Avenir At Mark Twain
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeton, Missouri.
- Location
- 11988 Mark Twain Lane, Bridgeton, Missouri 63044
- CMS Provider Number
- 265236
- Inspections on file
- 29
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Avenir At Mark Twain during CMS and state inspections, most recent first.
A resident with multiple medical conditions experienced a fall after not locking their wheelchair. Nursing staff assessed the resident and notified the physician, but there was no documentation that the resident's representative was informed of the incident, contrary to facility protocol.
The facility did not consistently follow physician orders for blood glucose monitoring and failed to obtain or document parameters for physician notification for several residents with diabetes. In multiple cases, blood sugar checks were missed or out-of-range results were not reported to the physician as ordered, and staff practices varied when notification parameters were not specified.
A resident with multiple wounds and complex medical conditions was not thoroughly assessed or documented for surgical wounds upon admission and in subsequent weekly assessments, as required by facility policy. Key wounds were omitted from initial documentation, and wound tracking was delayed, with incomplete entries in the medical record and wound report. Staff interviews confirmed that expected assessment and documentation procedures were not followed.
A resident with multiple medical conditions and high risk for skin breakdown did not consistently receive ordered wound care, skin assessments, or use of heel protectors. Staff failed to complete and document weekly skin assessments, did not follow physician orders for compression wrap removal and wound dressing changes, and inconsistently recorded bathing and skin observations. The resident's skin was observed to be extremely dry, cracked, and bleeding, and staff interviews revealed confusion about treatment responsibilities and documentation.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility did not consistently provide meals that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing food options. Residents were observed receiving food that did not meet their individual dietary requirements or preferences.
The facility did not provide required documentation showing that CNAs received at least 12 hours of annual inservice training, with missing or incomplete records for several staff. The DON and Administrator confirmed the expectation for annual education, but stated that previous records may have been removed by a former DON, resulting in insufficient documentation for regulatory compliance.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A resident with full code status was found unresponsive and staff initiated but discontinued CPR before EMS arrived, with a significant delay in contacting 911. Staff were unclear on code status procedures, and some were not CPR certified. The facility also failed to ensure a CPR-certified staff member was present on multiple night shifts, contributing to inadequate emergency response.
A resident with severe cognitive impairment and a full code status was found unresponsive and CPR was initiated by two LPNs but stopped before EMS arrived, contrary to facility policy and physician orders. The incident, which met the criteria for alleged neglect, was not reported to the State Survey Agency within the required two-hour timeframe. The Administrator acknowledged the reporting failure, citing a misunderstanding about who was responsible for notifying authorities.
Three residents did not receive care in line with professional standards after falls and hospital transfers, as staff failed to complete required progress notes, post-fall follow-up, and notifications to physicians and families. Care plans were not updated with new interventions, and fall prevention indicators were missing, with vital signs and neuro checks not consistently documented as per facility policy.
A facility failed to ensure lab services were obtained as ordered by a physician for a resident with multiple health issues, including heart failure and diabetes. Despite physician orders for several lab tests due to the resident's confusion and agitation, there was no documentation that these tests were conducted or that the resident refused them. Interviews revealed that the nurse responsible for entering the orders did not ensure they were completed, and the lab confirmed the orders were not processed, leading to a deficiency.
The facility failed to report an allegation of staff-to-resident verbal abuse to DHSS within the required two-hour time frame. A resident overheard a staff member threatening another resident with physical harm and reported it to the Social Worker, who did not report the incident due to being busy with a respiratory outbreak.
A facility failed to investigate an allegation of verbal abuse reported by a resident, despite the facility's policy requiring immediate action. The Social Worker did not initiate an investigation, and the staff involved were not questioned or suspended until the surveyor's intervention.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and end stage renal failure requiring dialysis, was found on the bathroom floor after not locking their wheelchair. The resident was assessed by nursing staff, found to be stable, alert, and oriented, with no pain or neurological changes. Documentation showed that the medical doctor was notified, but there was no evidence that the resident's representative was informed of the incident. Interviews with nursing staff and facility leadership confirmed that the expected protocol was to notify the physician and the resident's representative after a fall and to document these notifications in the progress notes. However, the administrator acknowledged that there was no documentation to show the family had been notified following the fall, indicating a failure to follow the facility's notification procedures.
Failure to Follow Physician Orders and Obtain Notification Parameters for Blood Glucose Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician orders related to blood glucose monitoring and physician notification for residents with diabetes. For one resident, there were multiple instances where blood sugar readings exceeded 300 mg/dl, as specified in the physician's sliding scale insulin order, but there was no documentation that the physician was notified as required. The Assistant Director of Nursing confirmed the lack of documentation for physician notification when blood sugars were outside the ordered parameters. Another resident had physician orders for blood glucose monitoring before each meal and a sliding scale for insulin administration, including instructions to notify the physician if blood sugar exceeded 350 mg/dl. However, documentation showed that blood glucose checks were not completed before supper, and there was no evidence that the physician order was changed to reflect this omission. The Assistant Director of Nursing stated that staff were expected to complete blood sugar checks before each meal as ordered. A third resident had an order for insulin administration before meals but lacked specific parameters for when to notify the physician of out-of-range blood glucose levels. On one occasion, the resident's blood sugar was documented as hypoglycemic at 57 mg/dl, and insulin was administered, but there was no documentation that the physician was notified. Interviews with nursing staff revealed inconsistent practices regarding when to notify the physician in the absence of specific parameters, and the Assistant Director of Nursing and Administrator both indicated that perimeter orders should be obtained and physician orders followed.
Failure to Accurately Assess and Document Surgical Wounds on Admission and Weekly
Penalty
Summary
The facility failed to thoroughly and accurately assess and document a resident's surgical wounds upon admission and then weekly, as required by facility policy. Specifically, the admission skin assessment did not include all wounds present, omitting the wound on the resident's left thumb and failing to provide a description of the wound on the left hand. Additionally, there was no admission note documented in the progress notes, and the care plan in use at the time of the survey did not reflect the wounds on the resident's left hand. The wound was not included in the facility's wound report for two consecutive weeks, and there was no wound documentation in the medical record until several weeks after admission. The resident involved had multiple diagnoses, including an open wound of the left hand, cellulitis of the left finger, abscess of the left hand, and diabetes, and required surgical wound care. Interviews with staff confirmed that wound assessments and documentation were expected to be completed on admission and weekly thereafter, including details such as location, size, drainage, odor, and surrounding tissue. However, these assessments and documentation were not completed as required, resulting in incomplete and delayed wound tracking for the resident.
Failure to Provide and Document Ordered Wound Care and Skin Assessments
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards for a resident with significant skin integrity issues. The staff did not consistently administer treatments as ordered for non-pressure wounds, failed to complete comprehensive skin assessments on a routine basis, and did not reassess the efficacy of treatments for ongoing skin problems. Documentation was incomplete or missing for weekly skin assessments, and there was a lack of follow-through on physician orders for wound care, application of creams, and use of heel protectors. Staff also failed to accurately document the administration of treatments, sometimes marking them as completed when they were not actually provided. The resident involved had multiple complex medical conditions, including paraplegia, morbid obesity, amputation, kidney failure, and osteomyelitis, and was at high risk for pressure ulcers and other skin breakdown. The resident was dependent on staff for mobility, hygiene, and wound care. Observations revealed that the resident's compression wraps were not being removed at night as required, heel protectors were not in place, and wound dressings were not changed according to schedule. The resident's skin was noted to be extremely dry, cracked, and in some areas bleeding, indicating that current treatments were not effective. Staff interviews confirmed a lack of clarity regarding treatment responsibilities and documentation procedures. Further review showed that shower and bed bath documentation was inconsistent, with missing or incomplete records of skin assessments during these activities. Staff were unsure about the use of certain lotions and the availability of bariatric shower chairs, despite one being present in the facility. The wound nurse and other staff acknowledged that skin assessments and treatments were not always completed as ordered, and that communication and documentation lapses contributed to the deficiencies. The facility's policies required regular skin assessments, accurate documentation, and adherence to physician orders, but these were not consistently followed.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options. This deficiency was identified based on observations that the facility did not consistently provide meals tailored to individual dietary needs and preferences, as required. The report notes that residents were not always offered food choices that considered their specific allergies or intolerances, nor were the meals always presented in an appealing manner.
Lack of Documentation for CNA Annual Inservice Training
Penalty
Summary
The facility failed to provide documentation of ongoing educational training for active Certified Nursing Aides (CNAs), as required by regulation, which mandates at least 12 hours of education per year. Record review showed that for four of six sampled active CNAs, there was insufficient or no documentation of completed inservice training for the required period. Specifically, some CNAs only had records of inservices from January 2025 onward, with no documentation for prior months, while others had no record of inservices for the past year from their hire date. The sample included 18 CNAs, and the facility census was 75.1. During interviews, the DON stated she was unable to locate annual education logs for four of the six sampled CNAs and did not have access to any annual training records completed before January 2025. The DON and Administrator both acknowledged that all CNAs are expected to receive 12 hours of ongoing education annually. It was reported that the previous DON may have taken inservice records and education documentation upon resigning, contributing to the lack of available documentation.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. No further details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Provide Timely and Appropriate CPR and Maintain CPR-Certified Staff
Penalty
Summary
The facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive and without a pulse. The resident had a full code status, as documented in the care plan and physician orders, and had expressed a clear desire to be resuscitated in the event of cardiac arrest. When the resident was discovered unresponsive, staff initiated CPR but discontinued efforts before emergency medical services (EMS) arrived. There was a significant delay in contacting EMS, with over an hour passing between the time the resident was found without a pulse and the time 911 was called. During this period, staff made phone calls to the family and physician, and CPR was not in progress when EMS arrived on the scene. Interviews with staff revealed confusion and lack of knowledge regarding code status determination and CPR procedures. Certified Nurse Aides (CNAs) on duty did not know how to access or determine a resident's code status, and some staff members involved in the event were not CPR certified. There were inconsistencies in staff accounts regarding who performed CPR, for how long, and whether appropriate equipment such as a backboard or ambu bag was used. Documentation and interviews indicated that CPR was stopped based on staff judgment rather than the arrival of EMS or a qualified medical professional pronouncing death, which was contrary to facility policy and standard practice. Additionally, a review of staffing records showed that the facility failed to ensure the presence of at least one CPR-certified staff member on 14 night shifts within a 30-day period, despite having a significant number of residents with full code status. The staffing coordinator was unaware of the requirement to have CPR-certified staff on each shift and did not maintain an updated list of staff CPR certifications. Human Resources did not provide the staffing coordinator with information on which staff were CPR certified, and there was no system in place to identify CPR-certified staff on staffing sheets. This lack of oversight contributed to the deficiency in providing timely and appropriate life-saving measures.
Failure to Timely Report Alleged Neglect After CPR Was Stopped Before EMS Arrival
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency. The incident involved a resident with severe cognitive impairment, lower extremity impairment, and diagnoses including COPD, emphysema, and dependence on supplemental oxygen. The resident was designated as a full code, with physician orders and care plan interventions specifying immediate initiation of CPR and calling 911 in the event of cardiac arrest. On the day of the incident, an LPN found the resident unresponsive and cold to the touch. The LPN, along with another nurse, attempted resuscitation per protocol but determined the resident had no heartbeat or oxygenation and ceased CPR before EMS arrived. The LPN notified the resident's family and physician, and subsequently called 911. Administration was notified early after the incident and assisted with contacts. However, CPR was not continued until EMS arrival, as required by facility policy and the resident's code status. The Administrator acknowledged during interviews that the incident should have been reported to the state as neglect within two hours, as stopping CPR prior to EMS arrival constituted a failure to follow physician orders and facility policy. The Administrator did not report the incident, stating that the Assistant Fire Chief indicated he would report it to the hotline. The facility's policies require immediate reporting of all alleged violations involving neglect, but this was not followed in this case.
Failure to Document and Follow Post-Fall Protocols and Notifications
Penalty
Summary
The facility failed to ensure that three residents received care in accordance with professional standards and facility policies following falls and hospital transfers. Specifically, staff did not complete required progress notes after residents experienced falls, were sent to the hospital, or returned from the hospital. There was also a lack of documentation regarding notifications to physicians and family members when these incidents occurred. Additionally, the facility did not consistently complete post-fall follow-up for 72 hours, which should have included progress notes per shift, vital signs monitoring, and neurological checks as outlined in facility protocols. For one resident, there was no documentation of the fall, notifications to the physician or emergency contact, or the resident being sent to or returning from the hospital. The care plan was not updated with appropriate interventions, and required fall prevention signage was missing from the resident's room. Vital signs were not monitored or documented for 72 hours post-fall. Another resident, who had severe cognitive impairment and was dependent on staff for most activities, also lacked documentation of family notification after a fall, and there was a missing neurological assessment entry. The care plan did not include interventions for the most recent fall. A third resident, identified as high risk for falls, had no progress notes regarding a fall or notification to the physician. There was also no documentation of post-fall follow-up notes for several shifts, and fall prevention indicators were not present in the resident's room. Across all three cases, the facility did not adhere to its own fall prevention, clinical protocol, and notification of changes policies, resulting in incomplete assessments, lack of care plan updates, and insufficient communication with medical providers and families.
Failure to Obtain Ordered Lab Services for Resident
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring that laboratory services were obtained as per physician orders for one resident. The resident, who was cognitively intact, had multiple diagnoses including heart failure, high blood pressure, diabetes, and COPD. On a specific date, the physician ordered several lab tests, including a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and others, due to the resident's confusion and agitation. However, there was no documentation that these labs were drawn, nor was there evidence that the resident refused the blood draw or that the family was notified of the new orders. The progress notes indicated attempts to obtain a urine sample through catheterization, but there was no success until several days later. Despite the physician's orders, the facility did not follow up with the lab to ensure the tests were conducted. The lab representative confirmed that the facility was responsible for entering lab orders into the computer system, and the phlebotomist would check for these orders during routine visits. However, the lab did not have records of the orders being entered for the specified period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the nurse who obtained the order was responsible for entering it into the system. The DON acknowledged that the lab orders might have been overlooked or the resident might have refused the blood draw, but there was no documentation to confirm this. The lab admitted to not drawing the labs, and the facility did not have a system in place to verify the completion of lab orders, leading to the deficiency.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. Resident #1 overheard a staff member threatening Resident #2 with physical harm if the resident pinched the staff member again. The incident occurred in the shared bathroom of the two residents. Resident #1 reported the incident to the Social Worker (SW) on 4/4/24, but the SW did not report the allegation to DHSS as required. The SW admitted to not reporting the incident due to being busy with a respiratory outbreak in the facility. Resident #1, who is able to make needs and wants known, has diagnoses including chronic pain, anxiety, and depressive disorder. Resident #2, who can make some needs and wants known, has diagnoses including diabetes, dementia with behavioral disturbances and agitation, depression, and muscle weakness, and requires moderate to total assistance with daily care needs. The Administrator confirmed that the SW should have reported the allegation to DHSS immediately upon receiving the report from Resident #1.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to follow its policy to investigate an allegation of verbal abuse between a Certified Nurse Aide (CNA) and a resident. The incident was reported by another resident who overheard the alleged abuse from a shared bathroom. Despite the report being made to the facility's Social Worker (SW), no investigation was initiated, and the allegation was not taken seriously. The SW admitted to not starting an investigation due to being busy with a respiratory outbreak in the facility. The resident who reported the incident described the staff member based on their voice and physical appearance. The description matched CNA A, who frequently cared for the resident involved in the alleged abuse. However, neither the Assistant Director of Nursing (ADON) nor the Director of Nursing (DON) were aware of the allegation until informed by the surveyor. The staff involved had not been interviewed or suspended as per the facility's abuse prohibition policy. Interviews with other staff members, including Licensed Practical Nurse (LPN) C and CNA B, revealed that they were not questioned about the incident, and no witness statements were taken. The Administrator confirmed that the SW should have started the investigation immediately upon receiving the report. The facility only began the investigation and took necessary actions after the surveyor's intervention.
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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