Cotton Point Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Matthews, Missouri.
- Location
- 609 South Railroad Street, Matthews, Missouri 63867
- CMS Provider Number
- 265859
- Inspections on file
- 22
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Cotton Point Living Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to lapses in safeguarding measures.
The facility failed to maintain a safe, clean, and homelike environment, with observations of dust, dirt, and poor maintenance in resident rooms and equipment. Staff interviews revealed inadequate communication and documentation of maintenance needs, contributing to unresolved environmental issues. Resident Council Meeting Minutes also noted concerns about wheelchair cleanliness.
The facility did not follow its policies for conducting Criminal Background Checks (CBC) and periodic Employee Disqualification List (EDL) checks for several employees. A CBC was not completed for one employee before hire, and EDL checks were not performed quarterly or annually for others, as required. Interviews revealed a lack of awareness of these requirements among staff.
The facility failed to transmit quarterly MDS assessments on time for four residents, as required by OBRA regulations. The MDS Coordinator acknowledged delays, while the Administrator expected timely completion, and the Regional Nurse Consultant believed all assessments were current.
The facility did not transmit the MDS assessments for two residents within the required 14-day period after completion, as per federal and state guidelines. The MDS Coordinator acknowledged delays, while the Administrator expected timely submissions. The Regional Nurse Consultant believed all assessments were current.
A facility failed to include PTSD-specific interventions in a resident's baseline care plan within 48 hours of admission, despite the resident's multiple diagnoses including PTSD. Interviews revealed the resident, a military veteran, experienced PTSD triggers from loud noises, and staff acknowledged the oversight in not including PTSD interventions in the care plan.
The facility failed to follow physician's orders for medications and treatments for several residents. A resident with bipolar disorder did not receive scheduled Invega Trinza injections, while another with dementia used oxygen without a physician's order. A resident in hospice care lacked a timely order, and another with mental health issues missed a scheduled Invega Sustenna dose, leading to an altercation. Staff interviews confirmed expectations for adherence to orders were not met.
The facility failed to implement and monitor nutritional interventions for two residents, resulting in significant weight loss. Despite RD recommendations for dietary changes, these were not followed, and staff did not encourage meal consumption. Observations showed one resident eating only 50% of meals without assistance, while another resident experienced severe weight loss despite eating 100% of meals provided.
The facility failed to reconcile narcotic medications at each shift change, affecting all residents. Reviews of narcotic count logs for three medication carts and the medication room revealed numerous missed opportunities for reconciliation. Interviews with staff confirmed that the facility's protocol required both on-coming and off-going staff to count narcotic medications together and sign the narcotic log book. However, the facility did not provide a policy on narcotic reconciliation documentation, contributing to the failure in ensuring consistent reconciliation practices.
The facility failed to provide appropriate diagnoses for the use of Seroquel, an antipsychotic medication, for three residents. The facility's policy requires specific conditions and documented diagnoses for such medications, but Seroquel was prescribed for unspecified dementia, behaviors, and psychosis without proper justification. Interviews confirmed that dementia is not an appropriate diagnosis for Seroquel, indicating non-compliance with the facility's guidelines.
The facility failed to maintain sanitary conditions in food storage and distribution, with missing temperature logs and undated, unlabeled food items. Observations showed a lack of proper cleaning in the kitchen, increasing the risk of cross-contamination and food-borne illness for all 54 residents.
A housekeeper in an LTC facility misused a resident's bank card for personal transactions without consent. The resident, with no cognitive impairment, was unaware until a family member noticed unusual transactions. Video footage confirmed the housekeeper's unauthorized use, leading to a police investigation. The facility's abuse prevention policy was not followed.
The facility failed to manage resident funds appropriately, leading to delayed refunds and unauthorized withdrawals for several residents. Additionally, the facility did not provide timely Social Security/Medicaid allowances, affecting residents' financial management. Interviews revealed a lack of clarity in financial processes, contributing to these deficiencies.
The facility failed to manage the resident trust fund account according to proper accounting principles by not reconciling the account monthly. The account, which managed funds for 34 residents, showed no reconciliations for several months, and attempted reconciliations did not match the residents' current balances. Interviews revealed that the reconciliations for October and November were not completed due to the workload.
The facility failed to provide timely final accounting of resident funds for two residents. A resident's funds were refunded 70 days post-discharge due to book closure delays. Another resident's trust fund withdrawal for room and board was not reported to the Department of Social Services until 107 days after their death, as the Business Office Manager was unaware of the reporting requirement.
A resident with moderately impaired cognition had their bank card misappropriated by a CNA, who used it for personal transactions. The resident's family discovered unauthorized charges, and the CNA admitted to some of the transactions. The resident confirmed they never gave permission for the card's use, highlighting a failure to adhere to the facility's abuse prevention policy.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas within the facility. Specific observations included a buildup of dust and dirt on air filters, long dark markings on walls, exposed sheetrock, and peeled paint in several rooms. Additionally, there was a buildup of dried food and dirt on a resident's wheelchair and grime on a Hoyer lift. A missing vent cover was also noted in the resident private phone room. These conditions were observed over multiple days, indicating a persistent issue with maintaining a clean and homelike environment. Interviews with facility staff revealed a lack of effective communication and documentation regarding maintenance needs. The Maintenance Supervisor acknowledged being aware of the numerous repairs and painting required but expressed difficulty in keeping up with tasks due to the informal way staff communicated these needs. The Administrator also recognized the environmental concerns and emphasized the importance of staff documenting issues in the maintenance log rather than relying on verbal communication. The February 2025 Resident Council Meeting Minutes further highlighted concerns about the cleanliness of resident wheelchairs, indicating that these issues were known to both staff and residents.
Failure to Conduct Required Background and Disqualification Checks
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for several employees. Specifically, the facility did not complete a CBC for Employee I prior to their hire date, as required by the facility's policy. Additionally, the facility did not perform periodic checks of the EDL for Employees G, I, J, K, L, and M, as mandated by their policy. The policy requires that the EDL be checked at the time of hire and periodically thereafter, including quarterly and annually, to ensure that employees have not been placed on the list for abuse, neglect, or misappropriation of funds or property from residents. Interviews with the Human Resources staff and the Administrator revealed a lack of awareness and understanding of the requirements for EDL checks beyond the initial hire. The HR staff was unaware of the need for periodic checks, while the Administrator believed that checks should occur at least quarterly. This oversight resulted in the facility not conducting the necessary EDL checks for the sampled employees, which is a deviation from the established policies designed to prevent abuse, neglect, and theft within the facility.
Failure to Timely Transmit Quarterly MDS Assessments
Penalty
Summary
The facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for four residents, two of whom were part of the sample and two who were not. The facility's policy requires that comprehensive assessments be completed at intervals designated by OBRA regulations and PPS requirements, with data submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. However, the facility did not complete quarterly MDS assessments for Residents #37, #38, #40, and #42 within the required 92-day timeframe from the last MDS assessment. Interviews conducted during the investigation revealed that the MDS Coordinator, who was new to the position, acknowledged that some MDS assessments were behind schedule. The Administrator expressed an expectation for timely completion of MDS assessments, while the Regional Nurse Consultant was under the impression that all MDS assessments were up to date. This discrepancy highlights a communication and procedural lapse within the facility, leading to the failure in meeting the federally mandated assessment timelines.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessments for two residents in a timely manner, as required by federal and state guidelines. Resident #17 and Resident #41 both had quarterly MDS assessments completed but not transmitted within the mandated 14-day period following the completion date. The facility's policy, dated October 2023, stipulates that MDS assessments must be conducted and submitted according to the current requirements published in the Resident Assessment Instrument (RAI) Manual. During interviews, the MDS Coordinator acknowledged being aware of some assessments being behind or late, while the Administrator expressed an expectation for timely submissions. The Regional Nurse Consultant was under the impression that all MDS assessments were up to date.
Failure to Address PTSD in Baseline Care Plan
Penalty
Summary
The facility failed to include an admitting diagnosis of post-traumatic stress disorder (PTSD) with specific interventions on the baseline care plan for a resident within 48 hours of admission. The resident, who was admitted with multiple diagnoses including PTSD, paranoid schizophrenia, schizoaffective disorder, major depression disorder, irritability, and anger, did not have PTSD-specific interventions addressed in the baseline care plan. This omission was identified during a review of the resident's medical record and baseline care plan. Interviews conducted with the resident and facility staff revealed that the resident, a military veteran, experienced PTSD triggers from loud noises. The Social Service Director noted that the resident avoided discussing PTSD shortly after admission. The Director of Nursing and the Administrator both acknowledged that a PTSD diagnosis should have been included in the baseline care plan with specific interventions. This oversight indicates a failure to adhere to the facility's policy requiring a baseline care plan to meet immediate health and safety needs within 48 hours of admission.
Failure to Follow Physician's Orders for Medications and Treatments
Penalty
Summary
The facility failed to obtain and follow physician's orders for several residents, leading to deficiencies in care. Resident #2, diagnosed with bipolar disorder and major depressive disorder, had a physician's order for Invega Trinza to be administered intramuscularly every three months. However, the medication was not administered as scheduled in November 2024 and February 2025. Resident #15, with diagnoses including dementia and COPD, was observed using an oxygen concentrator without a corresponding physician's order, despite experiencing difficulty breathing. The Director of Nursing and the Administrator acknowledged the absence of a necessary order for oxygen. Resident #37, diagnosed with hypertension, congestive heart failure, and atrial fibrillation, was admitted to hospice care without a physician's order until March 2025, despite being in hospice since July 2024. Resident #158, with multiple mental health diagnoses, had an order for Invega Sustenna to be administered monthly, but the medication was not given as scheduled in February 2025. This resident was involved in a resident-to-resident altercation shortly after the missed medication. Interviews with staff, including the Regional Nurse Consultant and the Administrator, revealed an expectation for nursing staff to document medication administration and adhere to physician's orders, which was not met in these cases.
Failure to Implement Nutritional Interventions for Residents
Penalty
Summary
The facility failed to implement, monitor, and modify interventions to maintain acceptable nutritional status for two residents. Resident #19 experienced a severe weight loss of 8.11% over three months, from November 14, 2024, to February 7, 2025. Despite recommendations from the Registered Dietitian (RD) to add ice cream and health shakes to the resident's diet, these were not provided, and staff did not encourage the resident to eat meals. Observations showed the resident eating only 50% of meals without assistance, and the facility did not address the RD's recommendations. Resident #40 experienced a severe weight loss of 6.9% in one month and 11.3% over six months. The RD recommended increasing health shakes and liberalizing the diet to allow more food choices. However, the facility failed to implement these recommendations. Observations showed the resident eating 100% of meals and ice cream provided, but the necessary dietary changes were not made. Interviews with staff revealed a lack of follow-through on RD recommendations and a failure to address significant weight changes in a timely manner.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure proper reconciliation of narcotic medications at each shift change, affecting all residents. The review of narcotic count logs for three medication carts and the medication room revealed numerous missed opportunities for reconciliation. Specifically, the 100 Hall Medication Cart showed 13 missed reconciliations out of 44 opportunities for one shift period and 6 missed out of 21 for another. The 200 Hall Medication Cart had 22 missed reconciliations out of 47 opportunities, and the 300 Hall Medication Cart had 20 missed out of 42 opportunities. Additionally, the Medication Room showed 10 missed reconciliations out of 35 opportunities for one shift period, 13 missed out of 35 for another, and 4 missed out of 13 for a subsequent period. Interviews with staff, including an LPN, the Regional Nurse Consultant, and the Administrator, confirmed that the facility's protocol required both on-coming and off-going staff to count narcotic medications together and sign the narcotic log book. However, the facility did not provide a policy on narcotic reconciliation documentation, which contributed to the failure in ensuring consistent reconciliation practices. This deficiency had the potential to affect all residents in the facility, which had a census of 54.
Inappropriate Use of Antipsychotic Medication Due to Lack of Proper Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of psychotropic medication for three residents out of five sampled. The facility's policy on antipsychotic medication use, revised in July 2022, stipulates that such medications should only be administered when necessary to treat specific conditions and must be supported by documented diagnoses consistent with the Diagnostic and Statistical Manual of Mental Disorders. However, the facility did not provide appropriate diagnoses for the use of Seroquel, an antipsychotic medication, for three residents. Resident #1 was prescribed Seroquel for unspecified dementia, Resident #15 for behaviors, and Resident #20 for psychosis, but none of these prescriptions were supported by appropriate diagnoses as per the facility's policy. Interviews with the Regional Nurse Consultant and the Administrator confirmed that dementia is not an appropriate diagnosis for prescribing Seroquel. The facility's failure to adhere to its policy on antipsychotic medication use resulted in the inappropriate prescription of Seroquel for these residents. This deficiency highlights a lack of compliance with the facility's own guidelines, which require specific conditions and documented diagnoses to justify the use of antipsychotic medications.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and distribution, as observed during a survey. There were no food temperature logs for the period from February 22 to March 4, and refrigerator temperature logs were missing from March 1 to March 4. Observations revealed undated and unlabeled food items in the refrigerators, including opened biscuits, frozen pancakes, French fries, red jello, boiled eggs, shredded cheese, and butter. Additionally, the dishwasher machine had a buildup of debris, crumbs, and a hard white substance, indicating a lack of proper cleaning. Interviews with the Dietary Manager, Registered Dietician, and Administrator confirmed that the facility's policies required daily checks and logs of food and refrigerator temperatures, as well as daily cleaning of kitchen equipment. All foods were expected to be labeled, dated, and secured to prevent contamination. The failure to adhere to these policies increased the risk of cross-contamination and food-borne illness, potentially affecting all 54 residents in the facility.
Misappropriation of Resident's Bank Card by Housekeeper
Penalty
Summary
The facility failed to protect a resident from the wrongful use of their belongings, specifically a bank card, by a staff member. The incident involved a housekeeper who used the resident's bank card for personal transactions without consent. The resident, who had no cognitive impairment, was unaware of the card's misuse until a family member noticed unusual transactions and notified the facility. The housekeeper was identified through video footage using the card at a gas station ATM, correlating with the times and locations provided by the bank. The resident's family reported the incident to the facility's Director of Nursing, who then informed the Administrator and assisted in notifying the police. The police investigation confirmed the housekeeper's unauthorized use of the card, with video evidence from both the gas station and the facility supporting the claim. The housekeeper was seen entering the resident's room and later using the ATM, withdrawing a significant amount of money. Interviews with other staff members revealed that the housekeeper had asked for rides to the gas station under false pretenses, claiming personal reasons unrelated to the resident's card. The housekeeper denied the allegations, despite the evidence against them. The facility's policy on abuse prevention, which the housekeeper had acknowledged, was not followed, leading to the misappropriation of the resident's property.
Deficiencies in Resident Financial Management
Penalty
Summary
The facility failed to ensure that resident funds were managed appropriately, leading to several deficiencies. Specifically, the facility did not place resident funds in an account separate from the facility's operating account, resulting in delayed refunds for 12 residents. Additionally, the facility staff did not obtain written authorization for withdrawals from the accounts of five residents, which included duplicate charges and unauthorized withdrawals for room and board, cigarettes, and shopping expenses. The facility also failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner for five residents, which hindered their ability to manage their financial affairs. This issue was compounded by the facility's inability to close the books for a specific month, further delaying the disbursement of allowances. Interviews with the Interim Administrator and Business Office Manager revealed a lack of clarity and control over the financial processes, contributing to these deficiencies. The report highlights specific instances where residents' financial rights were not honored, such as duplicate room and board charges for a resident who was hospitalized and unauthorized withdrawals for clothing and other personal expenses. The facility's failure to manage resident funds properly and obtain necessary authorizations reflects a significant oversight in financial management practices, impacting the residents' ability to manage their own financial affairs.
Failure to Reconcile Resident Trust Fund Account
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile the account each month. The facility managed funds for 34 residents, with a total census of 53. Record reviews of the facility-maintained bank statements for the account ending in 2107 from December 2023 through November 2024 showed no documentation of reconciliations for several months, including December 2023, June 2024, July 2024, September 2024, October 2024, and November 2024. Additionally, attempted reconciliation forms for the same account from December 2023 through September 2024 did not reconcile to the residents' current balance at the time of the attempted reconciliation, and there were no attempted reconciliations for October 2024 through November 2024. Interviews with the Regional Accountant and Business Office Manager revealed that the books for October 2024 and November 2024 had not been closed out, and the reconciliations for these months were not completed due to the amount of financial work.
Delayed Final Accounting of Resident Funds
Penalty
Summary
The facility failed to provide a final accounting of resident fund balances within the required thirty days for two residents. Resident #18 was discharged, and their funds were not refunded until 70 days after discharge, as confirmed by the Regional Accountant, who attributed the delay to closing out the books. Additionally, Resident #16 expired, and a withdrawal of $734.64 was made from their trust fund to pay for room and board. This transaction was not reported to the Department of Social Services, Third Party Liability Unit, until 107 days after the resident's death. The Business Office Manager stated that the resident's guardian instructed the payment, but they were unaware that the transaction needed to be reported to the relevant department.
Misappropriation of Resident's Bank Card by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property when a Certified Nurse Aide (CNA) used the resident's bank card for personal transactions. The resident, who had a moderately impaired cognition due to conditions such as metabolic encephalopathy, type 2 diabetes mellitus, heart failure with a pacemaker, anxiety, and depression, reported the bank card missing. The resident's family member discovered unauthorized transactions on the bank statement, including transfers to the CNA's account and an online shopping charge. The CNA admitted to using the resident's bank card for two transactions but denied the larger online shopping charge. The resident confirmed they never gave permission for the CNA to use the card and did not receive any items or food as claimed by the CNA. The facility's policy on abuse prevention, which includes misappropriation of resident property, was not followed by the CNA, leading to the deficiency.
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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