Camdenton Windsor Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Camdenton, Missouri.
- Location
- 2042 N Business Route 5, Camdenton, Missouri 65020
- CMS Provider Number
- 265091
- Inspections on file
- 19
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Camdenton Windsor Estates during CMS and state inspections, most recent first.
Facility staff discharged a resident to a hospital and then refused to allow the resident to return, without having an emergency discharge policy in place. Staff documented an immediate discharge notice stating the facility could no longer meet the resident’s needs and listed the hospital as the discharge destination. The administrator stated the resident would not be accepted back due to safety concerns for other residents and acknowledged that the hospital was not an acceptable discharge location. A care plan coordinator notified the hospital social worker by email that the facility would not readmit the resident, resulting in an inappropriate emergency discharge notice and failure to ensure the transfer/discharge met the resident’s needs and preferences.
Staff did not review or revise care plans for three residents after they experienced falls, despite facility policy requiring updates following changes in condition. The MDS Coordinator, responsible for care plan updates, had not added new interventions after the falls, and interviews confirmed that care plans were not promptly revised to reflect these incidents.
Staff did not complete or document required neurological checks for two residents with severe cognitive impairment following unwitnessed falls, as mandated by facility policy. Despite clear procedures for post-fall neurological assessments, records and interviews confirmed the absence of documentation and completion of these checks.
A facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment to the DHSS within the required two-hour timeframe. A CNA reported that an RN hit the resident and threw a sheet over their head, but the report was made to the administrator later in the afternoon. The CNA was unaware of the immediate reporting requirement and was educated on their responsibility to notify management promptly.
The facility did not document the administration of the pneumococcal vaccine for six out of eight sampled residents, despite having signed consents. This lapse occurred even though CDC guidelines recommend specific vaccination protocols based on age and prior vaccine history. One resident was diagnosed with pneumonia following chest congestion, underscoring the potential risks. The DON acknowledged delays in vaccine delivery due to conflicting information from the pharmacy and an allergic resident causing a specific vaccine order to be canceled. Staff emphasized the importance of documentation and obtaining consents upon admission, while the MD highlighted the need for timely vaccine administration to prevent respiratory infections.
Facility staff failed to ensure pureed food items were reheated to proper temperatures and did not follow puree recipes. Hot foods were not held at 140°F or greater during meal service, and hot food on room trays for three residents was not maintained at 120°F at the time of delivery. Staff were unaware of the appropriate food temperatures and did not take corrective actions when food was served below the required temperature.
The facility staff failed to implement complete water management policies to prevent Legionnaire's Disease and did not consistently follow proper hand hygiene protocols, leading to potential infection risks for residents.
Facility staff failed to maintain a clean and homelike environment by not properly cleaning resident rooms and common areas. Observations showed debris and dirty floors, and the Housekeeping Supervisor used visibly dirty mop water to clean various areas, which could spread germs and cause infections. Staff interviews confirmed that mop water should be changed every three rooms or when visibly dirty.
Facility staff failed to accurately document MDS assessments for several residents, including the use of BiPAP/CPAP machines, rejection of care behaviors, and anticoagulant medications. Interviews revealed a lack of awareness and understanding regarding proper MDS coding and the classification of medications.
Facility staff failed to develop and implement comprehensive care plans for four residents, leading to undocumented oxygen use, missing podus boot applications, unaddressed weight loss risk, and lack of BiPAP and hospice care documentation. Staff interviews and observations confirmed these deficiencies.
Facility staff failed to ensure residents who were unable to complete their own ADLs received necessary care and services to maintain good personal hygiene. Four residents were observed with unkempt hair and facial hair despite care plans indicating preferences for being clean-shaven. Staff interviews confirmed that residents were expected to receive showers twice a week, but documentation and observations indicated this standard was not consistently met.
Facility staff failed to lock medication and treatment carts and did not store medications and chemicals safely. Observations showed unattended carts with accessible medications and chemicals, and interviews confirmed that staff were aware of the policies but did not adhere to them. The facility lacked a specific chemical storage policy, and issues with cart locks had been reported but not addressed.
Facility staff failed to store oxygen/nebulizer masks and tubing properly, leading to potential contamination for six residents. Additionally, two residents lacked orders for oxygen therapy. Staff interviews revealed a lack of knowledge and adherence to proper procedures, highlighting systemic issues in the facility's handling of respiratory care equipment.
Facility staff failed to accurately count controlled medications for two residents and did not remove expired medications and supplies. An LPN admitted to taking shortcuts, and expired items were found in the medication storage room. The DON and administrator confirmed that proper procedures were not followed.
The facility failed to provide an appropriate 30-day discharge notice and did not allow a resident to return after hospital discharge. The resident's medical record lacked the required discharge notice, and the facility decided not to readmit the resident due to additional information about the resident's history and behaviors.
Improper Emergency Discharge and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to ensure an appropriate and safe transfer/discharge for a resident when they discharged the resident to a hospital and refused to allow the resident to return. Record review showed the resident had been admitted to the facility in early February and was discharged to the hospital on 02/23/26. On 3/3/26 at 11:52 A.M., staff documented in the progress notes that they spoke with the resident’s guardian regarding a notice of immediate discharge because the facility could no longer meet the resident’s needs, and an Immediate Discharge Notice dated 3/3/26 indicated the resident would discharge to the hospital. The facility did not have a policy for emergency discharge, and the administrator stated on 3/3/26 at 10:09 A.M. that the resident would not be accepted back due to safety concerns for other residents and acknowledged awareness that the hospital was not an acceptable discharge location. The care plan coordinator reported emailing the hospital social worker to inform them that the facility would not accept the resident back, effectively using the hospital as the resident’s discharge destination without appropriate notice or planning to meet the resident’s needs and preferences for a safe transfer/discharge. These actions and omissions, including the lack of an emergency discharge policy, the issuance of an immediate discharge notice listing the hospital as the discharge location, and the administrator’s refusal to readmit the resident, led to the deficiency related to failure to provide an appropriate emergency discharge notice and to ensure the transfer/discharge met the resident’s needs and preferences.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for three residents who experienced falls. According to the facility's policy, care plans are to be updated with measurable goals and interventions as changes occur in a resident's condition, including after falls. For each of the three residents, documentation showed that after they sustained falls—some resulting in injury and others not—there were no new interventions added to their care plans. The MDS Coordinator, responsible for updating care plans, stated that due to assisting with resident care, they had not had the opportunity to update the care plans following these incidents. The administrator and DON both indicated that they would expect new interventions to be added after each fall, depending on the circumstances. Interviews with staff confirmed that the care plan is intended to guide care and should be updated after changes such as falls. In one case, the MDS Coordinator was unaware of a resident's fall, and in another, staff provided education to the resident but did not document a new intervention in the care plan. The facility census at the time was 49, and the sampled residents had varying levels of cognitive impairment and histories of both injury and non-injury falls. The lack of timely care plan updates following these events constituted the deficiency.
Failure to Complete and Document Neurological Checks After Unwitnessed Falls
Penalty
Summary
Facility staff failed to complete and document neurological checks for two residents who experienced unwitnessed falls, as required by facility policy. The policy mandates neurological assessments for seventy-two hours following an unwitnessed fall or head injury, with specific intervals for checks and documentation in the medical record. For both residents, who had severe cognitive impairment and a history of falls, there was no documentation in event reports or progress notes indicating that neurological checks were performed after their unwitnessed falls. Interviews with staff, including an LPN, the MDS Coordinator, the administrator, and the DON, confirmed that neurological checks should have been completed and documented for residents after unwitnessed falls. However, staff were unaware of the missing documentation for these two residents, and the DON only identified and addressed a separate missed assessment. The required neurological assessments for these two incidents were not completed or documented as per facility policy.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility staff failed to report an allegation of physical abuse involving a resident with severe cognitive impairment to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The incident involved a Certified Nurse Aide (CNA) who reported that a Registered Nurse (RN) hit the resident and threw a sheet over their head. The CNA reported the incident to the administrator later in the afternoon, which was beyond the mandated reporting period. The facility's investigation policy requires all allegations of abuse to be reported to the State Survey Agency and, if applicable, law enforcement within two hours. Interviews revealed that the CNA was unaware of the immediate reporting requirement and only reported the incident when they first had contact with the administrator. The administrator confirmed that the CNA did not know to report allegations of abuse immediately and stated that the CNA was educated on their responsibility to notify management as soon as abuse was witnessed. The RN confirmed that staff are directed to notify upper management and the State agency within two hours of reported or observed abuse.
Pneumococcal Vaccine Documentation Lapses Identified
Penalty
Summary
The facility failed to document the administration of the pneumococcal vaccine for six out of eight sampled residents, despite CDC guidelines recommending specific vaccination protocols based on age and prior vaccine history. Medical records for Residents #8, #14, #21, #25, #33, and #38 did not contain documentation of staff offering or administering the pneumococcal vaccine, even though signed consents were present for vaccine administration. Notably, Resident #25 was diagnosed with pneumonia after being diagnosed with chest congestion, highlighting the potential consequences of missed vaccinations in this population. During interviews, the Director of Nursing (DON) acknowledged the delay in vaccine delivery, with conflicting information on the expected arrival dates provided by the pharmacy. The DON also mentioned an allergic resident causing a specific vaccine order to be canceled. The facility's staff, including the DON, Licensed Practical Nurse (LPN), Business Office Manager (BOM), and Administrator, emphasized the importance of documentation and the responsibility of obtaining consents for vaccinations upon admission. The Medical Director (MD) stressed the expectation for timely vaccine administration for long-term care residents to prevent potential outcomes like pneumonia or upper respiratory infections.
Failure to Maintain Proper Food Temperatures and Follow Puree Recipes
Penalty
Summary
Facility staff failed to ensure pureed food items were reheated to proper temperatures and did not follow puree recipes. Observations showed that hot foods were not held at 140 degrees Fahrenheit or greater during meal service. Additionally, hot food on room trays for three residents was not maintained at 120 degrees Fahrenheit at the time of delivery. Staff, including nurse aides and certified nursing assistants, were unaware of the appropriate food temperatures and did not take corrective actions when food was served below the required temperature. The facility's policy indicated that food should be at least 120 degrees Fahrenheit, but this was not consistently followed. Resident #27, who had moderately impaired cognition and required set-up assistance for eating, received food that was below the required temperature. The resident's stuffing, turkey, and green beans were all served at temperatures below 120 degrees Fahrenheit, and the nurse aide did not offer to reheat the food or provide a new tray. Resident #25, who was cognitively intact and also required set-up assistance, received ham that was below the required temperature. The nurse aide acknowledged the food was below 120 degrees Fahrenheit but did not take corrective action. Resident #105, who was cognitively intact and required set-up assistance, received a dinner tray with food below the required temperature, and the nurse aide did not reheat the food. The facility's dietary staff also failed to follow proper procedures for reheating and holding pureed food items. Observations showed that pureed meatloaf, scalloped potatoes, and bread were not reheated to the required 165 degrees Fahrenheit and were held at temperatures below 140 degrees Fahrenheit. The cook did not check the temperatures of the food before placing them on the steam table and did not follow the puree recipes. The dietary manager confirmed that the cook was responsible for ensuring proper food temperatures and consistency but acknowledged that the food items were not prepared correctly. The administrator stated that food should be 140 degrees Fahrenheit when served to residents, but this standard was not met.
Inadequate Water Management and Hand Hygiene Practices
Penalty
Summary
The facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease. The maintenance director was unaware of whether the public water supply was treated or if the facility had any disinfectants as part of the water system. Additionally, the maintenance director did not check the water for disinfectant or chlorine levels, and the water management program did not include policies or procedures related to control measures or disinfectant levels. Facility staff also failed to perform proper hand hygiene for two residents. One nurse assistant performed catheter care on a resident but did not follow proper hand hygiene protocols, such as washing hands after touching potentially contaminated surfaces and before providing care. Similarly, a licensed practical nurse performed wound care on a resident but did not follow proper hand hygiene procedures, including turning off the faucet with their elbow instead of using a paper towel. Another certified nurse assistant failed to perform proper hand hygiene while providing perineal care to a resident. The CNA did not wash their hands between glove changes and touched various surfaces and the resident with soiled gloves. Interviews with staff, including the Director of Nursing and the Quality Assurance nurse, revealed that staff were aware of the proper hand hygiene protocols but did not consistently follow them, leading to potential risks of infection and cross-contamination.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Facility staff failed to provide a clean, homelike, and comfortable environment by not maintaining resident rooms and common areas. Observations revealed debris on the floors outside multiple rooms and dirty floors in resident-occupied rooms. Additionally, there were multiple stains and black marks on the walls and floors of some resident rooms. The Housekeeping Supervisor acknowledged that some marks on the walls needed painting, which was a task for the maintenance team. Further observations showed that the Housekeeping Supervisor used dark brown, visibly dirty mop water to clean various areas, including the MDS office, staff bathroom, hallway, clean utility room, and resident-occupied rooms. Interviews with housekeeping staff, a CNA, an LPN, the Housekeeping Supervisor, the DON, and the Corporate QA nurse confirmed that mop water should be changed every three rooms or when visibly dirty. The use of dirty mop water was recognized as a practice that could spread germs and cause infections. The Housekeeping Supervisor admitted to being unaware of using dirty water for cleaning.
Inaccurate MDS Documentation
Penalty
Summary
Facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment for several residents. Specifically, staff did not accurately code for the use of Bi-level Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (CPAP) machines for three residents. For instance, one resident's care plan indicated the use of a BiPAP machine at night, but this was not reflected in the MDS assessment. Similarly, another resident's MDS assessment did not document the use of a CPAP machine, despite observations and care plans indicating its use at night. Additionally, the facility staff did not accurately document a resident's rejection of care behaviors in the MDS assessment, even though multiple nurse's notes and interviews confirmed the resident's refusal of showers and other care activities. The MDS assessments also failed to accurately code the use of anticoagulant medications for two residents. The staff incorrectly identified Clopidogrel as an anticoagulant, which led to inaccurate MDS coding. Interviews with the Director of Nursing (DON), MDS Coordinator, and other staff revealed a lack of awareness and understanding regarding the correct classification of Clopidogrel and the importance of accurate MDS documentation. The facility did not have a specific policy for MDS assessments and relied on the Resident Assessment Instrument (RAI) manual for guidance. The MDS Coordinator, who is responsible for completing the MDS assessments and care plans, admitted to not being aware that Clopidogrel is an antiplatelet medication and not an anticoagulant. The DON and other staff members also confirmed that the MDS assessments should accurately reflect the use of oxygen, BiPAP, CPAP, and anticoagulant medications.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for four residents out of 14 sampled residents. Resident #6, who was assessed as cognitively intact and diagnosed with sleep apnea, did not have an order for oxygen documented in the care plan despite using oxygen at night. The Director of Nursing and Licensed Practical Nurse confirmed the absence of a current oxygen order and the resident's refusal to use CPAP, preferring oxygen instead. This discrepancy was observed during multiple interviews and record reviews, highlighting a lack of proper documentation and care planning for the resident's oxygen use. Resident #14, assessed as cognitively intact and dependent on staff for all Activities of Daily Living (ADLs), was at risk for pressure ulcers. Despite having an order for a podus boot to be worn at all times, the care plan did not document this requirement. Observations on multiple occasions showed the resident without the podus boot, and staff failed to apply it even after providing care. Interviews with various staff members, including CNAs and LPNs, confirmed the expectation that the podus boot should be documented and applied as per the care plan, which was not adhered to. Resident #21, assessed as cognitively intact and requiring setup assistance for eating, experienced significant weight loss over several months. The care plan did not address the resident's risk for weight loss or include any interventions. Interviews with the resident and staff revealed that the resident often ate in their room, but the care plan lacked necessary documentation to manage the weight loss risk. Similarly, Resident #25, with diagnoses including obesity, sleep apnea, and acute bronchospasm, had an order for BiPAP at bedtime, which was not documented in the care plan. Observations and staff interviews confirmed the presence of the BiPAP machine and the need for its inclusion in the care plan, which was not done. Lastly, Resident #33, with severe cognitive impairment and on hospice care, did not have hospice care directions documented in the care plan despite being admitted to hospice services. Interviews with staff consistently indicated that the care plans should be individualized and updated with all relevant information, which was not the case for these residents.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
Facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADLs) received the necessary care and services to maintain good personal hygiene. Specifically, staff did not provide hair care and assist residents with facial hair for four residents out of fourteen sampled. The facility's policies did not adequately address the frequency and procedures for hair care, facial hair care, and nail care, contributing to the deficiency observed by surveyors. Resident #14, who was cognitively intact but dependent on staff for all ADLs, was observed multiple times with long chin hairs despite expressing a preference to be clean-shaven. The resident's care plan did not include directions for facial hair preference, and shower documentation repeatedly lacked records of shaving being completed. Similarly, Resident #24, who was severely cognitively impaired and dependent on staff for all ADLs, was observed with facial hair on several occasions, despite a care plan indicating a preference for being clean-shaven. Resident #33, also severely cognitively impaired and requiring maximum assistance for personal hygiene, was observed with unkempt hair and facial hair approximately half an inch long on multiple occasions. The resident's care plan indicated a preference for being clean-shaven, but shower documentation did not reflect that shaving was completed. Resident #50, who was severely cognitively impaired and dependent for all ADLs, was observed with greasy, disheveled hair and unshaved facial hair on several occasions, despite a care plan that indicated a preference for being clean-shaven or having facial hair as needed. Interviews with staff confirmed that residents were expected to receive showers twice a week, but documentation and observations indicated that this standard was not consistently met.
Failure to Lock Medication and Housekeeping Carts
Penalty
Summary
Facility staff failed to lock medication and treatment carts and did not store medications and chemicals safely. Observations showed a Certified Medication Technician (CMT) left a medication cart unattended with pills on top, and a treatment cart was found unlocked and unattended at the nurse's station. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that medication and treatment carts should be locked when not attended, and medications should not be left on top of the carts. The CMT admitted to leaving the medication on top of the cart due to being busy with other tasks, acknowledging the potential danger to residents who wander and get into things. Housekeeping carts were also found unlocked and unattended with bottles of toilet bowl cleaner on them. Multiple observations showed housekeeping carts left in various locations, including near resident rooms and the dining room, with chemicals accessible to residents. Interviews with housekeeping staff, the Housekeeping Supervisor, and the Maintenance Director revealed that the carts' locks were not functioning properly, and the issue had been reported but not yet addressed. Staff acknowledged that chemicals should be locked up to prevent residents from accessing them and potentially getting harmed. The facility's policy on the storage of medication directed that all medications must be stored in locked cabinets, rooms, or carts, and that poisonous substances and hazardous compounds must be kept in locked containers away from residents. However, the facility did not have a specific chemical storage policy. The Administrator and DON reiterated that all medication and treatment carts, as well as housekeeping carts with chemicals, should be locked when not attended to ensure resident safety.
Improper Storage and Lack of Orders for Respiratory Care Equipment
Penalty
Summary
Facility staff failed to store oxygen/nebulizer masks and tubing in a manner to prevent infection-causing contaminants for six residents. Observations showed that oxygen tubing was not dated, and BiPAP and CPAP machines and masks were not stored in bags. Additionally, nebulizer masks and tubing were found not dated and not stored in bags, leading to potential contamination. These deficiencies were observed across multiple residents' rooms, indicating a systemic issue in the facility's handling of respiratory care equipment. Staff also failed to ensure that two residents had orders for oxygen therapy. For instance, Resident #6 was observed using oxygen at night without a current order for oxygen in their Physician Order Sheet (POS). Similarly, Resident #105, who was on continuous oxygen, did not have an order for oxygen in their POS. This lack of proper documentation and orders for oxygen therapy further highlights the facility's failure to adhere to proper respiratory care protocols. Interviews with staff, including CNAs, LPNs, and the Director of Nursing (DON), revealed a lack of knowledge and adherence to the facility's policies regarding the storage and maintenance of respiratory care equipment. Staff were unaware of the proper procedures for storing oxygen tubing, nebulizer masks, and CPAP/BiPAP machines, leading to inconsistent practices and potential risks of infection for the residents. The DON and other staff members acknowledged the deficiencies and the potential for resident infections due to improper storage and handling of respiratory care equipment.
Failure to Accurately Count Controlled Medications and Remove Expired Supplies
Penalty
Summary
Facility staff failed to accurately count controlled medications for two residents. For Resident #13, the controlled medication record indicated 27 Hydrocodone APAP 5-325 mg tablets, but observation showed 28 tablets. Similarly, for Resident #16, the record indicated five tablets, but observation showed six tablets. An LPN admitted to taking shortcuts and not counting the actual pills due to being in a hurry. The DON and the administrator confirmed that staff should count both the cards and the pills at each shift change and notify the DON if the count is incorrect, which did not happen in this case. Additionally, the facility staff failed to remove and destroy expired medications and medical supplies. Expired items found in the medication storage room included Clearlax Polyethylene Glycol 3350 Powder and 51-25 gauge safety needles. The LPN responsible for monitoring the medication room admitted to not knowing that needles could expire and was unsure how the expired items were missed. The DON and the administrator confirmed that staff should check medication rooms and carts for expired medications weekly, which was not done properly in this instance.
Failure to Provide Appropriate Discharge Notice and Readmission
Penalty
Summary
The facility staff failed to provide an appropriate 30-day discharge notice for a resident and did not allow the resident to return to the facility after being discharged from the hospital. The facility's Discharge/Transfer of Resident policy requires staff to explain the transfer and reason to the resident and/or representative and provide a copy of the transfer or discharge notice. In the case of an emergency transfer, the notice form may be completed later but as soon as possible. However, the resident's medical record did not contain an emergency or 30-day discharge notice prior to discharge, and the resident was not provided with an acceptance of admission to an alternative facility. The resident was admitted to the facility and received intravenous (IV) antibiotic medication but became weak and unsteady, leading to an order to send the resident to the emergency room. The facility staff decided not to readmit the resident, citing the inability to meet the resident's needs due to additional information received about the resident's history of drug use, wound care, and behaviors. Interviews with the facility's social services designee, administrator, and LPN revealed that the hospital had not initially provided complete information about the resident's medical history and behaviors. The hospital social worker confirmed that the resident remained in the emergency department, and placement had not yet been found for the resident.
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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