Chariton Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, Missouri.
- Location
- 902 Manor Drive, Salisbury, Missouri 65281
- CMS Provider Number
- 265526
- Inspections on file
- 28
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Chariton Park Health Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, substance abuse history, suicidal ideations, and prior elopements was identified as an elopement risk and placed on intensive monitoring with q15‑minute face checks. Despite this, staff did not consistently or timely perform and document the required checks, often only opening the door to see if the resident was present and acknowledging being behind due to a busy shift. During this time, the resident used a metal watch band to remove a window security block, opened the window, pushed out the screen, exited into a fenced courtyard, moved a picnic table to climb onto the roof, then jumped down outside the fenced area and walked several blocks away before being noticed by an off‑duty employee and contacted by police.
A resident with schizoaffective disorder, PTSD, substance use history, and prior suicidal ideation had care-planned coping mechanisms that included watching calming TV programs and gaming. After staff removed items with cords, including the TV and gaming system, the resident was placed on 1:1 observation but was not provided access to the TV despite repeatedly requesting it as a coping tool. The assigned staff member had no prior 1:1 experience and focused only on physical supervision, while other team members were unaware of the resident’s escalating distress and requests. The resident became increasingly agitated, overturned carts, broke a window, and used a glass shard to cut the forearm, requiring ED and psychiatric care. Following the resident’s return, staff failed to thoroughly remove remaining glass shards from the room, allowing the resident to find and reuse shards on multiple occasions to cut the same forearm while alone. Although the care plan was updated to reflect high suicide risk and called for a written safety plan and specific self-harm interventions, the record showed no evidence that a written safety plan was developed with the resident, demonstrating a failure to implement person-centered behavioral health services and maintain a safe environment.
A resident with a history of aggressive behaviors was sent to a hospital for psychiatric evaluation after multiple assaults on staff. The facility issued an immediate discharge notice while the resident was hospitalized, but failed to specify an appropriate discharge location as required, instead listing the psychiatric hospital. The discharge notice was not amended to correct this, resulting in a deficiency.
A resident with a history of aggressive behavior and mental illness was not provided with the required level of supervision, resulting in an unprovoked physical assault on another resident in a vending room. The assaulted resident sustained facial lacerations requiring sutures. The facility's existing interventions and monitoring failed to prevent this incident, despite documented risks and care plan requirements.
Residents on the secured unit were routinely provided only plastic forks and spoons, with no knives, making it difficult to eat certain foods and leading some to use their hands. Staff and residents reported that plastic utensils were used to avoid delays in smoke breaks caused by the need to account for metal silverware, rather than based on resident preference or safety needs. This practice did not align with the facility's policy to promote dignity and consider resident preferences.
A resident with a history of substance abuse was admitted without staff completing the required search and inventory of personal belongings, allowing the resident to bring in and share illegal drugs and prescription medication with others. Multiple residents subsequently tested positive for methamphetamines and THC. Staff interviews confirmed the search was not done due to competing priorities, and leadership was unaware the protocol had not been followed.
Staff failed to document the clinical rationale for administering PRN antipsychotic and antianxiety medications to a resident with multiple psychiatric diagnoses. Despite facility policy requiring assessment and documentation of behaviors or symptoms justifying PRN use, staff administered these medications without recording the necessary behavioral evidence in the progress notes, as confirmed by MAR reviews and staff interviews.
Facility staff did not notify a resident's physician, NP, or guardian about significant changes in the resident's condition, including refusal of diagnostic procedures, ongoing weight loss, and low blood pressure readings, despite facility policy requiring such notifications. The resident had severe cognitive impairment and a guardian, but documentation and interviews confirmed that notifications were not consistently made regarding these critical health events.
The facility did not follow physician orders to provide double portions or double entrees at meals for several residents, as observed during meal service and confirmed by resident interviews. Despite documented orders and care plans indicating the need for increased food portions, dietary staff did not serve the prescribed amounts, citing budget cuts. Key staff members, including the DON, Administrator, and Dietitian, were unaware of the change and stated that physician orders should be followed.
A facility failed to provide adequate supervision after an altercation between two residents, leading to a second incident involving another resident. Despite being on one-on-one supervision, a resident approached others in the dining room, resulting in a physical altercation. Staff interviews revealed a lack of effective intervention and communication, contributing to the deficiency.
A resident with a history of aggression physically assaulted another resident after a verbal altercation. The facility staff failed to separate the residents or monitor the aggressive resident adequately, leading to the incident. The aggressive resident's care plan lacked necessary interventions, and staff were unaware of the incident's severity.
A facility failed to report a resident-to-resident abuse incident to the state agency. The incident involved a verbal and physical altercation between two residents, resulting in physical harm. The facility's policy requires immediate reporting, but the incident was not documented, and the resident's legal guardian, physician, or medical director were not notified. Staff interviews revealed a lack of awareness and communication about the incident.
A resident reported being verbally and physically attacked by another resident, but the facility failed to investigate the incident. The activity director intervened during the altercation, but the administrator and DON were unaware of the physical attack and no investigation was conducted. This resulted in a deficiency in handling abuse allegations.
A resident with mental health disorders engaged in inappropriate text communication with an LPN, who responded to the resident's requests for a sexual relationship via social media. The resident was cognitively intact but had hallucinations and delusions. The facility's policies prohibit such interactions, and the incident was discovered during an unrelated investigation.
The facility did not assess the ability of three residents to consent to sexual relations, resulting in a failure to protect one resident from sexual abuse. One resident, with mood disorders and mild mental retardation, reported being forced into oral sex by another resident with oppositional defiant disorder and moderate intellectual disabilities. The facility's policies on assessing consent capacity and preventing non-consensual sexual activities were not effectively implemented. Staff awareness of sexual activities and lack of intervention, along with concerns from legal guardians, highlighted deficiencies in supervision and adherence to guidelines.
The facility failed to store, prepare, and serve food in accordance with professional standards, leading to multiple deficiencies in food safety and sanitation. Observations revealed improperly sealed food items, unsanitary storage conditions, uncovered trash cans, dirty ice and water dispensing machines, and poor hygienic practices by staff.
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple incidents of staff being rude, dismissive, and using inappropriate language towards residents. Residents reported fear of retaliation for filing grievances, and specific staff members were identified as frequently mistreating residents. Observations and interviews confirmed these issues.
The facility failed to protect residents' rights to retain and use personal possessions, specifically instant coffee, by keeping it locked up and controlling access times. This affected eight residents, including those with guardians and those who were cognitively intact. Residents expressed frustration over the policy, and there was no documented reason in their medical records to justify the restriction.
The facility failed to provide reasonable accommodation for a resident who required assistance to get out of bed and had a broken wheelchair. Additionally, the facility did not provide adequate seating in the Station 2 dining area, forcing residents to eat with trays on their laps due to insufficient chairs and table space.
The facility failed to promptly address residents' concerns voiced in resident council meetings and did not hold monthly meetings as required. Various issues, including missing clothing and dietary requests, were not documented or resolved. Interviews revealed a lack of clarity and consistency in the process for addressing concerns, with lapses occurring during a transition period.
The facility failed to maintain a clean, sanitary, and orderly environment, with multiple deficiencies observed in resident rooms and common areas, including torn drywall, missing paint, water stains, and damaged furniture. A resident reported issues with a non-functional cold-water faucet and the removal of their TV, which had not been replaced despite requests. Staff interviews revealed a lack of clarity regarding cleaning responsibilities and insufficient maintenance efforts.
The facility failed to ensure residents knew how to file grievances, where forms were located, or how to complete them. Multiple residents expressed fear of retaliation and reported unresolved issues, such as missing clothing. The Social Services Director was unaware of her role in the grievance process, and no grievances had been filed since she assumed the role.
The facility failed to complete required pre-employment screenings for four of eight sampled employees, including criminal background checks, Employee Disqualification List checks, and Nurse Aide Registry checks, as mandated by facility policy. These checks were either not completed or were conducted after the employees had already started working.
The facility failed to ensure proper medication administration and monitoring, including preparation and administration by the same staff, obtaining physician orders for self-administration, completing accuchecks, and documenting narcotic counts.
The facility failed to provide an ongoing program of meaningful activities to meet the interests and well-being of residents. Several residents were observed with no staff interaction or activities, and there was a lack of documented participation in activities for extended periods. The Activity Director confirmed the lack of scheduled activities on weekends and evenings and acknowledged the need for more one-on-one programming for certain residents.
The facility failed to ensure the safety of a resident with suicidal ideations by not removing plastic bags from their room and not documenting increased monitoring. Additionally, the facility did not use wheelchair foot pedals for another resident, and failed to prevent a third resident from being transported unsafely in a rollator walker by another resident.
The facility failed to offer sufficient fluids to maintain proper hydration and health for three residents. Observations showed that residents did not have water pitchers or glasses of fluids in their rooms, despite the facility's policy. Staff interviews confirmed that water pitchers were either broken or not replaced, and fluids were not consistently offered as required.
The facility failed to ensure that two nurse aides completed a CNA training program within four months of their employment. The Administrator admitted awareness of the timeline but stated that the aides had 'slipped through the cracks.' The facility did not have a specific policy on CNA training programs.
The facility failed to ensure that four residents on psychotropic medications received a gradual dose reduction (GDR) unless clinically contraindicated. Pharmacy review notes and psychiatric physician notes lacked documentation of GDR attempts or contraindications, and observations showed residents experiencing symptoms without appropriate GDR attempts.
The facility failed to discard an opened insulin pen after 28 days of use for a resident with diabetes and did not dispose of expired house stock influenza vaccines. Inspections revealed lapses in following the facility's medication management policies.
The facility failed to meet the nutritional needs of residents and ensure correct portion sizes during meals. Dietary staff did not follow standardized recipes and portion sizes, leading to residents feeling hungry and not receiving adequate nutrition. The dietary manager and registered dietitian acknowledged the issue, but the expectations were not consistently met.
The facility failed to provide residents with palatable meals served at appetizing temperatures and a variety of snacks. Multiple residents reported that the food was often bland, lacked seasoning, and was not served at the appropriate temperature. Observations confirmed these complaints, and the facility's dietary policies were not consistently followed. The facility's staff also failed to honor residents' meal preferences and dietary needs.
The facility failed to implement proper infection control measures, including water system maintenance to prevent Legionnaire's Disease, appropriate COVID-19 precautions, and TB testing for staff. Additionally, hand hygiene protocols were not followed during medical procedures, and respiratory equipment was not stored correctly.
The facility failed to notify responsible parties and physicians when three residents experienced changes in condition, including a tooth extraction, pneumonia, and a significant drop in blood pressure. This lack of communication led to deficiencies in the facility's compliance with its policies and regulatory requirements.
A CNA took $450.00 from a resident who offered to help with unpaid bills after overhearing the CNA's financial problems. The CNA initially refused but later accepted the money, promising to repay it in installments. The CNA only made one repayment, leading the resident to report the incident. The CNA admitted to taking the money and was terminated after an investigation.
The facility failed to prevent a decline in range of motion and the development of contractures for a resident with a history of left hand contracture, hemiplegia, hemiparesis, and chronic pain. Despite the resident's condition, the facility did not provide necessary restorative therapy or regular care, leading to severe contraction and pain. Staff interviews revealed a lack of awareness and implementation of a restorative care program, and the resident's guardian and primary physician expressed concerns about the lack of therapy and contracture management.
The facility failed to assess residents for the risk of entrapment, document attempted alternatives, and obtain informed consent before installing bed rails for two residents. One resident with multiple diagnoses and another with cerebral palsy were observed with bed rails without proper documentation or consent. Interviews with staff confirmed that required assessments and consents were not completed.
The facility failed to properly administer insulin to two residents, as an LPN did not prime the insulin pens and did not hold the needle in the skin for the required six seconds after administration, leading to significant medication errors.
A resident with a history of anxiety and schizophrenia did not receive necessary dental services and follow-up care. Despite a recommendation for tooth extractions due to severe decay, the facility failed to act on these recommendations, leading to continued dental pain and decay. Staff interviews revealed that the recommendations were mistakenly filed away and not addressed in a timely manner.
A resident with a history of chronic conditions did not receive the pneumococcal vaccine despite giving consent upon admission. The DON confirmed the oversight, and both the Administrator and primary care physician expected the vaccine to be offered without delay.
The facility failed to complete entrapment assessments and obtain necessary consents and physician orders for two residents using bed rails. One resident had a 1/8 bed rail without documentation or assessment, while another used candy cane rails without a physician order or entrapment assessment. Interviews revealed that required safety measures were not followed.
The facility failed to post the results of the most recent survey and complaint investigations in places readily accessible to residents, family members, and legal representatives. Residents were unaware of their right to view the survey results, and observations confirmed the results were not posted in common areas or Station 2. Staff interviews revealed a lack of awareness about the requirement for survey results to be accessible without asking staff.
Failure to Perform 15‑Minute Safety Checks Allows Elopement Through Window and Roof
Penalty
Summary
The deficiency involves the facility’s failure to provide protective oversight and complete ordered 15‑minute safety checks for a known elopement‑risk resident, resulting in an undetected elopement through the resident’s room window. The resident had multiple psychiatric and behavioral diagnoses, including schizoaffective disorder, psychoactive substance abuse, suicidal ideations, mood disorder, ADHD, opioid abuse, anxiety disorder, and insomnia due to another mental disorder. The resident’s PASRR and care plan documented a long history of mental health issues, substance use, homelessness, prior overdoses, abuse history, and a need for ongoing psychiatric care, low‑stimulation environment, consistent routines, and environmental supports to prevent elopement. Facility assessments, including elopement risk evaluations, identified the resident as at risk for elopement, with a documented history of elopement from prior secured facilities and from home, as well as prior elopement from this facility shortly after admission. The facility’s own elopement and intensive monitoring policies required systematic identification and monitoring of residents at risk for elopement, including intensive monitoring and 15‑minute checks for residents with poor impulse control or elopement ideation. The resident’s elopement risk evaluation showed an increasing risk score over time, and nursing notes documented the resident’s agitation, drug‑seeking behavior, difficulty with redirection, and multiple attempts to get out the door. Staff documented that the resident was on intensive monitoring with every 15‑minute face checks, and the care plan called for completion of elopement risk assessments and face checks/intensive monitoring. On the day of the incident, staff recognized that the resident was “spiraling,” irritated, and had verbalized intent to run away and had attempted to open a door earlier in the day. Despite this, the 15‑minute checks were not consistently or timely completed as ordered, and staff responsible for the checks acknowledged being behind on face checks due to a busy day and documenting checks when they had time rather than at the required intervals. During the period when the resident was supposed to be under 15‑minute face checks, the resident used a metal watch band to loosen and remove the screws from a rubber security block in the windowsill, slid open the side window, pushed out the screen, and exited into a fenced courtyard. The resident reported that it took about an hour to remove the block and open the window and that he closed the curtain when staff entered the room so they would not notice his actions. Staff performing checks reported that they completed face checks by opening the door and seeing if the resident was in the room, without observing what the resident was doing. After exiting into the courtyard, the resident moved a picnic table next to the building, stood on it, climbed onto the roof, crossed the roof, jumped down into an open area outside the fenced courtyard, and walked several blocks down city streets. Facility staff were unaware the resident had eloped until an off‑duty employee saw the resident walking in pajamas and a coat and notified the facility, and a police officer subsequently made contact with the resident, who admitted leaving the facility through the window and walking away.
Removal Plan
- Transferred Resident #1 to the hospital by ambulance per the resident's request after the elopement event
- Placed Resident #1 on one-on-one observation for safety upon return to the facility
- Notified the resident's guardian and physician of the elopement
- Arranged psychiatric services evaluation for Resident #1
- Implemented additional interventions to ensure the security of Resident #1's window as well as all windows in the facility
- Secured the courtyard picnic table to the concrete patio
- Educated all staff regarding the resident elopement policy, residents at risk for elopement, and intensive monitoring procedures
- Educated staff on documentation requirements for face checks and window security
Failure to Implement Behavioral Health Care Plan and Maintain Safe Environment for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with serious mental illness, a history of trauma, and known coping mechanisms, resulting in multiple self-harm incidents. The resident had diagnoses including schizoaffective disorder, mood disorder, ADHD, PTSD, opioid abuse, anxiety disorder, and insomnia, with a documented history of severe bullying, sibling suicide, homelessness, substance abuse, and the death of a child. The PASRR and care plan identified the need for a low-stimulation environment, consistent routines, psychotherapy, ongoing psychiatric care, and person-centered, trauma-informed interventions. The care plan also directed staff to monitor for anxiety, avoid power struggles, provide opportunities for healthy energy release, and use non-invasive coping mechanisms before behavioral outbursts. Staff were aware that the resident’s coping mechanisms included watching calming television programs (especially Animal Planet), gaming, music, and writing in notebooks. On one occasion, the resident’s guardian reported that the resident had voiced self-harm ideations, after which the resident was placed on one-on-one supervision and staff were instructed to search the room and remove harmful objects. Items with cords, including the television, gaming system, power cords, shoelaces, and hoodies with strings, were removed from the room. Two days later, while on one-on-one observation, the resident repeatedly requested the return of the television to watch Animal Planet, a known coping mechanism, and repeatedly asked to see the Environmental Services Supervisor to help get the television back. The one-on-one staff member assigned that day had never previously provided one-on-one observation and understood their role as only to prevent the resident from hurting self or others. The staff member did not provide additional interventions or access to the television, and the Social Services Designee later stated there was no reason to keep the television and personal items from the resident while on one-on-one observation and was not aware of the resident’s repeated requests or escalating distress. As the resident’s requests for the television went unmet and the Environmental Services Supervisor was unavailable, the resident became increasingly agitated, knocked over linen carts, threw items in the hallway, and then went to the room and broke the inside pane of the double-pane window. The resident sat on the bed surrounded by glass, picked up a shard, and cut the left forearm from elbow to wrist, requiring emergency transport for medical and psychiatric evaluation. After the resident’s return from the hospital, staff failed to ensure the room was free of remaining glass shards. The resident later found glass in the windowsill and under the bed on separate occasions, cutting the same forearm multiple times while alone in the room. Staff documentation and interviews confirmed that shards remained in the windowsill and curtain area and that the room had not been thoroughly cleared of glass before the resident’s return. Although the care plan was updated to include high suicide risk and the need for a written safety plan and specific self-harm interventions, the record showed no evidence that staff collaborated with the resident to develop the written safety plan as directed. These actions and inactions demonstrate the facility’s failure to implement care-planned, person-centered behavioral health interventions, to maintain a safe environment free of known hazards, and to provide necessary services to support the resident’s highest practicable mental and psychosocial well-being. The deficiency is further supported by staff and resident interviews describing the mismatch between the resident’s identified needs and the care actually provided. Staff acknowledged that the resident’s coping mechanisms included watching calming animal shows and gaming, and that removal of personal items, including the television, increased the resident’s agitation. The resident reported feeling that staff had taken away all coping mechanisms, leaving nothing to do while on one-on-one observation, and stated that close proximity and talkative staff increased anxiety. The resident described breaking the window with a metal cup, cutting the left forearm to obtain transfer to the hospital, and later intentionally searching the windowsill and under the bed for glass shards to cut the arm again. The Social Services Designee confirmed that glass shards from the initial incident remained in the room and that staff did not thoroughly clean the room before the resident’s return. Additionally, although the care plan called for development of a written safety plan and teaching alternative coping skills, the record contained no documentation that such a written safety plan was created with the resident, indicating a failure to implement the care-planned intervention for managing self-directed violence risk.
Failure to Properly Identify Discharge Location During Immediate Discharge
Penalty
Summary
The facility failed to follow proper immediate discharge procedures for a resident who exhibited increased aggressive behaviors, including multiple physical assaults on staff. After a series of incidents involving physical aggression, law enforcement intervention, and psychiatric evaluation, the resident was sent to a hospital. The facility then determined it could not meet the resident's needs and issued an immediate discharge notice while the resident was at the hospital. However, the discharge notice identified the psychiatric hospital as the discharge location, which did not meet regulatory requirements for specifying an appropriate discharge location. The facility's policy required that, in cases of emergency transfer and subsequent discharge, the discharge location must be properly identified and the resident's status must be evaluated based on their condition at the time of transfer. Despite this, the facility did not amend the immediate discharge notice to reflect an appropriate discharge location after being informed of the error. The discharge letter was also improperly dated, and there was no documentation explaining why the resident was taken into custody on one of the dates in question. The resident, who had a guardian, remained in the hospital pending a hearing after the discharge was appealed. The facility had attempted to find an alternative placement for the resident for several months but was unsuccessful due to the resident's aggressive behaviors. The failure to properly identify a discharge location and to amend the discharge notice as required constituted the deficiency cited in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a documented history of serious mental illness, including schizophrenia, bipolar disorder, and intermittent explosive disorder, was admitted to the facility with known aggressive and assaultive behaviors. The resident's PASRR and care plan indicated a need for 24-hour protective oversight and specific environmental and supervision interventions to prevent harm to self or others. Despite these documented needs, the resident was on 15-minute face checks rather than continuous supervision at the time of the incident. On the day of the event, the resident entered a vending room where two other residents were present. Without provocation, the resident forcefully slammed another resident's head against a vending machine and struck the resident multiple times in the face with a closed fist. The assaulted resident sustained lacerations to the right eyebrow and upper lip, both requiring sutures. Multiple witness statements and progress notes confirmed the unprovoked nature of the attack and the injuries sustained. The facility's abuse and neglect policy required assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as sufficient staff deployment and supervision to prevent abuse. However, the interventions in place at the time did not prevent the resident with a known history of violence from attacking another resident, resulting in physical harm that met the facility's definition of abuse.
Failure to Provide Appropriate Utensils Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity on the secured unit by providing only plastic forks and spoons for meal service, with no knives available for residents to use. Observations showed that residents were served meals such as meatballs and pork chops, which could not be easily cut with the provided utensils, resulting in residents having to use their hands to eat meat. Multiple residents expressed dissatisfaction with the use of plastic utensils, stating it was difficult to eat certain foods and that they did not like using plastic silverware. Staff interviews confirmed that plastic utensils were routinely used for safety reasons and to avoid delays in residents' smoke breaks, which occurred if metal silverware was unaccounted for after meals. Although butter knives were reportedly available upon request, staff did not routinely provide them, and residents were not always aware they could request them. The facility's policy on promoting and maintaining dignity emphasized treating residents with respect and considering their preferences and former lifestyles. However, the practice of serving meals without appropriate utensils, particularly knives, did not align with this policy. Staff and residents indicated that the use of plastic utensils was primarily to prevent issues with accounting for metal silverware and to avoid delaying smoke breaks, rather than based on individual resident needs or preferences. The deficiency affected all 57 residents on the secured unit, as observed and confirmed through interviews and record review.
Failure to Search Resident Belongings Allows Illegal Substances in Facility
Penalty
Summary
Staff failed to follow facility policy regarding the search and inventory of a resident's personal belongings upon admission, resulting in the resident bringing prohibited and illegal substances into the facility. The policy required the admission coordinator or designee to complete an initial inventory and ensure no contraband entered the facility, with floor staff under the charge nurse responsible for addressing and removing any items not allowed. On the night of admission, staff did not complete the required search due to being occupied with other incidents, including a resident attempting to elope and multiple admissions, and subsequently did not want to disturb the new resident who had fallen asleep. The resident, who had a documented history of polysubstance abuse, later reported bringing a dab pen containing cannabis concentrate, 20 tablets of Adderall, and bath salts (an illegal synthetic stimulant) into the facility. The resident stated that none of the staff searched their belongings, which were kept in a duffle bag. The resident admitted to consuming some of the substances and sharing them with other residents. Drug testing confirmed that multiple residents tested positive for methamphetamines and THC, and the resident did not have a physician's order for Adderall. Interviews with staff revealed that the required inventory and search process was not completed at the time of admission, and the Director of Nursing and Administrator were unaware that the search had not occurred. Staff acknowledged that belongings should have been kept at the nurse's station until a search could be completed, but this protocol was not followed. As a result, illegal and controlled substances were introduced and distributed within the facility, directly violating facility policy and federal regulations.
Failure to Document Rationale for PRN Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to document the rationale for administering as needed (PRN) antipsychotic medications to a resident, as required by facility policy. The policy mandates that staff must assess and document the clinical rationale, including the resident's behaviors or symptoms that justify the use of PRN psychotropic medications, and record the effectiveness of the intervention. However, multiple reviews of the resident's Medication Administration Record (MAR) and progress notes revealed that staff consistently administered PRN antipsychotic and antianxiety medications without documenting the specific behaviors or evidence of anxiety that warranted their use. The resident involved had a complex psychiatric history, including diagnoses of schizophrenia, bipolar disorder, schizoaffective disorder, intermittent explosive disorder, and generalized anxiety disorder. The care plan and physician orders indicated the use of several scheduled and PRN psychotropic medications to manage behavioral symptoms such as aggression, agitation, and anxiety. Despite these directives, staff did not provide the required documentation in the progress notes to support the administration of PRN medications, even though the MAR indicated the medications were given and noted as effective. Interviews with staff, including an LPN, the DON, the Administrator, and the psychiatric provider, confirmed that documentation practices did not align with facility policy. Staff acknowledged that PRN medications were sometimes given based on the resident's request or non-verbal cues, but the necessary behavioral documentation was missing. The psychiatric provider also expected staff to document the resident's behaviors when PRN medications were administered to inform ongoing treatment decisions, but this was not consistently done.
Failure to Notify Physician and Guardian of Resident's Significant Condition Changes
Penalty
Summary
Facility staff failed to notify a resident's physician, nurse practitioner (NP), and guardian of significant changes in the resident's condition, including refusal of ordered diagnostic procedures, ongoing weight loss, and low blood pressure readings. The facility's policies required prompt notification of the resident, physician, and representative when there were changes in condition or treatment, but documentation and interviews revealed that these notifications did not consistently occur. Specifically, there was no evidence that the guardian, NP, or physician were informed when the resident refused a CT/Urogram, experienced notable weight loss over several months, or had low blood pressure readings while on antihypertensive medications. The resident involved had a history of severe cognitive impairment, bipolar disorder, and benign prostatic hypertrophy, and was under the care of a guardian due to impaired decision-making capacity. The resident's care plan and assessments indicated the need for involvement of the guardian in care decisions and highlighted the importance of notifying the physician and NP of changes in health status. Despite this, the medical record lacked documentation of notifications to the guardian or providers regarding the resident's refusal of diagnostic tests, significant and ongoing weight loss, and episodes of low blood pressure. The Registered Dietitian's notes also did not prompt documented communication with the NP or guardian regarding the resident's nutritional decline. Interviews with staff, the NP, and the resident's guardian confirmed that required notifications were not made. The NP stated he was not informed of the resident's refusal of an abdominal X-ray or of the low blood pressure readings, and the guardian reported not being notified of the resident's weight loss, low blood pressure, or refusal of procedures. Staff interviews revealed uncertainty or lack of recall regarding whether notifications were made, and the administrator acknowledged that staff should have communicated these changes to the NP and guardian. The deficiency centers on the facility's failure to follow its own policies for timely and appropriate notification of significant changes in a resident's condition.
Failure to Provide Double Portions as Ordered by Physician
Penalty
Summary
The facility failed to follow physician orders to provide double portions or double entrees at meals for five residents who had documented orders for such diets. Observations during meal service showed that dietary staff did not serve double portions or entrees to these residents, despite their orders being clearly listed on the Diet Type Report and physician order sheets. Interviews with the affected residents revealed that they were not receiving the prescribed amounts of food, with some reporting ongoing hunger and concerns about weight stabilization. Care plans for these residents also indicated the need for double portions, particularly in cases of past significant weight loss. The Dietary Manager stated that the practice of serving double portions had been discontinued due to budget cuts, under the belief that it was a matter of resident preference rather than a medical necessity. However, the Director of Nursing, Administrator, and Consultant Dietitian all indicated that they were unaware of this change and affirmed that staff should follow physician orders for diet. The failure to provide double portions as ordered was observed consistently during the lunch meal service, and staff interviews confirmed the deviation from prescribed dietary plans.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision and oversight following an altercation between two residents, leading to a second altercation involving another resident. Initially, Residents #1 and #3 were placed on one-on-one supervision after an altercation where Resident #1 was pushed down by Resident #3. Despite this measure, staff did not effectively separate the residents or intervene to prevent further incidents. Resident #1, who had moderately impaired cognition and a history of mental health issues, was involved in a subsequent altercation with Resident #2, who was cognitively intact but had a history of hallucinations and delusions. The facility's Behavioral Emergency Policy outlines that staff should recognize when a resident poses a danger and utilize de-escalation techniques as a first resort. However, during the incident, staff failed to adequately monitor and redirect the residents involved. Resident #1, while under one-on-one supervision, approached Resident #3 and Resident #2 in the dining room, leading to Resident #2 striking Resident #1. The staff member providing supervision to Resident #1 did not intervene effectively, citing concerns about personal safety and the speed of the incident. Interviews with staff, including the Director of Nursing and the Interim Administrator, revealed expectations for immediate response to de-escalate situations and protect residents from harm. However, the staff's actions did not align with these expectations, as they failed to prevent the second altercation. The report highlights a lack of effective communication and intervention strategies among staff, contributing to the deficiency in resident supervision and safety.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behaviors. The incident involved a resident who was verbally assaulted by another resident in the hallway, which escalated to a physical altercation in the dining area. The staff did not adequately separate the residents or monitor the aggressive resident after the initial verbal assault, allowing the situation to escalate to physical violence. The aggressive resident had a documented history of aggression and required 24-hour supervision due to safety concerns. Despite this, the resident's care plan did not include interventions or recommendations to address these behaviors. The staff's failure to implement a 1:1 monitoring system or to separate the residents after the initial verbal altercation contributed to the physical assault, resulting in the victim sustaining scratches and hair loss. Interviews with staff and administration revealed a lack of awareness and communication regarding the incident and the aggressive resident's history. The director of nurses and the administrator acknowledged that the residents should have been separated and that closer monitoring could have prevented the physical assault. The facility's policies on abuse and neglect were not effectively followed, leading to the deficiency.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents to the state agency as required. The incident involved a verbal and physical altercation between two residents, where one resident became frustrated with the other for using the phone for an extended period. This led to a confrontation where the resident on the phone became aggressive, resulting in physical harm to the other resident, including a scratch on the neck and hair being pulled out. The facility's policy mandates immediate reporting of such incidents to the administrator and appropriate agencies, but this was not followed. The incident was not documented in the medical records, and the resident's legal guardian, physician, or medical director were not notified. Interviews with staff revealed a lack of awareness and communication about the incident, with some staff members not recalling the event or their involvement in it. The director of nurses and the administrator were unaware of the physical altercation and the need for reporting. The administrator acknowledged awareness of a verbal altercation but not the physical attack. The failure to report and document the incident as per the facility's policy resulted in a deficiency in handling and reporting abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal and physical resident-to-resident abuse involving two residents. Resident #1, who was cognitively intact, reported that Resident #3 became angry after being asked to get off the phone, leading to a verbal altercation. Resident #3 then physically attacked Resident #1 by shoving, scratching, and pulling out a clump of hair. The activity director and another staff member intervened, but no investigation was initiated following the incident. The activity director witnessed the altercation and attempted to separate the residents, calling a code green for additional staff assistance. Despite the administrator being present in the facility at the time, there was no follow-up investigation or documentation of the incident. The activity director believed that witness statements were collected, but the Director of Nurses and the administrator were unaware of any such documentation. The administrator acknowledged awareness of a verbal altercation but was not informed of the physical attack until later. The Director of Nurses stated that she would have initiated an investigation had she been informed. The lack of communication and failure to investigate the incident resulted in a deficiency in the facility's handling of resident-to-resident abuse allegations.
Inappropriate Communication by LPN with Resident
Penalty
Summary
The facility failed to protect a resident from abuse when an LPN engaged in inappropriate text communication of a sexual nature with the resident. The resident, who had diagnoses of physical and mental health disorders, resided on a secured unit for residents with behavioral issues and was under guardianship. The incident involved the LPN responding to the resident's requests for a sexual relationship through social media, which is against the facility's policies. The resident was cognitively intact but had hallucinations and delusions, as noted in their quarterly Minimum Data Set. The inappropriate communication was discovered when the Director of Nursing (DON) reviewed the resident's phone messages with permission. The messages included sexual content initiated by the resident and responded to by the LPN, which violated the facility's abuse and social media policies. The facility's policies clearly state that staff should not engage in social media contact with residents or suggest any form of sexual relationship. The DON and interim administrator confirmed that such behavior is against the facility's policies and should not occur at any time. The incident was uncovered during an investigation into a different matter, highlighting a breach in the facility's protocol for protecting residents from abuse.
Failure to Assess Consent Capacity Leads to Sexual Abuse Incidents
Penalty
Summary
The facility failed to assess three residents (#19, #47, and #115) for the ability to consent prior to engaging in sexual relations, leading to a failure to protect Resident #47 from sexual abuse by Resident #115. Resident #47, with a history of mood disorders, impulse control disorder, bipolar disorder, and mild mental retardation, reported feeling worthless, experiencing flashbacks, and fearing contracting STDs after being forced into oral sex by Resident #115. Despite Resident #47's limited intellectual capacity and the presence of a guardian, there was no assessment for consent to sexual activity in the medical records. Resident #115, diagnosed with oppositional defiant disorder, ADHD, bipolar disorder, and moderate intellectual disabilities, engaged in sexual activities with Resident #19 without the capacity to understand the purpose, risks, and consequences of such actions. The facility's failure to assess and monitor residents' abilities to consent to sexual activity resulted in abusive situations and violations of residents' rights. The facility's policies regarding sexual activity and abuse were not effectively implemented in the cases of Residents #47 and #115. Despite clear guidelines on assessing residents' capacity to consent to sexual activity, documenting such assessments, and prohibiting non-consensual sexual activities, the facility did not conduct proper evaluations for Residents #47 and #115. Resident #47's care plan indicated the need for structured plans to address inappropriate behaviors and mood stabilization, highlighting the importance of monitoring and intervention in cases of vulnerability. Similarly, Resident #115's care plan identified behavioral challenges and the need for supervision to prevent harm to self and others, indicating the necessity for strict adherence to facility guidelines. The failure to follow established protocols and assess residents' abilities to consent led to instances of sexual abuse and inappropriate behavior within the facility. The lack of oversight and monitoring by facility staff, as evidenced by Resident #115's unauthorized presence on another hall and the failure to intervene in inappropriate behaviors, contributed to the deficiencies in protecting residents from abuse. Staff members, such as CNA E, were aware of residents engaging in sexual activities but did not take appropriate actions to prevent or address such incidents. Additionally, the residents' legal guardians expressed concerns about their wards' capacity to engage in relationships and the potential risks of harm or suicidal ideations following relationship issues. The facility's failure to enforce guardian directives and ensure residents' safety highlights systemic issues in supervision, monitoring, and adherence to established guidelines, ultimately resulting in instances of sexual abuse and misconduct among vulnerable residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety and sanitation. Observations revealed that opened food items in the walk-in freezer and dry storage room were not sealed properly, and dented cans were not segregated from active use. Additionally, resident food items in a unit refrigerator were stored under unsanitary conditions, with visible residues and splatters. Trash cans in the kitchen were left uncovered when not in use, and ice and water dispensing machines were found to be dirty and lacking proper air gaps to prevent potential backflow of liquids. Food preparation surfaces were not appropriately cleaned and sanitized, and staff were not knowledgeable about sanitization procedures or the use of the dishwashing machine. Utensils and food containers were found to be in poor condition and not protected from contaminants. Kitchen surfaces and equipment, including floors, ceilings, vents, shelves, drawers, and cooking appliances, were not maintained in a clean state. Staff also failed to practice proper hygienic practices, such as gloving, handwashing, and avoiding the consumption of personal food and beverages while preparing and serving food to residents. The facility census was 116.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple incidents involving staff behavior towards residents. During a group resident council, various residents expressed fear of retaliation if they filed grievances or complaints. They reported that night shift staff had a bad attitude and yelled at residents, with specific mention of a CNA who belittled residents. This was corroborated by individual interviews with residents who described instances of staff being rude, dismissive, and using inappropriate language towards them. One resident with schizoaffective disorder and other mental health diagnoses reported feeling ignored and mistreated by specific staff members, including a CNA who raised their voice when the resident requested extra food. Another resident with a hearing deficit and mental health issues stated that the same CNA yelled at residents who asked for meal alternatives. A third resident with behavioral challenges and mental illness described being yelled at and cursed by the CNA when requesting additional juice. Additional interviews revealed that other residents felt belittled and disrespected by staff, including a resident with multiple sclerosis who reported being cursed at by a nursing aide. Another resident with anxiety and personality disorders felt dismissed by staff when asking questions. A resident with major depressive disorder and schizophrenia reported that staff, particularly on the night shift, were hateful and delayed providing medications while engaging in personal activities. Observations confirmed that a CNA took a chair from a resident without returning it, leaving the resident standing. The DON and administrator acknowledged these issues and stated that they had previously addressed similar complaints with the staff involved.
Facility Fails to Allow Residents to Retain Personal Coffee
Penalty
Summary
The facility failed to protect the residents' right to retain and use personal possessions, specifically instant coffee, by keeping it locked up in the medication room and controlling the times residents could access it. This affected eight residents, including those with guardians and those who were cognitively intact. The facility's policy on Resident's Rights, revised on 07/05/23, states that residents have the right to retain and use personal possessions unless it infringes on the rights or health and safety of others. However, the facility enforced a policy where residents could only access their coffee at 1:00 P.M. and 6:30 P.M., and only in limited quantities, which was signed by the administrator but undated. Observations on multiple occasions showed that the coffee was kept in a large tote in the locked medication room, with each container marked with the resident's name. Interviews with residents revealed that they were unhappy with this arrangement, as they had purchased the coffee with their own money and did not understand why they could not keep it in their rooms. Some residents mentioned that they had no restrictions from their guardians or physicians regarding coffee consumption. They also expressed frustration over having to wait for staff to access their coffee, especially when staff were busy with other duties. The Director of Nursing (DON) and the Administrator acknowledged that residents should have access to their own property but cited issues with coffee being used as currency among residents, leading to trading, stealing, and overuse. The Administrator mentioned that residents had verbally agreed to the limited access policy during activities to make the coffee last longer, but nothing was documented in writing. Despite these explanations, there was no documented reason in the residents' medical records to justify why they could not keep their coffee in their rooms.
Failure to Provide Adequate Seating and Accommodation
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident #81, who required a Hoyer lift and two staff members to get out of bed. Despite the resident's requests to get out of bed more frequently, staff often cited a lack of time or help and did not return to assist. The resident's custom electric wheelchair had been broken for over a month, and although it could still be used manually, staff found it difficult to push. The resident expressed a desire to participate in meals in the cafeteria and go outside but was often left in bed due to the broken wheelchair and lack of alternative seating options that were comfortable for extended periods. Additionally, the facility failed to provide adequate seating in the Station 2 common/dining area, affecting all residents residing in that unit. Observations showed that seven residents had to eat their meals with trays on their laps or on the arms of high-back chairs due to insufficient dining room chairs and table space. Residents expressed dissatisfaction with this arrangement, noting the difficulty and discomfort of balancing meal trays on their laps. Interviews with staff, including CNAs, the Activity Director, the Therapy Director, and the DON, revealed a lack of communication and coordination in addressing the broken wheelchair and seating issues. The Therapy Director was unaware of the resident's discomfort with the alternative wheelchair, and the Maintenance Supervisor was not informed about the shortage of dining room chairs. The facility's failure to ensure appropriate and comfortable seating for Resident #81 and adequate dining arrangements for Station 2 residents led to the identified deficiencies.
Failure to Address Resident Council Concerns and Hold Monthly Meetings
Penalty
Summary
The facility failed to act promptly and follow up with a response to residents' concerns voiced in resident council meetings. Additionally, the facility did not hold monthly resident council meetings as required. The review of the resident council meeting minutes from December 2023 showed various concerns, including missing clothing, dietary requests, and maintenance issues, with no documentation of these concerns being communicated to staff or resolved. The facility did not provide minutes for a January 2024 resident council meeting, and only one meeting was held in February 2024 for station two, with no indication of a meeting for station one. Residents reported that resident council meetings were held sporadically without a specific schedule or agenda, making it difficult to address their concerns effectively. Interviews with the Activity Director (AD), Social Services Director (SSD), Director of Nursing (DON), and the Administrator revealed a lack of clarity and consistency in the process for addressing concerns raised during resident council meetings. The AD, who was new to the position, was unaware of the specific process to follow and admitted that some meetings and minutes fell through the cracks during the transition period. The DON stated that concerns should be emailed to department managers and followed up by the next day, but there was no documentation to support this process. The Administrator acknowledged that the AD was responsible for reporting concerns but admitted that the transition period led to lapses in holding meetings and documenting minutes.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to maintain a clean, sanitary, and orderly environment. Observations revealed multiple deficiencies in various resident rooms and common areas, including torn drywall, missing paint, water stains, and black scuff marks. Additionally, several rooms had issues with missing or damaged furniture, such as bed frames without mattresses, privacy curtains pulled out of the wall, and dresser drawers with missing paint. Bathrooms were found to be in poor condition, with stained floors, peeling ceiling texture, and black discoloration around the base of toilets. In one instance, a resident reported that the cold-water faucet in their sink did not work, and they could only get hot water. This issue had persisted since staff attempted to fix a leak. The resident also mentioned that their TV had been removed by staff, and despite requesting a replacement, they had not received one. The resident expressed frustration over the lack of cold water and the absence of a TV in their room. Interviews with staff members, including housekeepers and the maintenance supervisor, revealed a lack of clarity regarding responsibilities for cleaning certain areas, such as bathroom vents and common areas. The maintenance supervisor admitted that it took a long time to patch and paint walls and that he was running out of paint. He also acknowledged that he had not had time to address all the areas in need of repair, including dining rooms and furniture. The administrator confirmed that maintenance was responsible for ensuring that walls, doors, floors, ceilings, and furniture were in good repair, but the observations indicated that this was not being adequately managed.
Failure to Ensure Residents Knew How to File Grievances
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance, where grievance forms were located, or how to complete a grievance form. During a resident council group interview, multiple residents expressed that they did not know how to file a grievance and feared retaliation from staff if they did. Specific residents reported missing clothing and stated that they had informed staff but had not received any follow-up or resolution. These residents were also unaware of the grievance process or where to find the necessary forms to file a grievance. The facility's policies on resident rights and grievance procedures were reviewed and found to be comprehensive. However, the implementation of these policies was lacking. The Social Services Director (SSD), who was new to the position, was unaware of her role in the grievance process, and no grievances had been filed since she assumed the role. The Director of Nursing (DON) confirmed that grievances were to be filed using a form that residents or visitors had to request from staff, and there was a 24-48 hour turnaround time for resolution. The administrator acknowledged that residents should be able to file grievances without fear of retaliation and that grievance forms should be readily available without needing to ask staff. The SSD's lack of awareness of the grievance process and the residents' fear of retaliation contributed to the deficiency in ensuring residents' rights to voice grievances were upheld.
Failure to Complete Required Pre-Employment Screenings
Penalty
Summary
The facility failed to complete required pre-employment screenings for four of eight sampled employees hired since the previous survey. Specifically, the facility did not request a criminal background check (CBC) for two employees, did not check the Employee Disqualification List (EDL) for three employees, and did not check the Nurse Aide (NA) Registry for three employees prior to hire, as directed by facility policy. The facility's policy mandates that the Human Resources (HR) department conduct pre-employment screenings, including Criminal History, Federal Exclusion Lists, Licensure, Family Care Safety Registry (FCSR), EDL, NA Registry, and I-9 verification, prior to hiring any staff. However, these checks were either not completed or were conducted after the employees had already started working, which is against the facility's policy. The deficiencies were identified through a review of employee files and interviews with HR staff and the Administrator. For instance, the Maintenance Supervisor's file lacked documentation of an NA Registry check, CNA K's file lacked an EDL check, and Hall Monitor L's file showed that the FCSR and NA Registry checks were conducted 19 days after the hire date. Additionally, NA M's file had no documentation of a CBC, EDL, or NA Registry check either before or after the hire date. HR staff confirmed that these checks should be completed before the employee's first paid day, but this was not consistently done. The Administrator also confirmed that he expected all new employees to have these checks completed prior to their first paid day.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure staff prepared and safely administered medications to five residents. Certified Medication Technician (CMT) I prepared the medications, but Certified Nurse Aide (CNA)/CMT/Team Lead G administered them without observing the preparation process. This practice was observed during a medication pass, where medications for residents with various diagnoses, including schizoaffective disorder, anxiety, diabetes, and mood disorder, were involved. The facility's policy mandates that the person who prepares the medication must also administer it, which was not followed in these instances. Additionally, the facility failed to obtain a physician order for a resident to self-administer eye drops. During the medication pass, the resident self-administered the eye drops without a proper order, which is against the facility's policy. The facility's Resident's Rights Policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, which was not done in this case. The facility also failed to complete accuchecks as ordered for a resident with diabetes and did not obtain a urinalysis when ordered for another resident. The resident's care plan indicated the need for daily blood glucose monitoring, but there was no documentation of these checks being performed. Similarly, a urinalysis ordered for a resident with urinary issues was not obtained in a timely manner. Furthermore, the facility did not document the narcotic counts being completed by two staff members, as required by their policy, on multiple occasions.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency was observed in five residents out of 34 sampled residents. The facility census was 116. During a resident council meeting, residents reported that there were not many activities on the unit, the activity calendar was not followed, and there were no activities on weekends or after supper. Observations and record reviews confirmed that several residents did not participate in any documented activities for extended periods, and there was a lack of staff interaction and engagement with the residents. Resident #48's care plan indicated a need for cognitive stimulation and social activities, but there was no documentation of activity participation for several months. Observations showed the resident in their room with no staff interaction or activities provided. Similarly, Resident #96, who had dementia and other mental health diagnoses, was observed lying in bed or standing in the hallway with no staff interaction or activities. The resident's activity progress notes indicated minimal participation in activities, and there was no documentation of activity engagement for several months. Resident #110, who had dementia, anxiety, and depression, had no care plan for activities and no documented participation in activities for several months. Observations showed the resident pacing in their room or standing in the hallway with no activities provided. Resident #25, who had a traumatic brain injury and other mental health disorders, was observed sleeping in bed most of the time due to boredom. The resident expressed a desire for more activities but reported that there had not been an activity director for several months. Resident #116, who had schizophrenia and insomnia, participated in a craft activity but expressed a desire for more activities, especially in the evenings. The Activity Director confirmed the lack of scheduled activities on weekends and evenings and acknowledged the need for more one-on-one programming for certain residents.
Failure to Ensure Resident Safety and Proper Monitoring
Penalty
Summary
The facility failed to ensure the safety of Resident #102, who expressed suicidal ideations and threatened self-harm by placing a bag over their head. Despite the resident's high risk for suicide as indicated by the Columbia Suicide Severity Rating Scale, the care plan was inconsistent, and the resident's room contained plastic liner bags in trash cans, which could be used for self-harm. Staff interviews revealed a lack of awareness and documentation regarding the resident's increased monitoring, and the resident continued to express suicidal thoughts without appropriate intervention or documentation of face checks and room safety measures. The facility also failed to ensure the safety of Resident #48 by not placing their feet on wheelchair foot pedals while being propelled by staff. Observations showed the resident's feet were unsupported, which could lead to accidents or injuries. Staff interviews confirmed that wheelchair pedals should be used for resident safety, but this practice was not followed. Additionally, the facility did not implement effective interventions to prevent Resident #21 from being transported in their rollator walker by another resident. Despite staff and resident awareness that this practice was unsafe, it continued to occur. The DON and other staff members acknowledged the issue but failed to implement successful interventions to stop the behavior, putting Resident #21 at risk of injury.
Failure to Provide Sufficient Fluids to Residents
Penalty
Summary
The facility failed to offer sufficient fluids to maintain proper hydration and health for three residents. Observations over several days showed that Residents #48, #96, and #110 did not have water pitchers or glasses of fluids in their rooms. This was despite the facility's policy that fluids should be passed every two hours, with additional fluids provided during meals. Staff interviews confirmed that water pitchers were either broken or not replaced, and fluids were not consistently offered as required by the policy. Resident #48, who has diagnoses including dementia and schizophrenia, was observed without water pitchers or glasses of fluids in their room over multiple days. The resident's care plan emphasized the need to encourage fluids to promote prompted voiding responses. Similarly, Resident #96, who has dementia and bipolar disorder, was also observed without water pitchers or glasses of fluids in their room. The care plan for this resident also highlighted the importance of encouraging fluids to prevent urinary tract infections and skin breakdown due to incontinence. Resident #110, diagnosed with dementia, anxiety, and depression, was observed with dry lips and no water pitcher or glass of fluids in their room. Staff interviews revealed that fluids were not consistently offered, and water pitchers were not available for many residents. The Director of Nursing and the Administrator both confirmed that fresh water should be passed every two hours and that fluids should be offered with meals, but this was not being done consistently.
Failure to Ensure Timely Completion of CNA Training
Penalty
Summary
The facility failed to ensure that two nurse aides, NA BB and NA U, completed a certified nurse aide (CNA) training program within four months of their employment. NA BB was hired on 02/09/23, and NA U was hired on 06/02/23. Review of their employee files showed no documentation of completion of the CNA training program within the required timeframe. During an interview, the Administrator acknowledged responsibility for enrolling NAs in the training program and admitted awareness of the four-month completion timeline. However, the Administrator stated that the NAs had not yet tested and had 'slipped through the cracks.' The facility census was 116, and the Director of Nursing confirmed that the facility did not have a specific policy on Nursing Assistant and Certified Nursing Assistant training programs.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that four residents who were prescribed psychotropic medications received a gradual dose reduction (GDR), unless clinically contraindicated. The facility's Medication Administration and Monitoring Policy mandates that psychotropic medication reductions be reviewed by the pharmacy consultant and the prescribing physician. However, for Resident #48, there was no recommendation for a GDR for olanzapine from the pharmacy review notes, and the psychiatric physician's notes showed no documentation of any attempts at a GDR for the olanzapine. Similarly, Resident #96's pharmacy review notes recommended a GDR for aripiprazole, Trazadone, and Zoloft, but there was no documentation found by the physician to address these recommendations, and no GDR was attempted for these medications in the resident's medical record for March 2024. Resident #28's care plan indicated the use of multiple psychotropic medications, but there was no evidence of a GDR attempt or clinical rationale from the physician to show a GDR was contraindicated. The psychiatric physician notes for Resident #28 also lacked documentation of any attempts or contraindications for a GDR. Similarly, Resident #95's care plan and psychiatric visit notes showed the use of paliperidone and mirtazapine, but there was no documentation of a GDR attempt or clinical rationale for contraindication. Observations of Resident #95 showed a slight mouth tremor, which the resident reported as bothersome, yet no GDR was attempted for the medications. Interviews with the Director of Nursing and the residents' physician revealed that the facility protocol for GDRs was not followed. The Director of Nursing could not find any recommendations for a GDR for the residents, and the physician expected staff to consult with psychiatry if a resident experienced extrapyramidal symptoms when taking an antipsychotic medication. The physician also stated that a GDR should be done with consideration of the resident's clinical condition, aiming to use the lowest dose necessary to keep the resident stable and symptoms manageable.
Failure to Discard Expired Medications
Penalty
Summary
The facility failed to discard an opened insulin pen after 28 days of use for one resident with diabetes. The resident's Lantus insulin pen, which was opened on 2/6/24, was still in use on 3/6/24, exceeding the manufacturer's recommended usage period of 28 days. This oversight was observed during a medication cart inspection, revealing that the pen should have been discarded on 3/5/24. Additionally, the facility's policy mandates monthly inspections of medication carts and rooms, but this protocol was not effectively followed in this instance. Furthermore, the facility did not dispose of expired house stock influenza vaccines. During an inspection of the medication room refrigerator, 20 vials of influenza vaccine with an expiration date of 6/2023 were found. Despite the facility's policy requiring weekly destruction of expired medications by the DON and monthly checks by the pharmacy, these expired vaccines were still present. Interviews with the LPN and DON revealed a lack of awareness and adherence to the established protocols for managing expired medications.
Failure to Meet Nutritional Needs and Serve Correct Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of the residents and ensure staff served the correct portion sizes during meals. The dietary staff did not follow the standardized recipes and portion sizes as outlined in the facility's policies. For instance, during a lunch meal, residents were served one slice of turkey instead of the required three ounces, and a 3-ounce scoop was used for tomatoes instead of the required 4-ounce scoop. The dietary manager confirmed that the portion sizes were incorrect and that staff should use the diet spreadsheet menu to determine appropriate portion sizes. Several residents reported that the portion sizes were too small, and they often felt hungry after meals. One resident, who had been losing weight, was served a meal that did not include all the items listed on the diet spreadsheet, such as bacon for breakfast. Another resident mentioned that they had to take food from an uneaten tray because they were still hungry after their meal. Multiple residents expressed dissatisfaction with the portion sizes and the lack of availability of seconds or substitutes. The registered dietitian and the dietary manager acknowledged that staff should follow the diet menu spreadsheet, recipes, and physician orders when serving food items to residents. They also noted that substitutions should be recorded and monitored to ensure they are of equal nutritional value. The administrator expected the menu to be followed and the required portions to be served. However, the observations and interviews indicated that these expectations were not consistently met, leading to residents not receiving adequate nutrition.
Facility Fails to Provide Palatable Meals and Variety of Snacks
Penalty
Summary
The facility failed to provide residents with palatable meals served at appetizing temperatures and a variety of snacks. Multiple residents reported that the food was often bland, lacked seasoning, and was not served at the appropriate temperature. For instance, Resident #67 mentioned that the food was bad, not always seasoned, and that they did not always receive their preferred oatmeal for breakfast. Resident #91 also complained about the food being terrible, lacking flavor, and receiving overcooked and hard noodles. Additionally, the residents frequently received the same types of snacks, such as honey buns and oatmeal cream pies, which many found unsatisfactory and not filling. Observations confirmed these complaints. For example, Resident #91's meal tray included burnt and hard bow tie pasta, and Resident #57's lunch included a burrito and salad, which the resident refused to eat due to its poor quality. The facility's dietary policies were not consistently followed, as evidenced by the frozen health shakes served to residents like Resident #97 and Resident #4, which they could not consume. The dietary manager admitted that the health shakes were served frozen because they had just arrived and were not thawed in time. The facility's staff also failed to honor residents' meal preferences and dietary needs. Resident #100 reported that their breakfast was cold and tasted awful, and they were unable to get sandwiches because they were reserved for diabetics. Resident #116's meal of tomato soup and grilled cheese was described as tasting like watered-down ketchup, and the grilled cheese was cold and lacked cheese. The dietary manager acknowledged that meal preferences should be honored and that the facility should provide fresh fruits and vegetables, but these were often not available or served. The registered dietitian emphasized that food should be served at the correct temperature and that residents' requests for fresh fruits and substantial bedtime snacks should be honored.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The maintenance director admitted to not checking the cold-water temperatures throughout the facility, and the Director of Nursing (DON) confirmed that it was the maintenance supervisor's responsibility to ensure quarterly water testing was completed. The Administrator was unaware that cold water temperatures needed to be tested for the water management program. Additionally, the facility did not perform detection and surveillance of possible cases of LD among the residents, as evidenced by the lack of documentation and monitoring of water temperatures from December 2023 through February 2024. The facility also failed to ensure proper infection control measures for COVID-19. There was no signage on the entrance of the building notifying visitors of a COVID outbreak, and no transmission-based precaution signage outside of the rooms of COVID-positive residents. Two COVID-positive residents shared a bathroom with non-COVID residents, and one COVID-positive resident was taken out of their room without proper personal protective equipment (PPE). Staff did not consistently follow hand hygiene protocols, and there was a lack of hand sanitizer and proper PPE outside of isolation rooms. The facility's infection control procedures were not adequately followed, as evidenced by staff not wearing appropriate PPE and not performing hand hygiene after removing gloves. Additionally, the facility failed to ensure that Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. Three staff members hired since the previous survey did not have their TSTs administered and read prior to or on their first paid day. The facility also failed to use appropriate infection control procedures for hand hygiene and changing gloves during accu check procedures and insulin administration for three residents. Furthermore, the facility did not store a resident's respiratory equipment in a way that it remained free of contaminants, as the nebulizer machine and tubing were found on the floor and not properly covered.
Failure to Notify Responsible Parties and Physicians of Condition Changes
Penalty
Summary
The facility failed to notify the physician and/or responsible parties when three residents experienced a change in condition. Resident #19 had a tooth extraction and was prescribed antibiotics, but the legal guardian was not informed about the procedure or the new medication orders. The guardian expressed disappointment upon discovering the changes belatedly. Resident #55, who had a guardian and severely impaired cognition, developed pneumonia and was prescribed multiple medications, but there was no documentation that the guardian was notified about the infection or the treatment plan. The guardian later found out about the new antibiotic charge while reviewing bills and expressed a desire to be informed about all changes in the resident's condition. Resident #106, who had hypertension, experienced a significant drop in blood pressure and was sent to the emergency room for evaluation. Despite the resident's condition worsening throughout the day, there was no notification to the resident's physician about the change in condition. The resident's physician later stated that he expected to be informed about such significant changes. Interviews with staff, including the Director of Nursing and the Administrator, revealed that they expected nursing staff to notify guardians and physicians about condition changes and new medication orders, but this protocol was not followed in these cases. The facility's policies on notifying clinicians and significant changes were not adhered to, leading to a lack of communication with responsible parties and physicians regarding the residents' health conditions. This failure to notify relevant parties about significant changes in residents' conditions and new medication orders constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Misappropriation of Resident's Money by CNA
Penalty
Summary
The facility staff failed to ensure that a resident remained free from misappropriation of property when a Certified Nurse Aide (CNA) took $450.00 from the resident. The resident, who was alert, oriented, and able to make decisions, had diagnoses of quadriplegia, heart disease, anxiety, and pain. The incident began when the CNA discussed personal financial problems within earshot of the resident, who then offered to assist the CNA with unpaid bills. The CNA initially refused but eventually accepted the money, promising to repay it in installments. However, the CNA only made one repayment and failed to return the remaining amount, prompting the resident to inform a family member, who then reported the incident to the facility administrator. The Assistant Director of Nursing (ADON) initiated an investigation upon learning of the incident from the administrator. The ADON interviewed both the resident and the CNA, who admitted to taking the money. The CNA was suspended pending the investigation and subsequently terminated from employment. The Human Resource Director confirmed the CNA's admission and termination. The administrator and primary physician both stated that they would expect staff to decline any offers of money from residents and to avoid discussing personal problems with them.
Failure to Prevent Decline in Range of Motion and Contracture Development
Penalty
Summary
The facility failed to prevent a decline in the range of motion and the development of contractures for a resident with a history of left hand contracture, hemiplegia, hemiparesis, and chronic pain. Despite the resident's condition, the facility did not provide the necessary restorative therapy or regular care to manage the contracture. The resident's care plan included measures such as checking nail length, cleaning the palm, and referring to therapy as needed, but these were not consistently followed. Observations showed that the resident's left hand was severely contracted, with fingers bent and nails untrimmed, causing discomfort and pain. Interviews with staff revealed a lack of awareness and implementation of a restorative care program. Nurse aides and certified nurse aides were unaware of any restorative services being provided to the resident. The physical therapist confirmed that therapy orders were pending insurance approval, and the therapy director noted that the resident had refused initial screenings and had no therapy orders since admission. The director of nursing acknowledged the absence of a restorative care program and the inability to keep a restorative aide employed. The resident's guardian and primary physician expressed concerns about the lack of therapy and contracture management. The guardian was unsure if the resident had received any therapy services since admission and desired such services if beneficial. The primary physician expected the facility to identify and address contractures upon admission. The facility's failure to provide appropriate care and therapy services led to the worsening of the resident's contracture and associated pain, highlighting significant deficiencies in the facility's restorative care practices.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment, document attempted alternatives prior to installing a bed rail, and obtain informed consent with risks prior to installing and using a bed rail for two residents. Resident #32, who had multiple diagnoses including Type 2 diabetes mellitus, morbid obesity, rheumatoid arthritis, and impaired visual function, was observed with a bed rail in the raised position on multiple occasions. There was no documentation in the resident's care plan addressing the use of the bed rail, nor was there any record of a bed rail assessment or obtained consent for its use. Resident #35, who had a history of fractured femurs and cerebral palsy, was also observed with assist rails on each side of the bed. The resident was able to grab the assist rail and assist with rolling over in bed with staff assistance. However, similar to Resident #32, there was no documentation of a bed rail assessment or obtained consent for the use of the bed rail in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that no assessments or consents were completed for the assist rails. The ADON admitted that she did not complete an assessment for the residents, and the maintenance staff had not performed the entrapment assessment. The DON confirmed that consents and assessments should be done quarterly, but this was not adhered to in these cases. The Administrator also acknowledged that an assessment should be completed before the use of bed rails.
Failure to Properly Administer Insulin
Penalty
Summary
The facility failed to appropriately administer insulin to two residents, leading to significant medication errors. Specifically, an LPN did not prime the insulin pens before administration and did not hold the needle in the skin for the required six seconds after administration, as directed by the manufacturer. This was observed during the administration of Novolog insulin to two residents, one receiving 5 units and the other receiving a combination of 8 units scheduled and 4 units sliding scale insulin. The LPN removed the needle immediately after the button stopped, contrary to the manufacturer's instructions. The facility's Blood Glucose Monitoring and Insulin Administration Policy did not address the specific procedure for administering insulin via an insulin pen, only covering administration via vial and syringe. During interviews, the LPN acknowledged awareness of the need to prime the pen but mistakenly believed that holding the pen for three seconds was sufficient. The Director of Nursing confirmed the expectation for staff to prime the insulin pen with two units and hold for six seconds after administration.
Failure to Provide Necessary Dental Services and Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services and follow-up care. The resident, who had a history of anxiety and schizophrenia, was dependent on staff for activities of daily living, including brushing teeth. The resident was seen by a local dental clinic, which recommended the extraction of all remaining teeth due to multiple areas of decay and non-restorable teeth. However, the facility did not follow up on these recommendations, and the resident continued to experience dental pain and decay, as observed during a later inspection. Interviews with staff revealed that the recommendations for further dental intervention were mistakenly filed away and not acted upon. The Director of Nursing and the facility Receptionist both acknowledged that the resident's dental needs were not addressed in a timely manner. The primary physician also expressed that staff should have made arrangements for the resident to see a dentist and followed the recommendations promptly. The facility did not provide a policy for dental services, and the resident's care plan did not address dental care or issues.
Failure to Administer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to provide the pneumococcal vaccine to a resident who had given consent upon admission. The resident, who was cognitively intact and had a history of diabetes mellitus, seizures, multiple sclerosis, and chronic obstructive pulmonary disease, had not received the vaccine since their admission. Despite the resident's consent and the facility's policy to offer the vaccine upon admission, the vaccine was not administered, and the resident expressed a desire to receive it during an interview. The Director of Nursing confirmed that the resident had not been offered the pneumococcal vaccine and was unsure why this had not occurred. The process typically involves ordering the vaccine if a pharmacy immunization clinic is not scheduled soon. The Director of Nursing is responsible for ensuring the vaccine is administered once consent is obtained. The Administrator and the primary care physician both expected that all residents, especially new admissions, would be offered the pneumococcal vaccine without delay. The facility's policy and CDC guidelines indicate that the pneumococcal vaccine should be offered to residents upon admission unless medically contraindicated or previously received. However, the facility did not follow through with this policy for the resident in question, leading to a deficiency in providing the necessary immunization.
Failure to Complete Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure complete entrapment assessments for two residents who had side rails attached to their beds. Resident #32 had a 1/8 bed rail on the left-hand side of the bed in the raised position, but there was no documentation in the care plan addressing the use of the bed rail, nor was there a bed rail assessment or consent for its use. The resident's medical history included conditions such as Type 2 diabetes mellitus, morbid obesity, rheumatoid arthritis, and impaired visual function, among others. Despite these conditions, the necessary safety assessments and consents were not completed. Resident #35 had candy cane rails on each side of the bed at the head of the bed, which the resident used to assist with rolling over in bed with staff assistance. However, there was no physician order for the use of side rails, no consent for their use, and no entrapment assessment documented. The resident's medical history included cerebral palsy, diabetes, anxiety, schizoaffective disorder, depression, and bipolar disorder. The resident was dependent on staff for all bedside care and mobility, yet the required safety measures were not in place. Interviews with the Assistant Director of Nursing, Maintenance Director, Director of Nursing, and the Administrator revealed that assessments, consents, and physician orders for the use of bed rails were not completed as required. The Maintenance Director admitted to not measuring mattresses for entrapment risks, and the Director of Nursing confirmed that consents and assessments should be done quarterly but were not. The Administrator also acknowledged that assessments should be done before the use of side rails and that the maintenance department should measure the beds for entrapment risks.
Failure to Post Survey Results in Readily Accessible Locations
Penalty
Summary
The facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to all residents, family members, and legal representatives. During a resident council meeting, residents expressed that they were unaware of their right to view the survey results and did not know where the results were kept. Observations over several days confirmed that the survey results were not posted in the front foyer/common area or in Station 2, a secured unit. Interviews with residents and staff revealed that the survey results were not accessible without asking staff, and there was a lack of awareness among staff about the requirement for survey results to be readily accessible to residents. The Business Office Manager (BOM) and the Director of Nursing (DON) both indicated that the survey results should be available but were not aware of the specific requirements for accessibility. The BOM mentioned that the survey results binder was supposed to be on a cabinet at the front door and that a sign inside the nurses' station on Station 2, which informed residents they could ask to see the survey results, had fallen down. The Administrator acknowledged responsibility for ensuring the survey results were posted and accessible but was unaware that the results were not posted on Station 2. The survey results binder had been moved during furniture rearrangement and was not returned to its proper place.
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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