Aspire Senior Living Roaring River
Inspection history, citations, penalties and survey trends for this long-term care facility in Cassville, Missouri.
- Location
- 812 Old Exeter Road, Cassville, Missouri 65625
- CMS Provider Number
- 265538
- Inspections on file
- 18
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aspire Senior Living Roaring River during CMS and state inspections, most recent first.
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.
The facility failed to provide and document wound care and weekly skin assessments according to physician orders and facility policy for multiple residents with venous wounds, surgical wounds, skin tears, and skin cancer excision sites. Policies required evidence-based wound treatments, weekly and as-needed wound assessments, and complete TAR documentation, but TARs for several residents showed multiple missing entries for ordered dressing changes and compression wraps, with no corresponding notes of refusals or alternative explanations. Observations found residents with undated leg wraps or facial wounds without bandages, while wound physician notes documented specific venous and other wounds that required ongoing care. Staff interviews, including with an LPN, RN, ADON, DON, and Administrator, confirmed that wound care was sometimes not completed or not charted, that weekly skin assessments were not consistently performed, and that if care was not documented it was considered not done.
Staff failed to consistently provide and document ordered pressure ulcer and wound care, as well as weekly skin and wound assessments, for multiple residents with stage 2–4 pressure injuries and other wounds. Despite policies requiring weekly assessments, detailed wound measurements, and documentation of each treatment, TARs showed numerous missing entries for daily and scheduled wound care, including complex regimens for sacral, ischial, stump, scrotal, coccyx, and posterior thigh wounds. Dressings were frequently found undated, and during observation a nurse acknowledged that wound care sometimes was not completed or charted due to other work demands. No nursing notes documented resident refusals or missed care, even when residents reported that wound care was sometimes not done, demonstrating a pattern of noncompliance with the facility’s own wound management and documentation standards.
Surveyors found that the DON, whose job description emphasized full-time leadership, oversight, regulatory compliance, and quality monitoring responsibilities, was frequently scheduled and working as a floor/charge nurse despite a census near 70. Review of assignment sheets showed the DON covering multiple day and night shifts as charge nurse over a short period, while interviews with an LPN, the ADON, the DON, and the Administrator confirmed that ongoing staffing shortages led the DON and ADON to work many hours on the floor. As a result, key DON and ADON duties such as audits of TARs, MARs, wound care, and CNA charting were not being completed, demonstrating that the DON was not functioning in a full-time administrative capacity as required when the census was 60 or more.
A resident with cognitive impairment and a pressure ulcer experienced a significant decline in wound condition, progressing from stage two to stage four with necrotic tissue. Although the physician was notified and new treatment orders were received, the resident's representative was not informed of the change until two days later, when the family was present at the bedside and requested hospital evaluation. Staff interviews confirmed that required notifications and documentation were not completed in a timely manner.
A resident with diabetes experienced multiple instances of elevated blood glucose levels above 500 mg/dL, but the facility staff failed to notify the physician or document insulin administration as required by the facility's protocol. Interviews revealed inconsistencies in staff understanding of the protocol, and the Director of Nursing confirmed the lack of documentation and adherence to physician orders.
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 Provide and Document Ordered Wound Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document wound care and weekly skin assessments according to physician orders, facility policy, and standards of practice for multiple residents with skin conditions and wounds. Facility policies required evidence-based wound treatments per physician orders, weekly and as-needed wound assessments, and complete documentation of wound characteristics and treatments on the TAR or in the electronic health record. Policies also required weekly skin assessments by licensed nurses, use of a weekly schedule for skin checks, and documentation of wound status each shift when no treatment was due. Interviews with nursing leadership and staff confirmed that if care was not documented, it was considered not done, and that there should not be blank spaces on the TAR. For one resident with diffuse traumatic brain injury, peripheral vascular disease, and dermatitis, the MDS showed severe cognitive impairment and risk for pressure injuries, and the care plan identified fragile skin and potential for skin impairment. This resident had physician orders for a light two-layer compression wrap to the left lower extremity, later revised to include cleansing with wound cleanser and continued compression wraps. The TAR for February showed multiple dates where these ordered treatments were not documented as completed, and there were no nursing notes indicating that wound care was not provided or was refused. The ADON’s wound measurement list contained no measurements for this resident, and no weekly skin assessment was documented, despite observations of undated wraps on both lower legs and subsequent wound physician notes describing bilateral stasis dermatitis and recommendations for doppler testing and continued wrapping. For another resident with CHF, an infected right lower extremity amputation stump, and an open wound on the right lower leg, the weekly skin observation documented multiple existing skin issues, including a wound vac to the right stump and ulcers and scabs on the left lower extremity and foot. The care plan required weekly skin assessments, wound treatments as ordered, and weekly skin audits by a licensed nurse. The wound care provider documented a skin tear on the left lateral calf present on admission, and the admission MDS showed the resident was cognitively intact, at risk for pressure injuries, and had open lesions and a surgical wound. Physician orders directed daily dressing changes to the left lower extremity and daily dressing changes to the right stump incision. The February TAR showed several days where these treatments were not documented as completed. The ADON’s wound measurement list showed an improved left calf wound, and observation with the wound physician and DON revealed undated bandages on the right stump and left lower leg, with the left leg wound improved and new orders initiated. A third resident with acute and chronic respiratory failure with hypoxia, COPD, and end stage renal disease had a quarterly MDS indicating cognitive intactness, risk for pressure injuries, and no open wounds at that time, with substantial to moderate assistance needed for ADLs. Later physician orders directed cleansing and dressing of venous wounds on both lower extremities three times per week and as needed, and then daily cleansing and skin prep to the right lower leg. The February TAR showed multiple dates where these ordered treatments were not documented as completed. Nursing progress notes contained no documentation of wound care not being provided or refused, and no weekly skin assessments were noted. Wound physician notes documented full-thickness venous wounds on both legs with specific measurements and no signs of infection, and later measurements showed changes in wound size. Observations showed the resident’s bilateral lower legs wrapped with undated gauze, and during wound rounds the DON removed undated dressings, revealing a scabbed right leg and a draining left leg wound. Another resident with COPD, CHF, cardiac arrhythmias, chronic kidney disease, and mitral insufficiency had a care plan identifying risk for impaired skin integrity and requiring weekly skin assessments and reporting of issues to the physician. Physician orders directed daily cleansing of facial sutures from a skin cancer excision with antibacterial soap and water, removal of crusts, and application of Bacitracin with a nonadherent dressing for two weeks on the evening shift. The February TAR showed that this treatment was documented on only two dates, with several ordered days lacking documentation. During an observation and interview, the resident reported recent skin cancer removal from the face and concern that staff were not treating and bandaging the area daily; at that time, the resident had no bandage on the face. The quarterly MDS indicated moderate cognitive impairment, open lesions requiring non-surgical dressings and ointments, and dependence on staff for transfers, bed mobility, and showers. Interviews with nursing staff and leadership confirmed systemic issues with completing and documenting wound care and weekly skin assessments. An LPN reported that residents had complained that wound care was not completed at times and that some days it was difficult to complete all resident care. An RN stated that nurses were responsible for weekly wound assessments using a binder schedule, that the TAR showed when wound care was due, and that if care was not charted it was considered not done; the RN would not expect to see gaps on the TAR without notes or handoff in report. The ADON acknowledged monitoring wound tracking, stated that dressings should be dated and documented on the TAR, and admitted that some days wound care was not charted even though he/she believed it was done, and that he/she had been doing most wound care until floor nurses took over. The DON stated that floor nurses complete weekly skin assessments, that TARs should always be completed including refusals, and that she had not been able to audit TARs weekly due to staffing issues. The Medical Director, primary care physician, wound physician, and Administrator all stated that staff were expected to follow physician orders and document care, and that if it was not documented, it was considered not done.
Failure to Provide and Document Ordered Pressure Ulcer Care and Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care and weekly skin and wound assessments in accordance with its own policies, physician orders, and accepted standards of practice for multiple residents with pressure injuries and other wounds. Facility policies required evidence‑based wound treatments per physician orders, weekly and as‑needed wound assessments with detailed measurements and descriptions, and documentation of each treatment or dressing status. Despite these requirements, treatment administration records (TARs), weekly skin observation tools, and nursing notes showed repeated gaps in documentation of ordered wound care and incomplete weekly skin assessments, with no corresponding documentation that care was refused or not provided. One resident with diabetes, neuropathy, osteomyelitis, a stage 4 sacral pressure ulcer, and other wounds had numerous wound care orders for the coccyx, right ischium, scrotum, and right stump that were not documented as completed on many ordered days across January and February. For example, daily wound care orders to cleanse and dress the coccyx and right ischium, and daily hydrocolloid paste to the scrotum, showed large numbers of days with no TAR documentation, and there were no nursing notes indicating refusals or missed care. Observations showed undated dressings on the coccyx, right ischium, and right stump, and a nurse stated that the stump bandage appeared unchanged since several days earlier and acknowledged that wound care sometimes did not get completed and was not charted due to other work. The DON and wound provider were also observed removing undated dressings and reapplying new dressings without dating them. Another resident with Arnold Chiari syndrome, spina bifida, paraplegia, and two stage 4 pressure ulcers to the sacrum and left ischium had daily wound care orders that were not documented on multiple days in January and February, including a period in February where documentation was missing on most ordered days after the treatment time was changed to afternoons. There were no progress notes indicating that wound care was refused or not provided. A cognitively intact resident with a stage 3 pressure ulcer on the posterior right thigh had an order for wound care three times weekly, yet TARs showed most ordered treatment days in January and February without documentation, and the bandage observed on the wound was dated several days prior; the DON again completed wound care without dating the new dressing. A resident with a stage 2 coccyx pressure ulcer had every‑other‑day and then nightly wound care orders with multiple undocumented treatment days, while weekly skin observation and wound physician notes documented the presence and progression of the coccyx wound. Across these residents, the facility’s own weekly skin assessment schedule and wound documentation policies were not consistently followed, as evidenced by missing weekly full‑body skin assessment details and repeated failures to document ordered wound treatments or dressing status. A further resident, identified as at risk for skin breakdown with significant medical comorbidities, was also included in the facility’s census of affected residents, though the excerpted report section ends before detailing that resident’s specific wound orders and documentation gaps. Overall, the survey findings show that for at least five residents with pressure ulcers or other wounds, staff did not ensure weekly skin and wound assessments were completed and documented, did not consistently date dressings, and did not consistently document completion of ordered wound care on the TARs, despite facility policies and care plans requiring weekly assessments, measurement of wound progress, and documentation of each treatment or dressing status.
DON Frequently Assigned as Charge Nurse Instead of Full-Time Administrative Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) worked full time in the DON role and did not function as a charge nurse when the facility’s average daily census was 60 or more residents. The facility census was 69–70 during the reviewed period. The DON job description outlined extensive leadership, oversight, regulatory compliance, quality monitoring, staff education, and interdisciplinary collaboration responsibilities, emphasizing that the DON is responsible for providing strategic direction and operational oversight to the nursing department and ensuring high-quality, resident-centered care. Review of the nursing schedules and Daily Assignment Sheets showed that the DON was scheduled and worked as a floor/charge nurse on multiple shifts despite the high census. Specifically, the DON was listed as charge nurse on night shift with a census of 70, and on several day and night shifts with censuses of 69–70, and was scheduled to work 5 shifts out of 9 days as a floor/charge nurse. Staff interviews corroborated that the DON was often filling in as a charge nurse. An LPN reported uncertainty about when the DON would have time to complete DON duties, indicating that the DON’s time was being diverted from administrative and oversight responsibilities to direct floor coverage. Further interviews with the Assistant Director of Nursing (ADON) and the DON confirmed that both the DON and ADON were frequently working as charge nurses due to staffing issues, including staff not showing up for scheduled shifts. The ADON stated she worked more than 40 hours per week, was often on the floor, and had not had time to complete audits on wound care and CNA charting. The DON reported working most weekends and one to two nights per week, sometimes staying through the morning meeting, and acknowledged that she had not had time to audit Treatment Administration Records (TARs) or Medication Administration Records (MARs) weekly because of her frequent floor assignments. The Administrator confirmed awareness that the DON was often working on the floor and expected that when she did so, she was the nurse in charge, further demonstrating that the DON was not functioning in a full-time administrative DON capacity as required when the census was 60 or more residents.
Failure to Timely Notify Resident Representative of Wound Decline
Penalty
Summary
The facility failed to promptly notify a resident's representative of a significant decline in the resident's wound condition. The resident, who was cognitively impaired and required substantial assistance with daily activities, had a history of a stage two pressure ulcer on the sacrum/coccyx upon admission. Over the course of the stay, the wound deteriorated from a stage two to a stage four pressure area with necrotic tissue, as documented by the Assistant Director of Nursing (ADON). Although the physician was notified and new treatment orders were received, there was no documentation that the resident's representative was informed of the change in the wound's condition or the new orders at the time the decline was identified. The facility's policy required prompt notification of the resident, physician, and representative in the event of significant changes in condition, including wound deterioration. Despite this, the resident's family was not informed of the wound's decline until two days after the deterioration was documented, when they were present at the bedside. At that time, the family requested the resident be sent to the emergency room for wound evaluation. Interviews with facility staff, including the ADON, LPN, DON, and Administrator, confirmed that the family was not notified of the wound's decline or new treatment orders until the family was physically present at the facility. Staff interviews revealed a lack of clarity and follow-through regarding notification responsibilities. The ADON admitted to not notifying the family when the wound began to decline or when new orders were received. The LPN and DON both stated that family notification and documentation are required when there are changes in a resident's wound condition. The Administrator was unaware that the family had not been notified until after the fact and stated an expectation for timely notification of both the physician and family in such situations.
Failure to Follow Physician Orders for Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders and document insulin administration for a resident with diabetes, leading to a deficiency in care. The resident, diagnosed with type 2 diabetes mellitus with hyperglycemia, had several instances where blood glucose readings exceeded 500 mg/dL. According to the facility's policy and physician orders, staff were required to notify the physician and document the insulin administered when blood glucose levels were above this threshold. On multiple occasions, including specific dates in October and November 2024, the resident's blood glucose levels were recorded above 500 mg/dL. However, staff failed to document any notification to the physician, the orders received, or the amount of insulin administered. Interviews with nursing staff revealed inconsistencies in their understanding and execution of the protocol for handling elevated blood glucose levels, with some staff indicating they would administer insulin without contacting the physician, contrary to the established protocol. The Director of Nursing and the Administrator confirmed that the expected procedure was not followed, as there was no documentation of physician notification or insulin administration for the elevated readings. This lack of documentation and adherence to physician orders represents a failure in providing care per standards of practice, as outlined in the facility's blood glucose monitoring policy.
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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