Brookhaven Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 3405 West Mt Vernon, Springfield, Missouri 65802
- CMS Provider Number
- 265835
- Inspections on file
- 28
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brookhaven Nursing & Rehab during CMS and state inspections, most recent first.
A resident with dementia and schizophrenia requested pain medication and, after being told to wait, became agitated and struck the medication cart. The CMT responded in a raised voice with a statement perceived as threatening by multiple staff, such as warning it would be the last time the resident hit the cart. Staff interviews and documentation confirmed the CMT's conduct was disrespectful and violated the resident's right to dignity and respect.
A resident with multiple chronic conditions did not receive scheduled medications at the prescribed times, with morning medications administered over two hours late. Staff interviews confirmed that medication administration was frequently delayed due to high workloads, and residents had complained about late medications. The facility lacked an effective system to ensure medications were given within the required time frames.
A resident with complex psychiatric and medical needs did not receive proper pharmaceutical services after returning from the hospital due to staff failing to accurately transcribe, clarify, and administer new medication orders. Several prescribed medications were omitted or incorrectly entered into the EHR, and staff did not consistently document medication administration or reasons for omissions, resulting in the resident not receiving all ordered medications.
The facility failed to enforce its smoking policy, allowing residents to keep smoking materials in their rooms and on their person, contrary to the policy that requires these items to be stored at the nurses' station. Residents with various health conditions, including COPD, were found smoking unsupervised, and staff interviews revealed a lack of adherence to the policy. The Director of Nursing and the Administrator were unaware of these practices, indicating a lack of oversight.
The facility failed to serve food at the required temperature, with residents reporting cold and unappetizing meals. Observations confirmed that food temperatures were below the required 120 degrees Fahrenheit, and staff acknowledged resident dissatisfaction with meal quality.
The facility failed to follow proper food safety protocols by stacking wet dishes, which could lead to contamination. Observations showed numerous dishes stacked upside down with trapped water droplets, contrary to the facility's policy and FDA guidelines. Interviews with dietary staff confirmed the expectation for dishes to be air-dried before stacking, highlighting a deficiency in practice.
The facility failed to maintain an effective infection control program, with deficiencies in TB screening for new hires, improper catheter maintenance, and inadequate hand hygiene and medication administration practices. Staff did not consistently follow protocols for sanitizing shared medical equipment, such as glucometers, increasing the risk of cross-contamination.
A facility failed to complete the required PASARR for a resident with paranoid schizophrenia and major depressive disorder prior to or upon admission. The resident's care plan addressed delusions, but the absence of a PASARR indicates a failure to ensure appropriate care and services. The Business Office Manager could not locate the PASARR documentation, and the Social Services Director stated they try to complete these forms within 48 hours of admission.
A resident with a history of cerebral infarction and Parkinson's disease had inconsistencies in their code status documentation. While the resident's face sheet and care plan indicated a DNR status, the physician's order sheet listed them as a full code. Staff interviews confirmed that the code status should be consistent across all records, but discrepancies were found, highlighting a failure in maintaining accurate documentation.
A resident with a history of osteomyelitis and MRSA experienced a deficiency in care due to the facility's failure to document and treat a worsening elbow wound. Despite the resident's complaints and the presence of drainage, staff did not maintain current treatment orders or consistently document assessments. Interviews revealed communication issues among healthcare providers, contributing to the deficiency.
A facility failed to document regular wound assessments for a resident with a pressure ulcer on the right hip. Despite having a care plan and physician orders, the facility did not consistently record assessments or measurements, leading to a deficiency in care. Interviews revealed that wound assessments were not regularly performed unless by a visiting clinic, and documentation was acknowledged as an issue by the ADON.
Two residents in the facility did not receive their prescribed medications due to unavailability. One resident, with a vitamin B12 deficiency, missed numerous doses of B Complex-Vitamin B12 tablets, while another resident, with constipation and pain, missed doses of Senna Plus and acetaminophen. Staff interviews revealed a lack of communication and follow-up regarding medication availability, and the facility's policy on medication administration was not adhered to, resulting in a deficiency in pharmacy services.
The facility experienced a 12.5% medication error rate due to incorrect Vitamin D3 dosing and unavailability of acetaminophen and Senna Plus for two residents. Additionally, fast-acting insulin was administered without ensuring a meal within the recommended time frame. Staff interviews revealed procedural lapses in medication administration and communication about unavailable medications.
A resident with diabetes was administered rapid-acting insulin but was not provided a meal or snack within the recommended time frame. Observations showed a delay of 54 minutes before a meal was served, contrary to staff interviews indicating meals should be provided within 30 minutes. The facility's policy lacked specific guidance on insulin administration timing.
Resident Rights Violated by Disrespectful and Threatening Staff Conduct
Penalty
Summary
A deficiency occurred when a Certified Medication Tech (CMT) spoke to a resident in a disrespectful and threatening manner during a medication pass. The resident, who had diagnoses including unspecified dementia and schizophrenia, approached the medication cart to request pain medication, reporting significant pain at the time. The CMT told the resident to wait, which led to the resident becoming agitated, striking the medication cart, and using derogatory language toward the CMT. In response, the CMT raised their voice and made a statement interpreted by multiple witnesses as threatening, such as, "if you hit my cart again, that will be the last time you hit it," or similar variations. Multiple staff members, including CNAs, nurses, and supervisors, either overheard or were present during the incident and described the CMT's tone as raised, disrespectful, and threatening. Written and verbal statements from staff corroborated that the CMT's response was inappropriate and not in line with resident rights or facility policy, which requires residents to be treated with dignity and respect. The resident expressed feeling uncomfortable and not wanting to be around the CMT due to the interaction. The facility's own policy emphasizes the right of residents to be treated with consideration and respect, and staff interviews confirmed that threatening language toward residents is unacceptable. The Director of Nursing and Administrator both acknowledged that the CMT's statements were disrespectful and should not have been made. The incident was reported and documented by several staff, and the situation was de-escalated after intervention by other staff members.
Failure to Administer Medications Timely According to Policy and Standards
Penalty
Summary
The facility failed to ensure that medications were administered to a resident in accordance with professional standards of quality and facility policy. Observation, interview, and record review revealed that a resident with multiple diagnoses, including bipolar disorder, anxiety disorder, heart failure, and hypertension, did not receive scheduled medications at the prescribed time. The resident's Medication Administration Record (MAR) indicated several medications were scheduled for administration at 8:00 A.M., but on the observed date, these medications were not administered until 10:15 A.M., which was two hours and fifteen minutes after the scheduled time. The resident also reported that medications were frequently not given at the scheduled times, including evening doses being administered late. Interviews with staff, including Certified Medication Technicians (CMTs), Registered Nurses (RNs), Certified Nurse Aides (CNAs), and the Director of Nursing (DON), confirmed that there were ongoing issues with timely medication administration. Staff consistently stated that medications should be administered within one hour before or after the scheduled time, and that administration outside this window is considered late and a medication error. Staff attributed the delays to high medication loads, with one CMT responsible for administering medications to up to 58 residents across multiple halls, making it difficult to adhere to scheduled times. Additional interviews with CNAs revealed that they had received complaints from residents about late medication administration, particularly in the afternoons. The DON and Administrator acknowledged the staffing assignments and the expectation that medications be administered as ordered, but were not aware of the extent of the delays until brought to their attention during the survey. The facility did not have an effective system in place to ensure timely medication administration, resulting in repeated late administration of medications to residents.
Failure to Accurately Transcribe and Administer Medications After Hospital Discharge
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident following discharge from the hospital. Upon the resident's return, staff did not properly transcribe or clarify new medication orders, resulting in discrepancies between the hospital discharge instructions and the medications entered into the facility's electronic health record (EHR). Several medications ordered at discharge, including fluphenazine, Seroquel, ketoconazole, clotrimazole, and Miralax, were not added to the physician's order sheet, and there were inconsistencies in the dosages and administration instructions for other medications such as gabapentin and oxybutynin. Additionally, staff failed to document administration or reasons for omission of multiple medications on the Medication Administration Record (MAR) for the day of the resident's return. The resident involved had a complex psychiatric and medical history, including schizoaffective disorder, bipolar type, PTSD, depression, and a history of suicidal ideation. The care plan required close monitoring, administration of psychotropic medications as ordered, and assessment for side effects. Despite these needs, the facility did not ensure that the resident's medication regimen was accurately reconciled or administered as prescribed after the hospital stay. Interviews with staff revealed confusion about the process for entering and verifying new medication orders, with several staff members unsure of their responsibilities or the accuracy of the orders entered into the EHR. Further, the nurse practitioner and other staff reported that the medication list in the EHR did not match the hospital discharge orders, and it took several days to identify and attempt to correct the discrepancies. During this period, the resident was not receiving all prescribed medications, and staff did not consistently document or clarify missing or incorrect orders. The lack of timely and accurate medication reconciliation and administration directly contravened facility policy and resulted in the resident not receiving necessary pharmaceutical care as ordered.
Failure to Enforce Smoking Policy in LTC Facility
Penalty
Summary
The facility failed to ensure an environment as free of accident hazards as possible by not adhering to its smoking policy. The policy mandates that all smoking materials be kept at the nurses' stations and that residents should not retain smoking materials or lighters in their rooms. However, several residents were found to have smoking supplies on their person and in their rooms, contrary to the facility's policy. This was observed during interviews and inspections, where residents were seen with cigarettes and lighters in their possession and in their rooms. Resident #27, who was diagnosed with chronic obstructive pulmonary disease (COPD) and other health issues, was found to have cigarettes and lighters in his/her room and on his/her person. Despite being assessed as a safe smoker, the resident was not following the facility's policy of keeping smoking materials at the nurses' station. Similarly, Resident #268, who had a history of COPD and other conditions, was not care planned for smoking, and there was no documentation of a smoking assessment. This resident also kept smoking supplies in his/her room and smoked unsupervised. Other residents, such as Resident #49 and Resident #67, were also found to have smoking materials in their rooms and on their person, despite being care planned to store these items at the nurses' station. Interviews with staff, including a CNA and an RN, revealed that residents often carried their own smoking supplies and smoked unsupervised, which was against the facility's policy. The Director of Nursing and the Administrator were unaware of these practices, indicating a lack of enforcement and oversight of the smoking policy.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was palatable and at a safe and appetizing temperature. The facility's policy, as outlined in the Nutrition and Dining Services Manual, requires hot foods to be served at a minimum of 120 degrees Fahrenheit. However, multiple residents reported that their meals were often cold, with specific complaints about cold eggs and low-quality meat. During a resident council meeting, several residents expressed dissatisfaction with the temperature and quality of their meals, indicating that the food was often barely warm or cold. Observations of meal trays confirmed these complaints, with recorded temperatures for various food items falling below the required 120 degrees Fahrenheit. For instance, scrambled eggs were measured at 97.1 degrees Fahrenheit, and a sausage patty at 85.9 degrees Fahrenheit. Additionally, the food was described as bland and unappetizing. Interviews with staff revealed that while tray audits were conducted when complaints were made, the issues with food temperature and quality persisted. The Dietary Manager acknowledged that residents were not satisfied with certain meals, and the Administrator expected staff to adhere to the facility's food service policy.
Improper Dish Drying Practices Lead to Potential Contamination
Penalty
Summary
The facility failed to adhere to proper food safety protocols by not allowing dishes to air dry before stacking them, which could lead to potential contamination or bacterial growth. Observations on multiple occasions revealed that a significant number of plastic bowls, dessert cups, ceramic plates, serving trays, plate covers, and metal steam table pans were stacked upside down while still wet, trapping water droplets and preventing adequate air flow. This practice was contrary to the facility's policy and the 1999 Food Code issued by the FDA, which mandates that equipment and utensils must be air-dried before being stacked or stored. Interviews with dietary staff, including a Dietary Aide, a staff member identified as [NAME] T, and the Dietary Manager, confirmed that dishes should be air-dried before being put away. The Dietary Manager specifically noted that dishes should not be stacked wet due to the risk of bacterial growth. The facility's Administrator also expressed an expectation that staff follow the food service policy, which includes allowing dishes to air dry before stacking. Despite these expectations and policies, the facility's practices did not align with the required standards, leading to the identified deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by multiple deficiencies observed during the survey. The facility did not adhere to its own policy and standards of practice regarding tuberculosis (TB) screening for new hires. Three staff members, including a CNA, an LPN, and a Dietary Aide, did not receive the two-step tuberculin skin test within the required timeframe. The initial TB tests for these staff members were either delayed or not read within the 48 to 72-hour window, and the second step was not administered according to the recommended schedule. Additionally, the facility failed to maintain catheters in a manner that prevents bacterial contamination. Observations revealed that a resident's catheter bag and tubing were repeatedly found on the ground, potentially introducing bacteria into the system. Staff interviews confirmed that catheter bags and tubing should not be dragging on the floor, yet this practice was not consistently followed. The facility also demonstrated lapses in medication administration and hand hygiene practices. Staff were observed touching medications and the inside of medication cups with bare hands, potentially contaminating the medications. Hand hygiene was not consistently performed during incontinent care or wound care, increasing the risk of cross-contamination. Furthermore, shared medical equipment, such as glucometers, was not properly sanitized between uses, contrary to the facility's policy and manufacturer recommendations.
Failure to Complete PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with diagnoses of paranoid schizophrenia and major depressive disorder prior to or upon admission. The resident was admitted with a diagnosis that necessitated a PASARR, but the facility did not have documentation of a completed PASARR in the resident's medical record. The Business Office Manager was unable to locate the level one PASARR documentation, and the Social Services Director indicated that they attempt to complete these forms within 48 hours of admission. The resident's care plan included interventions for managing delusions, such as redirecting the resident and administering medication as per physician orders. However, the absence of a PASARR indicates a failure to ensure the resident received appropriate care and services tailored to their mental health needs. The Administrator mentioned that the PASARR was done in 2007 before electronic records, and staff should verify the presence of a DA 124 form upon admission if required by the resident's diagnosis.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in a resident's code status across their medical records, leading to a deficiency. The resident, who had a history of cerebral infarction, Parkinson's disease, cognitive communication deficit, and Type 2 diabetes mellitus, had chosen a Do Not Resuscitate (DNR) status. However, discrepancies were found in the documentation: the resident's face sheet and care plan indicated a DNR status, while the physician's order sheet listed the resident as a full code. This inconsistency was observed despite the resident having signed an Outside the Hospital Do Not Resuscitate (OHDNR) form, which was also signed by the physician. Interviews with various staff members, including CNAs, CMTs, LPNs, and the Director of Nursing, revealed that the code status should be consistent across all documentation, including the resident's door, care plan, and electronic medical records. However, the inconsistency persisted, as evidenced by the red dot on the resident's door indicating a DNR status, while the physician's order contradicted this. The staff, including the Assistant Director of Nursing and the Administrator, acknowledged that the code status should be uniform throughout the resident's chart, highlighting a failure in maintaining accurate and consistent documentation of the resident's wishes.
Failure to Document and Treat Resident's Elbow Wound
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the management of a wound on the resident's left elbow. The resident, who had a history of osteomyelitis and MRSA, experienced an elbow wound that was not consistently documented or treated according to physician orders. The facility's staff did not maintain current lists of orders in the resident's clinical record, leading to confusion and errors in treatment. Additionally, there was a lack of documentation regarding the notification of the physician and assessments of the wound. The resident's medical records showed multiple instances where staff failed to document the assessment or treatment of the elbow wound. Despite the resident's complaints of pain and the presence of drainage, there were no documented orders for treatment of the wound from early November through mid-December. The visiting wound clinic's notes indicated that the wound had worsened over time, with increased drainage and the presence of bone fragments. However, the facility staff did not consistently document these findings or follow up with appropriate treatment orders. Interviews with facility staff revealed a lack of communication and coordination among the various healthcare providers involved in the resident's care. The Assistant Director of Nursing (ADON) and other staff members acknowledged the documentation issues and the challenges posed by the involvement of multiple physicians. Despite the resident's requests for a wound culture and concerns about the worsening condition, the facility did not adequately address these issues, leading to a deficiency in the standard of care provided to the resident.
Inadequate Documentation of Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice. The resident, who was admitted with an unspecified open wound on the right hip, had a care plan indicating the presence of a pressure ulcer. However, the facility did not document regular full wound assessments as required. The resident's medical records showed gaps in documentation, with no assessments or measurements recorded for extended periods, despite the presence of a wound management log and physician orders for treatment. Interviews with staff revealed inconsistencies in the wound assessment and documentation process. The Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) indicated that wound assessments and measurements were not consistently performed or documented unless conducted by a visiting wound clinic. The ADON acknowledged that documentation was an issue, and the Director of Nursing (DON) stated that wound monitoring should be completed weekly and documented in the nurses' notes. The resident expressed that staff did not assess the wound on a weekly basis, and the facility's policy required documentation of skin assessments, including any abnormalities. Despite the policy and the resident's care plan, the facility did not maintain consistent documentation of the wound's condition, leading to a deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Medication Unavailability for Residents
Penalty
Summary
The facility failed to provide pharmacy services to meet the needs of each resident, as evidenced by the unavailability of ordered medications for two residents. Resident #49, who was admitted with a diagnosis of vitamin B12 deficiency, did not receive the prescribed B Complex-Vitamin B12 tablets for a significant portion of November and all of December. The Medication Administration Record (MAR) indicated that the medication was unavailable for 18 out of 30 doses in November and all 13 doses in December. The resident confirmed during an interview that there were times when medications were not available, and the Assistant Director of Nursing (ADON) was unaware of the issue until it was brought to her attention. Resident #13, who was admitted with diagnoses including constipation and pain, also experienced medication unavailability. The resident's MAR showed that Senna Plus, a laxative, was not administered for several days in December due to unavailability. Additionally, acetaminophen, prescribed for pain management, was not administered for multiple doses. Interviews with staff, including Certified Medication Technicians (CMTs) and Licensed Practical Nurses (LPNs), revealed that there was a lack of communication and follow-up regarding the unavailability of medications, and the staff did not consistently notify the appropriate personnel to address the issue. The facility's policy on medication administration requires that medications be given as ordered by the physician. However, the report highlights a breakdown in the process, as staff failed to ensure that medications were available and administered as prescribed. Interviews with the Director of Nursing (DON) and the Administrator confirmed that staff should follow procedures for medication administration and notify the appropriate personnel if medications are unavailable. Despite these expectations, the residents went without their prescribed medications for extended periods, indicating a deficiency in the facility's pharmacy services.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 12.5 percent error rate. This was due to four medication errors out of 32 opportunities, affecting two residents. For one resident, the Certified Medication Tech (CMT) administered incorrect doses of Vitamin D3 and failed to provide acetaminophen and Senna Plus due to unavailability. The CMT acknowledged the absence of these medications and had informed the Assistant Director of Nursing (ADON) about the supply issue. Interviews with staff revealed a lack of adherence to procedures for checking emergency kits and notifying physicians when medications were unavailable. Another deficiency involved the administration of insulin to a resident. The Licensed Practical Nurse (LPN) administered fast-acting insulin without ensuring the resident received a meal within the recommended time frame. The resident did not receive a meal until 54 minutes after insulin administration, contrary to best practices that suggest a meal or snack should be provided within 30 minutes. Interviews with staff, including the ADON and Director of Nursing (DON), confirmed the expectation that meals should be provided promptly after insulin administration. The facility's policy on medication administration lacked specific guidance on insulin administration timing, contributing to the deficiency. Staff interviews highlighted inconsistencies in following procedures for medication administration and communication regarding unavailable medications. The Director of Nursing and Administrator emphasized the importance of adhering to physician orders and ensuring residents do not go without necessary medications.
Failure to Provide Timely Meal After Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of rapid-acting insulin. Resident #42, who has diagnoses including chronic kidney disease, high blood pressure, diabetes, and weakness, was administered six units of insulin aspart subcutaneously at 11:21 A.M. However, the resident was not provided with a meal or snack within the recommended time frame after insulin administration. Observations showed that the resident had not received a lunch tray 54 minutes after the insulin was given, and there were no snacks visible in the resident's room. Interviews with staff, including LPNs, CMTs, the ADON, and the DON, revealed inconsistencies in the understanding and implementation of insulin administration protocols. While some staff members indicated that a meal or snack should be provided within 30 minutes of insulin administration, others suggested that waiting up to an hour might be acceptable, though not best practice. The facility's policy on medication administration did not provide specific guidance on the timing of meals or snacks in relation to insulin administration, contributing to the deficiency observed.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
