Eldon Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Eldon, Missouri.
- Location
- 1001 East North Street, Eldon, Missouri 65026
- CMS Provider Number
- 265555
- Inspections on file
- 17
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Eldon Nursing & Rehab during CMS and state inspections, most recent first.
Multiple residents who required assistance with showers did not consistently receive this care, as evidenced by missing documentation, resident interviews, and observations of poor hygiene. Staff cited time constraints and lack of available personnel for two-person assists as reasons for incomplete care, and leadership had not recently reviewed shower records, resulting in unmet hygiene needs.
A resident with moderate cognitive impairment and ongoing tooth pain, including broken teeth and facial swelling, did not receive timely assistance from staff to schedule a dental appointment despite repeated complaints and requests for pain relief. The social worker, responsible for arranging dental care, was aware of the issue but did not act, and facility records showed no attempts to secure dental services for the resident.
Staff failed to document assessments and obtain physician orders for new wounds in a resident with multiple pre-existing wounds and severe cognitive impairment. Despite facility policy requiring specific orders and documentation, new wounds were identified but not properly assessed or treated according to protocol, and records lacked evidence of timely interventions.
The facility did not ensure that residents were protected from all forms of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report does not provide additional details about the specific events or individuals involved.
Staff did not report an allegation of abuse involving a cognitively impaired resident with visible injuries to the state agency within the required two-hour timeframe. An LPN notified the DON about the injuries and the resident's statement, but the DON determined it was not reportable, and the incident was not escalated to the administrator or reported to authorities as required by policy.
Staff did not initiate or complete an investigation after a resident with severe cognitive impairment was found with a black eye and bruising and stated someone hit them. Although the LPN reported the incident to the DON, no formal investigation was conducted, and the incident was not reported to the state, contrary to facility policy.
A resident with moderate cognitive impairment exhibited repeated physical and verbal aggression toward others, as documented in nurse's notes, but staff failed to update the care plan to reflect these behaviors or include interventions. Interviews with CNA, RN, MDS Coordinator, DON, and the administrator confirmed that such behaviors should be care planned, but the omission was attributed to a lack of reporting or communication.
A cognitively impaired resident with a history of wandering and exit-seeking was able to leave the facility undetected, access a transport van with keys left inside, and drive several miles away. Staff had not updated the care plan or completed required elopement assessments after previous incidents, and the facility's elopement policy was not followed, resulting in the resident's absence only being discovered after notification by law enforcement.
A resident with cognitive impairment, delirium, and daily wandering behaviors was not properly assessed for elopement risk. The initial assessment inaccurately identified the resident as low risk, and subsequent assessments were left incomplete. Staff interviews revealed confusion over assessment responsibilities, and the facility's policy lacked clear instructions for completing elopement assessments.
Facility staff failed to properly store and label medications, with expired items and loose tablets found in storage areas. Staff interviews revealed inconsistent monitoring and accountability, with a CMT not checking carts due to vacation and the DON and administrator acknowledging the need for regular checks. This indicates a breakdown in medication management processes.
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which required signage and PPE for residents with wounds or indwelling devices. Observations showed that staff did not post EBP signage or provide PPE outside the rooms of affected residents, and staff did not wear gowns during care. Interviews revealed a lack of awareness and understanding of the EBP policy among staff, with concerns about resident dignity and unclear responsibility for oversight.
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition. Despite RD recommendations for supplements and weight monitoring, these were not communicated to the physician or implemented. Staff interviews revealed a lack of awareness regarding the need for supplements and meal intake monitoring, and systemic issues in policy and communication contributed to the deficiency.
The facility failed to establish an agreement and maintain communication with a dialysis facility for a resident with ESRD. Despite having a policy requiring communication records, no agreement was in place, and no paperwork was sent with the resident on dialysis days. The resident's care plan lacked guidance on communication, and staff were not trained on dialysis or renal disease. Interviews revealed a lack of awareness and responsibility among staff regarding these requirements.
A resident with a history of cognitive changes and behavioral episodes was observed by a family member with their hand down another resident's pants without consent. The affected resident, who is severely cognitively impaired, was unable to recall the incident. Despite the facility's policy to protect residents from abuse, the staff failed to implement adequate interventions to prevent such an occurrence, highlighting a deficiency in ensuring resident safety.
A resident with severe cognitive impairment and diabetes experienced multiple high blood glucose readings over several weeks without timely notification to the physician, leading to hospitalization for diabetic ketoacidosis. Interviews revealed a lack of communication and documentation among staff, and the facility lacked a policy for notifying physicians of changes in resident conditions.
Failure to Provide and Document Assistance with Showers for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living, specifically showers, for six residents who required such support. Review of facility records and interviews revealed that these residents, many of whom had moderate to severe cognitive impairment and required substantial to total assistance for personal hygiene and bathing, did not consistently receive showers as care planned or as per their preferences. Documentation in the electronic medical record (EMR) was often missing, with several residents going weeks without a documented shower or any record of refusal, despite their care plans indicating a need for regular assistance. Observations on the survey date showed multiple residents with greasy, unkempt hair, and in some cases, soiled clothing, indicating a lack of basic hygiene care. Interviews with the affected residents confirmed that they had not received showers for extended periods, with some expressing feelings of discomfort and uncleanliness. Residents reported that staff were supposed to assist them with showers at least once or twice per week, but this was not occurring, and some residents attempted to clean themselves with washcloths due to the lack of assistance. Staff interviews revealed that the designated shower aide was unable to complete all required showers due to time constraints and staffing shortages, particularly for residents needing two-person assistance. Staff also admitted to not always documenting showers or refusals in the EMR when busy. The facility lacked a specific shower policy, and leadership acknowledged that they had not recently reviewed shower documentation, relying instead on visual monitoring and verbal direction to staff. These actions and inactions led to a failure to meet the basic hygiene needs of dependent residents.
Failure to Arrange Timely Dental Care for Resident with Ongoing Tooth Pain
Penalty
Summary
Facility staff failed to ensure that a resident with moderate cognitive impairment and a history of mouth or facial pain received timely assistance in scheduling a dental appointment after reporting broken teeth and intermittent toothache. The resident's care plan indicated the presence of missing or broken teeth and a need for staff assistance with oral care. Despite multiple documented complaints of tooth pain, requests for pain medication, and visible swelling of the face, there was no evidence in the progress notes that staff attempted to schedule a dental appointment for the resident during the review period. Interviews with facility staff revealed that the social worker, who was responsible for arranging dental appointments, was aware of the resident's dental complaints for about a month but had not met with the resident or attempted to schedule an appointment. The DON and administrator both confirmed that the social worker was responsible for this task and expressed that an attempt to schedule a dental appointment should have been made. The facility also lacked a policy for dental care and services, and the resident's physician expected staff to arrange for dental care following reports of tooth pain.
Failure to Document and Obtain Orders for New Wounds
Penalty
Summary
Facility staff failed to meet professional standards of care by not documenting assessments of new wounds and not obtaining timely treatment orders from a physician for a resident with multiple pre-existing wounds. The resident, who had severe cognitive impairment, was at risk for pressure ulcers, had one or more unhealed pressure ulcers, and was receiving hospice care. The facility's policies required specific physician orders for wound treatments and mandated that nurses provide treatment as ordered and implement preventive measures. On review, staff documented the presence of new wounds, including a deep tissue injury to the left medial knee and a scabbed area on the right lower leg, but did not document a full assessment or obtain physician orders for these new wounds. The Physician's Order Sheet and Treatment Administration Record for the relevant period did not contain documentation of wound treatment orders or evidence that treatments were provided for the new wounds. Progress notes also lacked documentation of assessment or interventions for these wounds. Interviews with staff revealed that while some interventions were performed, such as applying skin prep and instructing aides to float the resident's heels, these actions were not properly documented. The DON acknowledged that assessments and documentation were incomplete, and the physician confirmed that staff should have assessed and obtained treatment orders for new wounds. The lack of documentation and failure to obtain timely orders constituted a deficiency in meeting professional standards of care for wound management.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report identifies a deficiency related to the facility's inability to ensure residents were safeguarded from these forms of mistreatment. Specific actions or inactions leading to the deficiency, as well as details about the residents involved or their conditions at the time, are not provided in the report. No further factual observations or events are described beyond the stated failure to protect residents from abuse and neglect.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of abuse involving one resident with severe cognitive impairment within the required two-hour timeframe to the administrator and the Department of Health and Senior Services (DHSS). The resident was found with a black eye and bruising to the shoulders, and staff documented that the resident stated someone had hit them. Although the physician and Director of Nursing (DON) were notified, there was no documentation that the allegation was reported to DHSS as required by facility policy and federal regulations. Interviews revealed that an LPN informed the DON about the resident's injuries and the resident's statement, and specifically asked if the incident was reportable to the state. The DON responded that it was not reportable and planned to speak with the resident. Further interviews with nursing staff and the administrator confirmed that the facility's policy is to report all allegations of abuse within two hours, but the incident was not reported because the DON and administrator claimed they were not made aware of the abuse allegations documented in the nurse's notes. As a result, the required notification to the state agency did not occur.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an alleged incident of resident-to-resident abuse involving a resident with severe cognitive impairment. According to the facility's Abuse and Neglect policy, any reported incident of abuse requires immediate investigation by the administrator or designee, including interviews with the resident, roommates, other residents, staff, and witnesses, as well as documentation of injuries and environmental factors. However, when staff documented that a resident had a black eye and bruising to the shoulders and that the resident stated someone hit them, there was no evidence in the nurse's notes or other records that an investigation was initiated or completed. Interviews with staff revealed that the LPN reported the injuries and the resident's statement to the DON, but the DON did not conduct a formal investigation, citing the resident's history of self-injury as the reason. The administrator confirmed that allegations of abuse should be reported and investigated but stated that in this case, the allegations were not investigated or reported to the state because they had not been formally reported to the DON or administrator. The lack of investigation and documentation was contrary to the facility's policy and regulatory requirements.
Failure to Update Care Plan for Resident Behavioral Changes
Penalty
Summary
Facility staff failed to update the comprehensive care plan for a resident with documented behavioral issues, despite multiple incidents of physical and verbal aggression towards other residents. The resident, assessed as having moderate cognitive impairment, exhibited behaviors such as shoving, making threats, and physically assaulting peers, as recorded in nurse's notes over several months. However, the care plan did not reflect these behaviors or include interventions to guide staff response, contrary to the facility's policy requiring care plans to be revised with changes in a resident's condition. Interviews with facility staff, including a CNA, RN, MDS Coordinator, DON, and the administrator, confirmed that behavioral issues should be documented in the care plan and that interventions should be included. The MDS Coordinator acknowledged responsibility for updating care plans and was unsure why the resident's behaviors were not included. The DON and administrator also stated that such behaviors and interventions should have been care planned, but could not provide a specific reason for the omission, suggesting it may not have been reported to the MDS Coordinator.
Failure to Prevent Elopement and Unauthorized Vehicle Use by Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide adequate protective oversight for a cognitively impaired resident with a known history of elopement, wandering, and exit-seeking behaviors. Despite multiple documented incidents where the resident attempted or succeeded in leaving the facility, staff did not update the resident's care plan to include interventions for elopement or exit-seeking. Additionally, required elopement/wandering assessments were not completed on several occasions, and the resident continued to exhibit wandering and exit-seeking behaviors as documented in nurses' notes. On the day of the incident, the resident was able to exit the facility without staff awareness, access the facility's transport van, and drive it approximately nine miles away. The van keys had been left inside the vehicle by the transport driver, which enabled the resident to operate the van. Staff were unaware of the resident's absence until contacted by the local sheriff's office, who had found the resident at a residential location. Interviews with staff confirmed that the resident was known for exit-seeking and that the van keys had been left in the vehicle due to oversight. The facility's elopement policy required staff to conduct thorough searches, notify appropriate personnel, and complete timely assessments, but these procedures were not followed in this case. The resident's care plan and risk assessments were not updated after previous incidents, and staff failed to provide the necessary supervision and environmental controls to prevent the resident's elopement and subsequent unauthorized use of the facility vehicle.
Failure to Complete and Accurately Document Elopement Assessments
Penalty
Summary
Facility staff failed to accurately complete elopement assessments for a resident who was identified as wandering daily and exhibiting exit-seeking behaviors. The resident was cognitively impaired, suffered from delirium, and was documented in nurses' notes as frequently wandering the facility, approaching exit doors, and attempting to get out. Despite these behaviors, the initial elopement assessment inaccurately scored the resident as low risk, and subsequent required assessments were left incomplete. The facility's elopement policy did not provide guidance on how to complete these assessments. Interviews revealed confusion among staff regarding responsibility for completing elopement assessments, with the DON and MDS/Assessment coordinator providing conflicting accounts of their roles. The MDS/Assessment coordinator stated that assessments may have been overlooked, while the DON acknowledged that assessments were either inaccurate or not completed as required. Corporate oversight processes also failed to identify the missing assessments, contributing to the deficiency.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility staff failed to adhere to proper medication storage and labeling protocols in one of two medication storage rooms and two of three medication storage carts. During an observation, expired intravenous caps and a bottle of Liquid Protein were found in the 300/400 hall medication storage room. Additionally, loose tablets and capsules were discovered in the medication carts on both the 300/400 and 100 halls. These findings indicate a lack of compliance with the facility's policy, which mandates that discontinued, outdated, or deteriorated drugs must not be retained and should be returned to the issuing pharmacy or destroyed. Interviews with facility staff revealed a lack of consistent monitoring and accountability for medication storage. A Certified Medication Technician (CMT) admitted to not checking the carts daily due to returning from vacation, while a Registered Nurse (RN) and the Director of Nursing acknowledged that medication rooms and carts should be checked at least monthly. The Director of Nursing and the facility administrator both stated that nursing staff are responsible for ensuring the proper disposal of out-of-date or loose medications, but ultimately, they are accountable for ensuring these tasks are completed. This deficiency highlights a breakdown in the facility's medication management processes and staff responsibilities.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which was designed to prevent the transmission of multidrug-resistant organisms and protect residents with chronic wounds and indwelling devices. The policy required the use of gloves and gowns during high-contact care activities for residents with wounds or indwelling medical devices, such as feeding tubes. However, observations revealed that staff did not post signage or provide personal protective equipment (PPE) outside the rooms of residents who required EBP, including two residents with wounds and one with a gastrostomy tube. Resident #13, who was cognitively intact and had unhealed stage III and IV pressure wounds, did not have EBP signage or PPE outside their room. Staff, including a registered nurse, failed to wear gowns while providing wound care. Similarly, Resident #52, who was cognitively impaired and had a diabetic ulcer, also lacked EBP signage and PPE, and staff did not wear gowns during care. Resident #60, who was cognitively intact and had a feeding tube, also did not have EBP signage or PPE, and staff did not wear gowns during care activities. Interviews with staff, including a registered nurse and a certified nurse aide, revealed a lack of awareness and understanding of the EBP policy. The Director of Nursing (DON) and the facility administrator indicated that the policy was not fully implemented due to concerns about resident dignity and a lack of clarity on who was responsible for oversight. The DON mentioned that the decision to place residents on precautions was made by the charge nurse, but there was no clear system to notify staff of residents requiring EBP.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #21 experienced a weight loss of 8.97% over three months and 12.68% over six months. Despite recommendations from the Registered Dietician (RD) to monitor weekly weights and add supplements, these were not communicated to the physician, nor were they implemented. The resident's care plan and dietary card did not reflect the RD's recommendations, and staff interviews revealed a lack of awareness regarding the need for supplements and monitoring of meal intake. Similarly, Resident #61, who was severely cognitively impaired, showed a downward trend in weight since admission. The RD recommended adding a house supplement twice daily due to inadequate food intake, but this was not communicated to the physician or documented in the resident's medical records. Interviews with staff indicated a lack of awareness of the resident's weight loss and the RD's recommendations, with no supplements being provided. The deficiency was further compounded by systemic issues within the facility, including the absence of a policy addressing RD recommendations and weight monitoring. The Director of Nursing (DON) and other staff members were unaware of the RD's recommendations not being implemented, and the MDS Coordinator was not informed of significant weight loss during prior admissions. The facility's failure to communicate and act on RD recommendations and significant weight changes led to the deficiency in maintaining residents' health through adequate nutrition.
Failure to Establish Dialysis Communication and Agreement
Penalty
Summary
The facility failed to establish and maintain an agreement and ongoing communication with a dialysis facility for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's dialysis policy, dated March 2015, outlined the need for communication between the facility and the dialysis unit, including sending a Dialysis Communication record with the resident on each visit. However, the facility did not have a dialysis agreement in place, and there was no communication record maintained in the resident's medical record. Interviews with the resident and staff confirmed that no paperwork was sent with the resident on dialysis days, and the facility had not provided any specific training on dialysis or renal disease. The resident, who was cognitively intact and diagnosed with ESRD, was admitted to the facility and had a physician's order for dialysis three times a week at an outside facility. Despite this, the resident's care plan lacked guidance on communication with the dialysis facility. Interviews with the facility's administrator, DON, and RN revealed a lack of awareness and responsibility regarding the need for a dialysis agreement and communication process. The dialysis center's Nurse Manager also confirmed the absence of an agreement and noted that communication reports are typically sent by facilities to aid in resident care, but this process was not being followed.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to implement necessary interventions to protect a resident from sexual abuse by another resident. Resident #2, who has a history of behavioral episodes due to cognitive changes, was observed by a family member with their hand down Resident #1's pants without consent. Resident #1, who is severely cognitively impaired and dependent on staff for daily activities, was unable to recall the incident. The facility's policy mandates that residents be free from abuse, but this incident indicates a failure to uphold that standard. Resident #1's care plan emphasized the need to keep the resident free from harm, yet the incident occurred in a public area, the main dining room, where Resident #2 was able to approach and engage in inappropriate behavior. Despite Resident #2's history of cognitive issues and a previous similar allegation at another facility, the staff did not have adequate measures in place to prevent such an incident. The incident was reported to the Director of Nursing and the Administrator shortly after it occurred, and the physician and family were notified. Resident #2's care plan was updated following the incident to address the inappropriate behavior, but prior to the event, there were no specific interventions to manage potential sexual behaviors. The facility's investigation revealed that neither resident could recall the incident, and the Director of Nursing was unaware of any prior sexual behaviors exhibited by Resident #2. The administrator acknowledged awareness of a similar past allegation but did not know the outcome, indicating a possible gap in communication or follow-up regarding Resident #2's behavioral history.
Failure to Notify Physician of High Blood Glucose Levels
Penalty
Summary
Facility staff failed to notify a resident's physician of critically high blood glucose levels, resulting in the resident being admitted to the hospital for diabetic ketoacidosis. The resident, who was severely cognitively impaired and completely dependent on staff for daily activities, had multiple blood glucose readings over 400 mg/dL over a period of several weeks. Despite these high readings, there was no documentation that the physician was notified until the resident's condition became critical, leading to hospitalization. Interviews with facility staff, including the Director of Nursing (DON), Certified Medication Technician (CMT), and Licensed Practical Nurse (LPN), revealed a lack of communication and documentation regarding the notification of the physician. The facility did not have a policy directing staff on when to notify the physician of changes in resident conditions. Staff members assumed that the physician was being notified, but this was not the case, particularly on days when the resident had multiple high glucose readings. The DON and administrator acknowledged the expectation to notify the physician of significant changes, but the failure to do so was not explained.
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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