interviews and records, but the plans only listed general ADL assistance without detailing specific needs. This lack of specificity in care plans contributed to the failure to provide adequate oral hygiene care for the residents.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for two residents, Resident #42 and Resident #36, who required assistance with activities of daily living (ADLs). Resident #42, who had hemiplegia and hemiparesis following a stroke, was observed to have poor oral hygiene with heavy plaque and calculus buildup, as well as marginal gingivitis. Despite being cognitively intact and requiring partial assistance for oral hygiene, the resident reported that staff did not offer to brush his/her teeth regularly, and observations confirmed that the resident's toothbrush was dry and unused. Dental notes consistently indicated poor oral hygiene and the need for staff assistance in brushing the resident's teeth twice daily. Resident #36, diagnosed with dementia and muscle weakness, also required substantial assistance for oral hygiene. The resident's care plan indicated the need for staff assistance with all ADLs, including oral hygiene. However, interviews with CNAs revealed that the resident's teeth were only brushed on shower days, which occurred twice a week. Observations and dental notes confirmed poor oral hygiene, with heavy plaque and calculus buildup, and the need for staff to brush the resident's teeth twice daily. Interviews with the Director of Nursing (DON) and the Administrator highlighted a lack of adherence to the facility's policy on oral hygiene care. The DON stated that staff should brush residents' teeth in the morning and evening, and the Administrator confirmed that CNAs were responsible for ensuring oral hygiene was offered and provided. Despite these expectations, the facility failed to ensure that the necessary oral hygiene care was consistently provided to the residents, leading to the observed deficiencies.
Failure to Ensure Approved Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure an approved indication for the use of psychotropic medications for a resident with dementia-related psychosis. The resident was prescribed risperidone, an antipsychotic medication contraindicated for dementia-related psychosis, without proper documentation of the root cause of behaviors or attempts at non-pharmacological interventions. The resident's dosage of risperidone was increased after a single day of behavioral issues, without a comprehensive assessment or documentation of non-pharmacological interventions. The facility's policy on antipsychotic medication use requires that such medications be prescribed only after identifying and addressing medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms. However, the resident's medical record lacked documentation of these assessments or any non-pharmacological interventions prior to the increase in medication. Additionally, the facility did not document any education or consent from the resident's responsible party regarding the use of antipsychotic medication. The resident's care plan did not include specific interventions for behaviors, and there was no documentation of monitoring for side effects or other behaviors beyond wandering. The facility's Director of Nursing acknowledged that the resident was on risperidone for unspecified psychosis, not dementia, but expected staff to follow the psychotropic drug use policy. The resident's responsible party reported not being informed of medication changes or behavioral issues, indicating a lack of communication from the facility.
Deficient Arbitration Agreement Components
Penalty
Summary
The facility failed to ensure that all required components of an arbitration agreement were included in their policy, affecting all 64 residents who had signed such agreements. The Admission Agreement Packet included an Alternative Dispute Resolution Addendum, which outlined procedures for mandatory non-binding mediation and arbitration. However, the arbitration agreement lacked critical components, such as a statement that signing the agreement was not a condition for admission or continued care, language allowing communication with federal, state, or local officials, and a clause allowing residents or their representatives to rescind the agreement within 30 days of signing. Interviews with the Social Services Director and the administrator revealed a lack of awareness regarding the specific language required in the arbitration agreement. The Social Services Director, responsible for obtaining signatures, was unaware of the 30-day rescission period and relied on corporate-produced agreements. Similarly, the administrator was unaware of the necessary components of the arbitration agreement until the survey date. This oversight resulted in all residents having signed agreements that did not meet regulatory requirements.
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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