Cedargate Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Poplar Bluff, Missouri.
- Location
- 2350 Kanell Blvd, Poplar Bluff, Missouri 63901
- CMS Provider Number
- 265205
- Inspections on file
- 14
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedargate Health Care Center during CMS and state inspections, most recent first.
The facility failed to store and distribute food under sanitary conditions, using non-pasteurized eggs for undercooked preparations and maintaining unclean kitchen equipment and storage areas. Eleven residents were served undercooked eggs made from non-pasteurized shell eggs, and various kitchen surfaces were found to be unclean, with black and white substances observed on the ice machine and sticky films on kitchen equipment. Dented cans and a sticky film on the floor were also noted.
The facility failed to maintain water temperatures between 105°F to 120°F in resident room sinks and a community shower, with recorded temperatures ranging from 129.2°F to 134.5°F. This deficiency persisted despite the installation of a new water heater, posing a burn risk to all 49 residents.
The facility failed to ensure resident privacy during care by leaving two residents exposed. One resident with multiple diagnoses, including diabetes and heart failure, was left exposed to the backyard view, while another resident with severe cognitive impairment and other conditions was exposed to the courtyard view. Staff did not close the blinds during incontinent care.
The facility failed to maintain a safe, clean, and comfortable environment, with observations of water leaks, fecal material, and unsanitary conditions in multiple areas. The maintenance log showed no completed work orders since December 2023, and the Maintenance Supervisor had only been in the position for three weeks. The Administrator confirmed that staff should complete work orders for maintenance to address.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers. Two residents were transferred multiple times without documented written notifications, despite the facility's process requiring such notifications.
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents. Interviews with staff revealed inconsistencies in the process of ensuring that the notifications were sent out as required by the facility's policy.
The facility failed to implement comprehensive, person-centered care plans with specific interventions for three residents diagnosed with Alzheimer's disease, anxiety disorder, major depressive disorder, and dementia. Interviews confirmed that these conditions should be included in care plans with both pharmacological and non-pharmacological interventions.
The facility failed to ensure a complete hospice care plan for a resident and did not adhere to the repositioning protocol for another resident, leading to extended periods without repositioning despite the care plan requirements.
The facility failed to ensure proper placement and handling of Foley catheter tubing and drainage bags for two residents. One resident's catheter tubing was touched by a nurse's shoe, and another resident's catheter drainage bag and tubing were observed touching the floor multiple times and not covered with a dignity bag, contrary to facility policy.
The facility failed to ensure proper storage of nasal cannulas and did not follow oxygen orders for two residents. One resident's nasal cannula was found on the floor and improperly placed back in use, while another resident's oxygen concentrator was set incorrectly, and the nasal cannula was improperly stored or not in use.
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with PTSD. Despite the resident's PTSD being documented in their medical records, the care plan did not address PTSD or include necessary interventions. Interviews with staff confirmed that PTSD should have been included in the care plan.
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 6.25%. Two residents were affected by the administration of expired insulin and incorrect insulin dosages, indicating a failure to adhere to the facility's policies on insulin administration and medication storage.
The facility failed to discard opened, multi-use vials of insulin after the 28-day expiration period, as per manufacturer's instructions. Observations revealed multiple expired vials on the CMT medication cart, and interviews with staff indicated a misunderstanding of the expiration guidelines.
The facility failed to maintain proper infection control practices during incontinent care, catheter care, and wound care for multiple residents. Staff did not perform hand hygiene between glove changes, use gloves and gowns as required, or clean contaminated surfaces. These actions were inconsistent with the facility's infection control policies.
The facility failed to document education provided to residents or their representatives regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines. This deficiency was identified for four residents, with no documentation found in their medical records despite receiving the vaccines.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, as observed during a survey. Non-pasteurized shell eggs were used to prepare undercooked eggs for eleven residents, contrary to the facility's policy that only pasteurized eggs should be used for such preparations. The walk-in refrigerator contained a partially full case of non-pasteurized eggs, and the interior surface of the door had a brown substance. The Dietary Manager confirmed that pasteurized eggs had not been ordered recently, and the Administrator acknowledged that the eggs should have been pasteurized if served undercooked. Additionally, the ice machine and various kitchen surfaces were found to be unclean, with black and white substances observed on the ice machine and sticky films on kitchen equipment. Dented cans were also found in the dry food storage room, and the floor had a sticky film and separated tiles with a black substance underneath. The Maintenance Director admitted that the ice machine had not been checked for cleanliness since he started three weeks ago. The Administrator confirmed that the conditions observed were not in line with the facility's standards for cleanliness and food safety. The facility did not provide a kitchen policy, and the existing policy on food preparation and service was outdated, last revised in 2014. The deficiencies observed had the potential to affect all residents in the facility, which had a census of 49 at the time of the survey.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower. This failure was observed during a survey where water temperatures in various rooms were recorded between 129.2 degrees F and 134.5 degrees F, significantly exceeding the safe range. The facility's policy required water heaters to be set to no more than 120 degrees F, and maintenance staff were responsible for checking and recording water temperatures. However, the facility's Weekly Temperature Check Logs showed inconsistent and often unsafe temperature ranges, indicating a lack of proper monitoring and adjustment of water temperatures over several months. Additionally, the facility had been experiencing water temperature issues for months, with a new water heater installed recently, but the problem persisted with temperatures now being too high instead of too low as previously reported by the Administrator and Maintenance Supervisor. During the survey, it was observed that the digital hot water heater had a reading of 131 degrees F and an operational set point of 135 degrees F, with an error message indicating a heating circuit issue. The Maintenance Supervisor admitted to turning up the hot water heater to compensate for having only one heater instead of two for a period of time. Despite the installation of a new water heater, the facility failed to adjust the temperature settings appropriately, resulting in dangerously high water temperatures that posed a risk of burns to residents. The facility census was 49, indicating that all residents were potentially affected by this deficiency.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect by leaving two residents exposed during care. Resident #6, who has diagnoses including diabetes mellitus, atrial fibrillation, chronic diastolic heart failure, anxiety disorder, major depressive disorder, and insomnia, was observed lying in bed while Nurse Aide E and Certified Nurse Aide F performed incontinent care without closing the blinds on the window. This exposed the resident to the view of the backyard from the window. The resident's quarterly Minimum Data Set (MDS) indicated that the resident had intact cognition, was always incontinent of bladder and bowel, had impairments to one side of upper limbs and both lower limbs, and was dependent for toileting, hygiene, and mobility. Similarly, Resident #19, who has diagnoses including dementia, contracture of the hand muscle, anxiety disorder, convulsions, Parkinsonism, aphasia, and a history of transient cerebral ischemic attack, was observed sitting in a wheelchair while Nurse Aide E and Certified Nurse Aide F performed incontinent care without closing the blinds on the window. The resident was transferred via hoyer lift to the bed closest to the window, exposing the resident to the view of the courtyard. The resident's quarterly MDS indicated severe cognitive impairment, always incontinent of bladder and bowel, impairments to both upper and lower limbs, and dependency for toileting, hygiene, and mobility. Interviews with the Director of Nursing, Nurse Aide E, and the Administrator confirmed that window blinds should always be closed prior to any resident care being provided.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of unsanitary and hazardous conditions. Over several days, surveyors observed water dripping from an HVAC ceiling vent near a resident's room and the west wing nursing station, with a yellow caution cone placed beneath it. Additionally, the east wing men's handicap shower room was found with piles of fecal material, a toilet with separated caulk seal and black substance, and ceramic tiles with black substance. Similar unsanitary conditions were noted in the east wing women's shower room and a resident's room, where fecal material was smeared on the toilet seat. Residents reported ongoing issues with fecal material in the bathrooms. Further observations revealed multiple brown areas on ceiling tiles in various locations, including the memory care hall, dining room, and medical record storage area, indicating potential water damage or mold growth. The men's and women's shower rooms on the 100 Hall also had caulking with black substance and missing sections of caulk, contributing to the unsanitary environment. The facility's maintenance log showed no completed work orders since December 2023, and the Maintenance Supervisor confirmed receiving work orders related to plumbing and electrical issues but had only been in the position for three weeks. The Administrator stated that staff should complete work orders for the Maintenance Supervisor to address. The lack of a policy regarding the environment and the failure to address these maintenance issues resulted in a deficient practice that had the potential to affect all 49 residents in the facility.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents were transferred to the hospital. Resident #11 was transferred to the hospital for medical evaluation on three separate occasions and readmitted each time, but there was no documentation of written notifications provided to the resident or the resident's representative for any of these transfers. Similarly, Resident #45 was transferred to the hospital for medical evaluation and readmitted, but there was no documentation of written notification provided for this transfer either. Interviews with various staff members, including a Registered Nurse (RN), the Administrator, the Social Services Designee (SSD), the Director of Nursing (DON), and the Business Office Manager (BOM), revealed that the facility had a process in place for handling transfer/discharge notifications. However, the process was not consistently followed, as evidenced by the lack of documentation in the residents' medical records. The RN mentioned that the transfer packet included a Notice of Transfer or Discharge form, which was supposed to be mailed to the resident's responsible party, but this step was not documented. The Administrator and other staff confirmed that the forms were supposed to be filed and mailed, but there was no evidence that this was done for the transfers in question.
Failure to Provide Written Notification of Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents. Resident #11 was transferred to the hospital multiple times and readmitted to the facility without any written documentation of the bed-hold policy being provided. Similarly, Resident #45 was transferred to the hospital and readmitted without any written notification of the bed-hold policy being provided to the resident or their representative. Interviews with the facility staff revealed that the process for handling the Notice of Transfer or Discharge involved multiple steps and personnel, including the nurse, the business office, and the medical records department. However, there was a lack of consistency and verification in ensuring that the written notification of the bed-hold policy was actually provided to the residents or their representatives. The Administrator, Social Services Designee, Director of Nursing, and Business Office Manager all described different aspects of the process, but none could confirm that the notifications were consistently sent out as required by the facility's policy.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans with specific interventions for three residents out of a sample of 13. Resident #5, diagnosed with Alzheimer's disease, had a care plan that did not address specific interventions related to their condition. Resident #7, diagnosed with anxiety disorder and major depressive disorder, had a care plan that lacked specific interventions for both conditions. Resident #18, diagnosed with dementia, also had a care plan that did not address specific interventions related to their condition. Interviews with the Social Services Designee, the Minimum Data Set (MDS) Coordinator, and the Administrator confirmed that it was expected for conditions such as anxiety, depression, Alzheimer's disease, and dementia to be included in a comprehensive care plan with both pharmacological and non-pharmacological interventions. The MDS Coordinator acknowledged that correcting and updating care plans had been an ongoing concern. The Administrator also confirmed that these issues should be included in the comprehensive care plan.
Failure to Ensure Complete Hospice Care Plan and Repositioning Protocol
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had a complete hospice coordinated plan of care. Specifically, Resident #4's medical record showed that the resident was admitted to hospice on 02/27/24, but there were no facility staff signatures on the hospice coordinated plan of care dated 02/09/24. The Director of Nursing (DON) confirmed that hospice coordinated plans of care should be signed by both hospice and facility staff, indicating a lapse in the required documentation and coordination of care for the resident receiving hospice services. Additionally, the facility failed to provide necessary care and services in accordance with professional standards of practice for Resident #23, who required repositioning due to an impairment. Despite the resident's care plan indicating the need for repositioning every two hours, observations showed that the resident remained in the same position for extended periods on multiple occasions. Interviews with the resident and staff confirmed that the resident was not being repositioned as required, and the resident's plan of care did not reflect a two-hour turn schedule. The DON acknowledged that residents who cannot turn themselves should be repositioned every two hours, highlighting a failure in adhering to the care plan and repositioning protocol for Resident #23.
Improper Handling of Foley Catheter Tubing and Drainage Bags
Penalty
Summary
The facility failed to ensure proper placement and handling of Foley catheter tubing and drainage bags for two residents. Resident #4, who was admitted with an unstageable sacral wound, had an incident where a Registered Nurse used their foot to push the resident's bedside table, causing their shoe to touch the catheter tubing. This action violated the facility's policy on catheter care, which emphasizes the importance of maintaining aseptic technique and preventing catheter-associated urinary tract infections by ensuring that catheter tubing and drainage bags are kept off the floor and not touched by shoes or other objects. Resident #7, admitted with a diagnosis of benign prostatic hyperplasia, was observed multiple times with their catheter drainage bag and tubing touching the floor. The drainage bag was also not covered with a dignity bag as required. Interviews with the resident and staff, including the Director of Nursing, Registered Nurse, and Licensed Practical Nurse, confirmed that catheter bags and tubing should not touch the floor and should be kept in dignity bags. The staff acknowledged that the catheter drainage bags should be changed weekly and maintained off the floor, but these protocols were not consistently followed for Resident #7.
Improper Storage and Use of Nasal Cannulas and Oxygen Orders
Penalty
Summary
The facility failed to ensure proper storage of nasal cannulas when not in use for two residents and did not follow oxygen orders for one resident. Resident #27, diagnosed with chronic obstructive pulmonary disease (COPD), was observed with a nasal cannula lying on the floor, which was then picked up by a CNA and placed in the resident's nostrils. Resident #42, diagnosed with congestive heart failure (CHF) and atherosclerotic heart disease, was observed multiple times with the nasal cannula improperly stored or not in use while the oxygen concentrator was set at incorrect levels. The nasal cannula was found on the floor, under a pillow, or hanging from the resident's ear, and the oxygen concentrator was set at 2.5 L/min and 3 L/min instead of the prescribed 2 L/min. Interviews with the DON, RN, LPN, and the Administrator confirmed that nasal cannulas should not touch the floor and should be stored in sealed containers when not in use. The oxygen concentrator should be set according to the physician's orders. The staff acknowledged that the nasal cannulas should not be left on the floor, under a pillow, or hanging from a resident's ear, and that the concentrator settings should match the physician's orders. The facility's policy on oxygen administration was not followed, leading to these deficiencies.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had multiple diagnoses including PTSD, bipolar disorder, essential tremor, and dementia, was admitted to the facility on an unspecified date. Despite the resident's PTSD being documented in their medical records and a PTSD assessment indicating a history of stressful sexual experiences, the facility did not address PTSD in the resident's care plan. The care plan lacked documentation of past trauma or any triggers that could cause the resident to exhibit behaviors related to PTSD. Interviews with the resident and facility staff revealed that the resident was not informed about their PTSD diagnosis, and the facility staff did not discuss PTSD with the resident. The Social Services Designee and the Minimum Data Set (MDS) Coordinator both acknowledged that PTSD should have been included in the resident's comprehensive care plan, with appropriate pharmacological and non-pharmacological interventions. The Administrator also confirmed that PTSD should be addressed in the care plan. The failure to include PTSD in the care plan and provide necessary interventions was identified as an ongoing concern in the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 6.25%. This deficiency was identified through observation, interview, and record review. Specifically, two residents were affected by the administration of expired insulin and incorrect insulin dosages. Resident #17 received expired Novolog insulin, which was administered by a Certified Medication Technician (CMT) who was aware of the expiration but stated that the pharmacy had not sent a new supply. Resident #19 was almost administered an incorrect dosage of Novolog insulin; the CMT drew up 4 units instead of the prescribed 2 units but stopped before administration upon realizing the mistake. Both incidents indicate a failure to adhere to the facility's policies on insulin administration and medication storage, as well as the manufacturer's instructions for Novolog insulin usage and expiration dates. The Director of Nursing (DON) and the Administrator both confirmed that they expected CMTs and nurses to double-check expiration dates and insulin dosages before administration. The DON emphasized that it was the responsibility of the CMTs and nurses to ensure that expired insulin was not used and to seek alternatives if necessary. Despite these expectations, the observed practices did not align with the facility's policies, leading to the identified deficiencies in medication administration for the affected residents.
Failure to Discard Expired Insulin Vials
Penalty
Summary
The facility failed to ensure that opened, multi-use vials of insulin were discarded after the expiration date of 28 days, as per the manufacturer's instructions. During an observation of the Certified Medication Technician (CMT) medication cart, it was found that multiple vials of insulin, including Novolog, insulin aspart, Fiasp, and lispro, were opened and dated beyond the 28-day expiration period. The CMT responsible for checking the expiration dates on the cart, along with other nursing staff, incorrectly stated that insulin would expire 27 days after the opened date, which contradicts the manufacturer's guidelines of 28 days. The Director of Nursing (DON) confirmed that insulin should not be used after 28 days from the opened date and that staff are expected to check expiration dates before administering the medication. The DON also stated that expired insulin should be held and a replacement should be called for. This deficiency was identified through both observation and interviews with the CMT and DON, highlighting a lapse in adherence to medication storage and expiration protocols within the facility.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care, catheter care, and wound care for multiple residents. Specifically, staff members did not perform hand hygiene between glove changes, did not use gloves and gowns as required, and failed to clean contaminated surfaces such as urine-soaked mattresses. These lapses were observed during care for four residents receiving incontinent care, one resident receiving catheter care, and two residents receiving wound care. The facility's policies on hand hygiene and wound care were not followed, contributing to these deficiencies. For instance, during incontinent care for one resident, nursing assistants failed to perform hand hygiene and change gloves appropriately, and did not clean a urine-soaked mattress before placing a clean sheet on it. Similarly, during wound care for another resident, a licensed practical nurse and a registered nurse did not perform hand hygiene between glove changes, did not use gowns, and handled wound dressings and supplies without maintaining a clean field. These actions were inconsistent with the facility's infection control policies. Additionally, during catheter care for a resident, a nursing assistant did not perform hand hygiene between glove changes. Observations also revealed that staff did not follow enhanced barrier precautions, such as wearing gowns and gloves, when required. Interviews with the Director of Nursing, nursing assistants, and the Administrator confirmed that hand hygiene and glove changes should be performed as needed, and enhanced barrier precautions should be followed, but these practices were not consistently implemented.
Lack of Documentation for Vaccine Education
Penalty
Summary
The facility failed to document pertinent education provided to residents or their representatives regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines. This deficiency was identified for four residents out of five sampled, with the facility's census being 49. Specifically, the medical records of these residents showed that they received the vaccines, but there was no documentation indicating that the facility provided the necessary information and education prior to administration. For instance, Resident #6 received the influenza vaccine on 11/20/23, but there was no documentation of education provided. Similarly, Resident #23 received both the influenza and pneumococcal vaccines, but again, no documentation of education was found in the medical records. During an interview, the Director of Nursing (DON) confirmed that education should be provided prior to any vaccine being administered and that this education should be documented. However, the facility did not have a policy regarding influenza and pneumonia immunizations, which contributed to the lack of documentation. This oversight was consistent across multiple residents, including Resident #43 and Resident #44, who also received vaccines without documented education. The absence of documented education for these vaccines indicates a systemic issue within the facility's vaccination process.
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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