Brooke Haven Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in West Plains, Missouri.
- Location
- 1410 North Kentucky Avenue, West Plains, Missouri 65775
- CMS Provider Number
- 265400
- Inspections on file
- 25
- Latest survey
- December 6, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brooke Haven Healthcare during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and poor safety awareness received a second-degree burn from spilled hot coffee after a CNA handed them a cup without a lid, contrary to their care plan. The incident was not promptly communicated to the wound physician, delaying appropriate medical intervention. The facility failed to conduct daily follow-up skin assessments, and a prescribed treatment was unavailable due to an allergy, contributing to inadequate wound care.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, risking cross-contamination and food-borne illness for all 69 residents. Observations showed unlabeled food bins, carbon build-up on equipment, and debris on floors. The walk-in freezer and refrigerator had significant build-up and debris, and the dry storage room contained undated and improperly stored food items. Staff interviews confirmed the absence of cleaning schedules and logs, and the dishwasher had been out of service for over a month.
The facility did not maintain a surety bond at the required level for residents' personal funds. The bond was $100,000, but the average monthly balance required a bond of at least $103,500. Both the Business Office Manager and the Administrator acknowledged the regulatory requirement, and the facility lacked a policy for the surety bond.
A facility failed to administer the correct insulin dosage to a diabetic resident due to a misreading of blood sugar levels by an RN, resulting in the administration of 14 units instead of the required 18 units. Additionally, the facility did not follow an RD's recommendation to reduce the enteral feed rate for a resident with cerebral palsy, leading to continued weight gain.
The facility failed to complete comprehensive discharge summaries for two residents who were discharged home. Both residents' closed medical records lacked documentation of a recapitulation or completed discharge summary. The Administrator and DON indicated that the discharging nurse was responsible for completing these summaries prior to discharge, but the facility did not provide a policy regarding this process.
A resident's urinary catheter drainage bag was improperly positioned, lying on the floor or touching a wheelchair wheel, contrary to facility policy. Staff interviews confirmed the bag should be hung below the bladder and off the floor, highlighting a lapse in catheter care adherence.
The facility failed to follow physician's orders for oxygen therapy for two residents and did not ensure proper tracheostomy care for a resident with a tracheostomy. A resident with COPD received oxygen at 4 liters per minute instead of the prescribed 2 liters. Another resident performed self-tracheostomy care without following aseptic techniques, using tap water instead of sterile water, and not inserting the inner cannula. The facility lacked a specific oxygen policy and did not document the resident's competency for tracheostomy cleaning.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan did not address PTSD or include goals and interventions for mental health support. The resident, diagnosed with PTSD, depression, and anxiety, expressed experiencing symptoms and triggers, but the facility lacked a PTSD policy and did not document past trauma or triggers in the care plan.
The facility failed to post the required daily nurse staffing information for three consecutive days, affecting the transparency of staffing levels for residents and visitors. The Staff Posting Sheet was outdated, and the facility lacked a policy on posting nurse staffing information. The Administrator and DON acknowledged the requirement for daily postings.
The facility failed to ensure accurate narcotic reconciliations for two residents, leading to discrepancies in narcotic counts. The narcotic medications were not documented accurately by staff, resulting in mismatches between recorded and actual counts. Interviews revealed that a nurse administered medication without signing it out in the narcotic book, and the CMT was unsure about another discrepancy. The DON and Administrator emphasized the importance of documenting narcotic administration properly.
The facility failed to limit PRN orders for psychotropic medications to 14 days, did not attempt gradual dose reductions for antipsychotic medications, and lacked appropriate diagnoses for the use of Seroquel in two residents. Interviews revealed a lack of responsibility for auditing chart orders, relying instead on a consultant pharmacist for reviews.
The facility failed to properly label and store medications, with opened insulin pens found undated and medication carts left unlocked and unattended. A resident was left with medication unattended in their room, contrary to facility policy. Staff interviews confirmed the need for proper labeling and secure storage, but these practices were not followed.
The facility failed to maintain the dumpster properly, as observed on multiple occasions with its lids left open, potentially affecting all 69 residents. Despite staff training to keep the dumpster closed when not in use, interviews with the Administrator and Assistant Maintenance Director confirmed that the lids were not consistently closed.
The facility failed to maintain proper infection control practices during wound, incontinence, and catheter care for several residents. Staff did not change gloves or perform hand hygiene as required, and glucometers were not properly disinfected between uses. Additionally, Enhanced Barrier Precautions were not followed during high-contact care activities.
The facility did not maintain an effective antibiotic stewardship program as required by its policy. Despite having a program in place, there was no documentation of antibiotic stewardship tracking. The Infection Preventionist reviewed antibiotic orders and ensured they met criteria, but the information was only discussed in monthly QAPI meetings without proper documentation. This deficiency had the potential to affect all residents, with one resident currently receiving antibiotics.
The facility failed to follow professional standards of practice for a resident with severe infections, leading to a deficiency in care. The resident was admitted without timely treatment orders for a wound, and several doses of prescribed antibiotics were missed without documentation. Interviews with staff revealed that the facility did not adhere to its policies on admission assessment, wound care, and medication administration.
Resident Burned Due to Inadequate Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to provide a safe environment for a resident with severe cognitive impairment, resulting in the resident receiving a second-degree burn from spilled hot coffee. The resident, who had diagnoses of non-traumatic brain injury, dementia, and anxiety, was dependent on staff for all activities of daily living and had poor safety awareness. Despite being care planned to use a spill-proof cup with a lid and straw, a CNA unfamiliar with the resident handed them a regular coffee cup without a lid, leading to the spill and subsequent burn. The incident report indicated that the CNAs and nurse immediately changed the resident and assessed the site, initially finding no redness or open areas. However, a large blister developed later, which was not promptly communicated to the wound physician. The physician was not informed of the burn until a week later, which delayed appropriate medical assessment and intervention. The facility's documentation lacked follow-up skin assessments after the initial incident, which should have been conducted daily to monitor the injury's progression. The facility's Director of Nursing acknowledged that the prescribed silvadene cream was not available due to the resident's sulfa allergy, and the pharmacy did not fill the prescription. This oversight contributed to the delay in appropriate wound care. The wound physician expressed concern over the delayed notification and the potential complications due to the resident's fragile state. The incident highlights a breakdown in communication and adherence to care plans, resulting in inadequate supervision and response to the resident's needs.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, which increased the risk of cross-contamination and food-borne illness for all 69 residents. Observations revealed multiple issues, including the absence of cleaning logs, unlabeled food bins, and significant carbon build-up on kitchen equipment. The kitchen's metal backsplash, can opener, and various cooking surfaces were found with oily films and carbon deposits. Additionally, the air conditioning diffuser and the floor beneath kitchen appliances were covered in dust, grime, and debris. The walk-in freezer had a significant frost build-up, and the walk-in refrigerator contained liquid and food debris on the floor, along with grime on the walls and ventilation louvers. In the dry food storage room, numerous food items were undated and unlabeled, and some were stored in containers with expired dates. Disposable bowls and paper towels were improperly stored on the floor, and food debris was scattered along the walls. Interviews with dietary staff and the administrator confirmed the lack of cleaning schedules and logs, and acknowledged the need for improvements in food labeling and storage practices. The dishwasher had been out of service for over a month, contributing to the unsanitary conditions, and a repair was delayed due to a part being specially made.
Failure to Maintain Adequate Surety Bond for Residents' Personal Funds
Penalty
Summary
The facility failed to maintain a surety bond for the security of residents' personal funds at the required level. The bond amount was supposed to be at least one and one-half times the average monthly balance of the residents' personal funds over the last twelve months. The facility's current bond was $100,000, while the average monthly balance of the residents' personal funds was $68,621.10, necessitating a bond of at least $103,500. During interviews, both the Business Office Manager and the Administrator acknowledged that the surety bond should be one and one-half times the residents' trust balance to meet regulatory requirements. Additionally, the facility did not provide a policy for the surety bond.
Insulin Administration Error and RD Recommendations Not Followed
Penalty
Summary
The facility failed to administer the correct amount of insulin to a resident diagnosed with diabetes mellitus. The resident's Physician Order Sheet specified a sliding scale for insulin administration based on blood sugar levels. On a specific date, a Registered Nurse (RN) documented the resident's blood sugar as 425, which required 18 units of insulin according to the sliding scale. However, the RN mistakenly administered only 14 units of insulin, believing the blood sugar level was 373. This error occurred because the RN misread the documented blood sugar level on a piece of paper and did not verify it in the electronic record. Additionally, the facility did not follow the Registered Dietician's (RD) recommendations for another resident diagnosed with cerebral palsy. The RD suggested reducing the resident's enteral feed rate to stabilize weight gain, as the resident had gained 20 pounds over six months. Despite this recommendation, the facility continued the existing feeding regimen without making the suggested adjustments. The facility's failure to implement the RD's recommendations contributed to the resident's continued weight gain.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for two residents who were discharged home. Resident #58 was discharged on 11/25/24, and Resident #66 was discharged on 09/19/24. In both cases, there was no documentation of a recapitulation or a completed discharge summary in their closed medical records. During an interview, the Administrator and Director of Nursing stated that the discharging nurse was responsible for completing the discharge summary, which should have been completed prior to the discharge of the residents. The facility did not provide a policy regarding a discharge summary or recapitulation.
Improper Catheter Care Observed
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, as the catheter drainage bag and tubing were observed to be improperly positioned. The drainage bag was found lying on the floor between the bed frame and a wheelchair, contrary to the facility's policy which mandates that the catheter tubing and drainage bag be kept off the floor. This was observed on multiple occasions, with the drainage bag either lying on the floor or touching the wheel of a wheelchair, despite having a privacy cover in place. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the catheter drainage bag should be hung below the bladder and off the floor, ideally on a non-moving part of the bed frame. The staff acknowledged that the drainage bag and tubing should not be in contact with the floor or any movable objects like wheelchair wheels. The deficiency was identified through observations and interviews, highlighting a lapse in adherence to the facility's catheter care policy.
Failure to Follow Physician's Orders and Ensure Proper Tracheostomy Care
Penalty
Summary
The facility failed to adhere to physician's orders for supplemental oxygen therapy for two residents and did not ensure proper tracheostomy care for one resident. Resident #39, diagnosed with malignant neoplasm of the supraglottis and having a tracheostomy, was observed performing self-care of the tracheostomy without following aseptic techniques. The resident used tap water instead of sterile water for cleaning, did not change gloves or perform hand hygiene during the procedure, and did not insert the inner cannula of the tracheostomy. The resident expressed difficulty breathing with the inner cannula in place, which was corroborated by an LPN who noted the resident sometimes removed it for comfort. Resident #62, diagnosed with chronic obstructive pulmonary disease, had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. However, the resident was observed receiving oxygen at 4 liters per minute, which was not in accordance with the physician's order. The DON confirmed that the oxygen order should have been followed as prescribed. The facility lacked a specific oxygen policy and did not document Resident #39's competency for tracheostomy cleaning. The DON stated that competency checks for tracheostomy care were conducted twice a year, but the resident's self-care did not align with the facility's tracheostomy care policy, which required sterile techniques and proper documentation of the procedure and the resident's response.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's medical record indicated a diagnosis of PTSD, depression, and anxiety disorder, with a Trauma Informed Care Assessment showing the resident was triggered for PTSD. Despite this, the comprehensive care plan did not address PTSD, lacked goals for maintaining the resident's psychosocial and mental health, and did not document the resident's past trauma or any triggers that could cause trauma. Additionally, there were no interventions outlined for addressing behaviors if they occurred or for providing support to the resident. During an observation and interview, the resident expressed experiencing PTSD symptoms, including replaying traumatic images and being triggered by a train whistle. The resident was tearful and spoke with a quivering voice about past trauma. The facility's administrator acknowledged that PTSD should be addressed in the care plan, and the Social Service Designee noted that the resident had recently started discussing their PTSD. However, the facility did not have a PTSD policy in place, contributing to the deficiency in care for the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care. This deficiency was observed for three out of four days, with the facility census being 69. Observations on specific dates revealed that the Staff Posting Sheet was outdated, showing a date of 12/02/24, and the required information was not posted for 12/04/24, 12/05/24, and 12/06/24. During an interview, the Administrator and Director of Nursing acknowledged that nurse staffing should be posted daily on the Nurse Staffing board. Additionally, the facility did not provide a policy regarding the posting of nurse staffing information.
Inaccurate Narcotic Reconciliation for Two Residents
Penalty
Summary
The facility failed to ensure accurate narcotic reconciliations for two residents, leading to discrepancies in narcotic counts. Specifically, the narcotic medications for two residents were not documented accurately by the on-coming and off-going staff. For one resident, the hydrocodone count was recorded as 22 tablets, but only 20 tablets were found in the medication cart. For another resident, the eszopichlone count was recorded as seven tablets, but only six tablets were found in the medication cart. The staff did not document the administration of these medications on the Controlled Drug Receipt-Record Disposition forms. Interviews revealed that the night nurse administered the eszopichlone but failed to sign it out in the narcotic book, although it was signed on the resident's MAR. The Certified Medication Technician (CMT) was unsure about the discrepancy in the hydrocodone count but mentioned that they counted the narcotics at the start and end of their shift, even if it was with themselves. The Director of Nursing and the Administrator stated that staff should always make time to perform narcotic counts during shift changes and document the administration of narcotic medications on both the MAR and the narcotic book.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the use of psychotropic medications for several residents. For one resident, the facility did not limit the use of a PRN order for clonazepam to 14 days, as required. This resident had a diagnosis of dementia and was prescribed clonazepam for agitation without a stop date. Additionally, the facility did not attempt a gradual dose reduction (GDR) for another resident who was prescribed Rexulti, an antipsychotic medication, despite the manufacturer's warning about increased mortality in elderly patients with dementia-related psychosis. This resident had diagnoses of unspecified dementia and major depressive disorder. Furthermore, the facility failed to ensure appropriate diagnoses for the use of Seroquel, an antipsychotic medication, for two residents. One resident was prescribed Seroquel for a cognitive communication deficit, and another for dementia, without documentation of an appropriate diagnosis. The manufacturer's safety information for Seroquel indicates it is not approved for elderly patients with dementia-related psychosis. Interviews with facility staff revealed that there was no designated responsibility for auditing chart orders for appropriate diagnoses, and the facility relied on a consultant pharmacist for monthly medication reviews.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to label and store medications properly, as evidenced by the presence of opened insulin pens that were not dated in the medication cart. This included Lantus, Fiasp, and lispro insulin pens, which should have been discarded 28 days after opening according to the manufacturer's recommendations. Additionally, the medication cart was observed to be unlocked and unattended on multiple occasions, with staff and residents passing by, creating a potential risk for unauthorized access to medications. In one instance, a resident was left with medication unattended in their room. The resident had a physician's order for diltiazem ER and gabapentin, which were left on the bedside table in a medication cup. The resident reported not having water to take the medication, which was later confirmed by a housekeeper who found the medication still on the table. The Certified Medication Technician responsible for administering the medication admitted to leaving it with the resident, contrary to the facility's policy that requires staff to watch residents take their medication. Interviews with staff, including LPNs and the Director of Nursing, confirmed that insulin pens should be dated when opened and that medication carts should be locked when unattended. The facility's policies on medication storage and administration were not adhered to, as evidenced by the unlocked medication carts and the failure to date insulin pens. The facility did not provide a policy regarding the storage of medications in a resident's room, further highlighting the lack of adherence to safe medication practices.
Improper Dumpster Maintenance
Penalty
Summary
The facility failed to maintain the dumpster in a manner that would prevent pests and ensure garbage containment, potentially affecting all 69 residents. Observations on three separate occasions revealed that the dumpster, located near the kitchen entrance, had its two plastic lids completely open. Interviews with the Administrator and the Assistant Maintenance Director confirmed that the dumpster should be closed when not in use, and staff had been trained to do so. However, it was noted that the lids were not consistently closed, indicating a lapse in adherence to the expected protocol.
Infection Control Deficiencies in Wound, Incontinence, and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care, incontinence care, and Foley catheter care for several residents. Specifically, during wound care for Resident #21, the RN did not change gloves or perform hand hygiene after removing the old dressing and before applying a new dressing. Additionally, the Xeroform dressing was placed on a non-sterile towel before being applied to the wound, which was against the semi-sterile procedure expected for such care. Similarly, during wound care for Resident #36, the LPN did not wear a gown as required under Enhanced Barrier Precautions (EBP). Incontinence care for Residents #9 and #60 was also performed without proper hand hygiene and glove changes. CNAs involved in the care did not change gloves or perform hand hygiene after cleaning soiled areas and before touching clean items or the resident's environment. This lack of adherence to hand hygiene protocols was further observed during catheter care for Resident #32, where gloves were not changed after cleaning the peri area and before touching other items. The facility also failed to properly disinfect glucometers between uses for Residents #62, #118, and #119. The RN used an alcohol pad instead of the manufacturer-recommended Sani wipes to disinfect the glucometer, which was insufficient for proper disinfection. Interviews with staff, including the Administrator and DON, revealed a lack of understanding and adherence to the facility's infection control policies, particularly regarding the use of EBP and proper hand hygiene practices.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program. The facility's policy, revised in December 2016, required antibiotics to be prescribed and administered under the guidance of the Antibiotic Stewardship Program, which aimed to monitor antibiotic use among residents. However, a review of the program on December 6, 2024, revealed no documentation of antibiotic stewardship tracking. The October 2024 Quality Assurance Performance Improvement (QAPI) meeting minutes for Infection Control included data on infections and antibiotic prescriptions, but there was no evidence of tracking compliance with the stewardship program. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) indicated that while the IP reviewed antibiotic orders and ensured they met criteria, the information was only discussed in monthly QAPI meetings without proper documentation or tracking. This deficiency had the potential to affect all 69 residents in the facility, with one resident currently receiving antibiotics at the time of the review.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility failed to follow professional standards of practice for one resident, leading to a deficiency in care. The resident was admitted with severe infections, including cellulitis and necrotizing fasciitis, but the facility did not obtain treatment orders for the wound in a timely manner. The initial assessment did not include a skin assessment, and the physician was not contacted immediately for wound care orders. It took three days for the staff to identify the lack of treatment orders, and the resident was only referred to a wound clinic after this delay. Additionally, the facility failed to administer prescribed antibiotics on multiple occasions without documenting the reasons for the missed doses. The facility's policies on admission assessment, wound care, and medication administration were not followed. The admission assessment should have included a skin assessment, and the attending physician should have been contacted immediately to obtain necessary treatment orders. The wound care policy required a physician's order for wound care, which was not obtained promptly. The medication administration policy required medications to be administered as prescribed, but the resident missed several doses of antibiotics without any documentation or notification to the supervisor. Interviews with the staff, including an LPN, the Assistant Director of Nurses (ADON), and the Director of Nurses (DON), revealed that the facility did not adhere to its policies and professional standards. The DON acknowledged that the admitting nurse should have performed a skin assessment and obtained treatment orders as needed. The ADON and the LPN confirmed that wound care and medication administration should be done per physician's orders and documented accordingly. The facility's failure to follow these procedures resulted in inadequate care for the resident, who was later hospitalized for a gastrointestinal bleed.
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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