Fair View Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sedalia, Missouri.
- Location
- 1714 W 16th Street, Sedalia, Missouri 65301
- CMS Provider Number
- 265856
- Inspections on file
- 17
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Fair View Health Care Center during CMS and state inspections, most recent first.
Facility staff did not ensure an RN was on duty for eight consecutive hours daily, separate from the DON, when the census was above 60. Staffing records and interviews confirmed that the DON regularly worked as the charge nurse during this period due to a shortage of RNs, despite awareness of the policy requiring separate RN coverage.
Staff did not complete or document required weekly skin assessments and physician-ordered wound treatments for three residents with significant risk factors for skin breakdown. Medical record and TAR reviews showed multiple missed assessments and undocumented treatments, despite facility policy and physician orders. Interviews with LPNs, the DON, and the Administrator confirmed these expectations and acknowledged the deficiencies in both completion and documentation.
Facility staff did not update the required Facility-Wide Assessment, resulting in missing and inaccurate information about resident census, acuity, special treatments, ADL needs, mobility, and staffing plans. Interviews with the DON and interim administrator revealed uncertainty about responsibilities and update frequency, leading to incomplete resource planning.
A resident admitted with severe cognitive impairment, acute respiratory failure, tracheostomy, Angelman syndrome, and a urinary catheter did not have a baseline care plan addressing their tracheostomy, gastrostomy tube, or urinary catheter within 48 hours of admission. Staff interviews revealed confusion about responsibility for care plan completion, and the DON acknowledged the plan was incomplete due to staffing issues.
Staff did not obtain physician orders for a resident's urinary catheter, tracheostomy, and gastrostomy tube, nor for the care and maintenance of these devices. Nursing staff and the DON were unaware of the missing orders and relied on prior experience to provide care, with responsibility for order entry and oversight not being properly executed.
The facility staff failed to follow infection control protocols during medication administration, perineal care, and glucometer disinfection. A CMT did not perform hand hygiene between residents, and CNAs did not wash hands during perineal care. An LPN used incorrect wipes for glucometer disinfection. The facility also lacked proper precautions for a resident with C-diff, and did not complete TB testing for several employees.
The facility failed to conduct required background checks, including EDL, CBC, and FCSR, for nine out of ten sampled employees before hiring. Interviews revealed confusion and lack of responsibility among staff regarding the completion of these checks, with the HR staff lacking access to complete FCSR checks and the Administrator unaware of the full requirements.
Facility staff failed to complete neurological assessments for two residents after falls, did not ensure pressure-relieving devices were used as ordered for two residents, and provided incorrect wound care for another resident. Interviews with staff, including an LPN, DON, and administrator, confirmed expectations were not met, leading to deficiencies in care.
Facility staff failed to provide scheduled bathing assistance to five residents, leading to inadequate hygiene maintenance. Despite the facility's policy, documentation showed missed showers for residents requiring assistance, with no records of refusal. Interviews confirmed that incomplete shower sheets likely indicated a lack of assistance.
The facility failed to provide a consistent activity program for residents, particularly on weekends, due to the absence of an activity director. This affected several residents who expressed a desire for activities. Staff confirmed that activities occurred randomly and infrequently, and an activities calendar was not posted as required by facility policy.
The facility failed to maintain a medication error rate below 5%, with a 20.69% error rate observed. Errors involved insulin administration without proper labeling of open and beyond use dates, and incorrect dosages. An LPN administered insulin from vials and pens missing these dates, and another resident received an incorrect insulin dose. The DON and administrator expected staff to check these dates and dosages, considering such errors as medication errors.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leave. Three residents were affected, with their medical records lacking documentation of such notifications. Interviews revealed that the Social Services Director was unaware of the requirement to notify upon each discharge, and an LPN was unfamiliar with the policy. The administrator believed the discharging nurse was responsible for this task but was unaware it was not being done.
The facility failed to complete required PASRR evaluations for two residents with mental health diagnoses, including schizophrenia and PTSD, residing in Medicare/Medicaid certified units. The Director of Nursing was unsure of the responsibility for these evaluations, and the administrator could not locate the completed screenings, despite acknowledging responsibility.
Facility staff failed to ensure call lights were within reach for three residents, all of whom were severely cognitively impaired and required assistance. Observations showed call lights were often on the floor or hung on walls, making them inaccessible. Interviews with staff, including a CNA, LPN, DON, and the administrator, confirmed the expectation for call lights to be within reach, yet they could not explain the oversight.
Facility staff failed to provide residents with access to their trust fund accounts on weekends, as the policy allowed access only during business hours, Monday through Friday. The Corporate Business Office Manager was unsure of regulations regarding access outside these hours, while the Administrator acknowledged awareness of the regulation but noted that the issue had never arisen.
The facility did not complete a detailed assessment to determine staffing and resource needs for resident care during routine and emergency situations. The assessment lacked information on licensed nurses, direct care staff per resident, and assistance with activities of daily living. The facility had 53 residents with various care needs, including oxygen therapy, tracheostomy care, and behavioral health care. The Administrator was unaware of the outdated assessment and noted that a new one would be implemented by the new corporation.
Failure to Provide Required RN Coverage When Census Exceeds 60 Residents
Penalty
Summary
Facility staff failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, separate from the Director of Nursing (DON), when the facility census exceeded 60 residents. Review of staffing sheets and census records over multiple dates showed that the DON regularly worked as the charge nurse during times when the census was above 60, contrary to the facility's own policy and regulatory requirements. The policy specifies that the DON may only serve as a charge nurse when the average daily occupancy is 60 or fewer residents. Interviews with the Administrator, staffing coordinator, and DON confirmed that the DON had been working as the RN charge nurse for several weeks due to a shortage of available RNs. The facility had only one other RN on staff, and both the DON and this RN alternated to cover required RN hours. The Administrator and DON acknowledged awareness of the requirement that the DON should not be counted as the floor RN when the census is above 60, but cited ongoing staffing challenges as the reason for noncompliance.
Failure to Complete and Document Weekly Skin Assessments and Wound Treatments
Penalty
Summary
Facility staff failed to meet professional standards by not completing and documenting weekly skin assessments and physician-ordered wound treatments for three residents out of a sample of six. The facility's policy required licensed or registered nurses to conduct full body skin assessments upon admission and weekly thereafter, as well as after any change in condition or new pressure injury. However, medical record reviews revealed multiple weeks where no documentation of these assessments was present for the affected residents. The residents involved had significant medical histories, including diagnoses such as stroke, pressure ulcers, chronic non-pressure ulcers, Parkinson's disease with dyskinesia, and immobility, all of which increased their risk for skin breakdown. Physician orders for these residents included specific wound care treatments and the use of barrier creams, which were to be documented on the Treatment Administration Record (TAR). Review of the TARs showed numerous dates where staff did not document that wound care was provided as ordered. Interviews with nursing staff, the DON, and the Administrator confirmed that weekly skin assessments and wound care documentation were expected responsibilities. Staff acknowledged that missing documentation on the TAR typically indicated that treatments were not completed. The DON admitted awareness of lapses in completing skin assessments but was not aware of the extent of missing documentation for wound care treatments.
Failure to Update Facility-Wide Assessment and Resource Planning
Penalty
Summary
Facility staff failed to update the Facility-Wide Assessment, which is required to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment tool, last dated 9/13/24, was missing critical information, including the names of persons involved in completing the assessment, dates of review with the QAA/QAPI committee, and accurate data on resident census, acuity levels, special treatments, ADL assistance needs, mobility, and the average daily staffing plan. These omissions meant the assessment did not accurately reflect the facility's current resident population or resource needs. Interviews with the DON and interim administrator revealed confusion regarding responsibilities for updating the assessment and the frequency with which updates should occur. The DON believed the administrator was responsible for updating the census and was unsure if the administrator knew how often the assessment should be updated. The interim administrator confirmed that the assessment should be updated annually and as needed, such as with changes in administration, DON, staffing requirements, resident acuity, or census, but could not explain why this had not been done.
Failure to Develop Comprehensive Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered baseline care plan within 48 hours of admission for one resident. The facility's policy requires that a baseline care plan be created within 48 hours, incorporating information from the admission assessment, hospital transfer documents, physician orders, and discussions with the resident and their representative. For the resident in question, who was admitted with severe cognitive impairment, acute respiratory failure, tracheostomy, Angelman syndrome, and a urinary catheter, the baseline care plan did not address critical needs such as the tracheostomy, gastrostomy tube, or urinary catheter. Interviews with staff revealed confusion and lack of clarity regarding responsibility for completing and verifying baseline care plans. The DON acknowledged that the baseline care plan was incomplete and attributed this to the absence of an MDS coordinator, resulting in the DON taking on the responsibility but not completing the required documentation. Other nursing staff were either unsure of how to access or update care plans or unclear about who was responsible for ensuring their completion. The administrator confirmed that nursing staff are responsible for completing baseline care plans, with the DON overseeing their completion.
Failure to Obtain Physician Orders for Critical Medical Devices and Care
Penalty
Summary
Facility staff failed to meet professional standards of quality by not obtaining physician orders for a urinary catheter, catheter care, tracheostomy, tracheostomy care, gastrostomy tube, gastrostomy tube care, or gastrostomy tube flushes for one resident. The resident, who was newly admitted, had severe cognitive impairment and diagnoses including acute respiratory failure, tracheostomy status, Angelman syndrome, and a urinary catheter. The clinical admission assessment documented the presence of a tracheostomy and urinary catheter but did not mention the gastrostomy tube, and the baseline care plan did not address these devices or their care. The physician's order sheet for the resident did not contain any orders related to these medical devices or their required care. Interviews with nursing staff and the Director of Nursing (DON) revealed that the charge nurse is responsible for entering orders for new admissions, while the DON is responsible for ensuring the orders are entered correctly. Staff were unaware that the necessary orders were missing from the system and relied on their prior nursing knowledge to provide care. The DON acknowledged a lack of knowledge among nurses regarding the process, and ongoing training was mentioned. The administrator confirmed that nursing staff are responsible for entering new admission orders, with oversight by the DON.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to infection prevention and control protocols during medication administration, perineal care, and glucometer disinfection. Certified Medication Technician (CMT) A did not perform hand hygiene between administering medications to multiple residents, despite knowing the importance of doing so. This lapse in protocol was acknowledged by the CMT, who attributed it to nerves and a lack of reeducation beyond initial training. Similarly, during perineal care, Certified Nurse Aides (CNAs) failed to wash their hands before and after glove use, increasing the risk of infection spread. The facility also failed to follow proper procedures for cleaning and disinfecting glucometers. An LPN used alcohol wipes instead of the required EPA-registered disinfectant wipes, which do not effectively kill bloodborne pathogens. This practice was not aligned with the facility's policy, and the LPN admitted to forgetting the correct procedure. The Infection Preventionist and Director of Nursing were unaware of this deviation from protocol, indicating a gap in oversight and training. Additionally, the facility did not implement appropriate transmission-based precautions for a resident with Clostridium difficile (C-diff) infection. There was no signage or personal protective equipment (PPE) available in or near the resident's room, and staff did not consistently use gowns and gloves as required. The Infection Preventionist and Director of Nursing were not fully aware of the necessary precautions, leading to inadequate infection control measures. Furthermore, the facility did not complete the two-step purified protein derivative (PPD) skin test for tuberculosis for several employees, as required by their policy, potentially exposing residents to TB.
Failure to Conduct Pre-Hire Background Checks
Penalty
Summary
The facility failed to adhere to its policy of conducting necessary background checks prior to hiring new employees. Specifically, the facility did not complete the Employee Disqualification List (EDL), Criminal Background Check (CBC), and Family Care Safety Registry (FCSR) screenings for nine out of ten sampled employees before their hire dates. These employees included a Registered Nurse, Nurse Aide, Certified Medication Technician, Dietary Aide, Laundry Aide, Housekeeping Aide, Maintenance staff, and two Certified Nurse Aides. The facility's policy, revised in May 2024, mandates that these checks be completed before hiring, but records showed that this was not done for the employees in question. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of these background checks. The Human Resources (HR) staff, who had been in the position for only two weeks, stated that they were responsible for onboarding new employees and conducting background checks, but they did not have access to complete FCSR checks yet. The Director of Nursing (DON) and the Administrator were unaware that some staff had been hired without the required screenings. The Administrator mentioned that prior to new ownership, the Business Office Manager (BOM) and they would collaborate on these checks, but with the new ownership, it became HR's responsibility. The Administrator was also unaware that all checks needed to be completed before hiring, believing that completing the EDL was sufficient.
Failure to Adhere to Professional Standards and Physician Orders
Penalty
Summary
The facility staff failed to adhere to professional standards of quality care by not completing necessary neurological assessments for two residents following falls. Resident #3, who had severe cognitive impairment and a diagnosis of dementia, experienced two falls resulting in head injuries. However, the medical records lacked documentation of neurological assessments or continuous monitoring for these incidents. Similarly, Resident #18, also with severe cognitive impairment and dependent on staff for all activities of daily living, was found on the floor, but no neurological assessment or continuous monitoring was documented. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the administrator, confirmed that neurological checks were expected but not performed or documented. The facility also failed to ensure the use of pressure-relieving devices as ordered for two residents. Resident #20, with severe cognitive impairment and upper extremity impairments, was observed multiple times without therapy carrots in place for hand contractures, despite physician orders. Similarly, Resident #22, with severe cognitive impairment and upper extremity impairments, was observed without hand rolls or pillows as ordered to alleviate pressure from contractures. Interviews with the occupational therapist, CMT, LPN, and DON revealed a lack of adherence to physician orders and a failure to ensure the prescribed treatments were administered. Additionally, the facility did not provide wound care treatment per physician orders for Resident #40, who had severe cognitive impairment and two unstageable pressure ulcers. The resident's care plan and physician orders specified a particular wound care regimen, but during an observation, an LPN used incorrect materials for the dressing change, based on a misunderstanding of the orders. The DON and administrator acknowledged the expectation for nurses to follow physician orders and the need for order clarification, but this was not done, leading to improper wound care treatment.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility staff failed to provide adequate bathing assistance to maintain proper hygiene for five residents who required assistance with their Activities of Daily Living (ADLs). The facility's Resident Showers Policy, revised in June 2024, mandates that residents should be provided showers as per request or facility schedule, with partial baths given between regular schedules. However, documentation and interviews revealed that several residents did not receive the scheduled showers or baths, and there was no documentation of refusal by the residents. Resident #15, who is cognitively intact and able to shower with assistance, did not receive scheduled showers on multiple occasions from June to August 2024. The resident reported not having received a bath or shower for about four weeks, despite being scheduled for showers twice a week. Similarly, Resident #26, who is dependent on staff for bed baths due to lower extremity impairment, did not receive any documented bed baths on scheduled days in June and July, and only one in August. The resident expressed difficulty in getting staff assistance for bed baths, resorting to using air fresheners to mask body odor. Resident #35, with severe cognitive impairment and dependent on staff for personal hygiene, also missed several scheduled showers from June to August 2024. Observations noted the resident with unkempt hair, indicating a lack of hygiene care. Resident #37, who requires moderate assistance, and Resident #38, with severe cognitive impairment and dependent on staff, both experienced similar issues with missed showers and lack of documentation. Interviews with nursing assistants and the Director of Nursing confirmed that if shower sheets were not completed, it likely indicated that the residents were not assisted with their scheduled showers.
Lack of Consistent Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs, interests, and well-being of residents, particularly on weekends. This deficiency affected four residents out of a sample of 14, as the facility did not have scheduled activities on several weekends in July and August 2024. Additionally, the facility did not post an activities calendar for residents to view, as observed on multiple occasions from August 26 to August 29, 2024. Interviews with residents revealed that they had not participated in activities for several months due to the absence of an activity director, and they expressed a desire for activities such as Bingo and Yahtzee. Staff interviews confirmed the lack of a consistent activity program. A CNA and an LPN mentioned that activities occurred randomly and infrequently due to the absence of an activity director. The Director of Nursing and the administrator acknowledged that the facility had not had consistent activities since the departure of the activity director, and they admitted that an activities calendar had not been posted recently. The facility's policy required an ongoing program of activities to promote residents' emotional health and self-esteem, but this was not being fulfilled due to staffing issues.
Medication Error Rate Exceeds 5% Due to Insulin Administration Issues
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20.69% error rate during the survey. Out of 29 medication administration opportunities observed, six errors were identified, affecting four residents. The errors primarily involved the administration of insulin without proper labeling of open and beyond use dates, as well as incorrect dosages being administered. Resident #23 was administered Lispro insulin from a vial that lacked a beyond use date. Similarly, Resident #26 received Aspart insulin from a pen with an illegible open date and no beyond use date. Resident #31 was given Glargine and Fiasp insulin from pens and vials that were either missing open dates or beyond use dates. In each case, the LPN involved was unaware of the importance of these dates and the potential for the insulin to be expired. Resident #58 was administered an incorrect dose of Aspart insulin, receiving only four units instead of the prescribed six units. The LPN acknowledged the error upon review of the physician's order sheet. Interviews with the DON and the administrator revealed that it was expected for staff to check open and expiration dates before administering insulin, and that administering expired insulin or incorrect dosages constituted medication errors.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for three residents out of a sample of three, with the facility's census being 53. The facility's policies did not include a procedure for bed hold notification, and the medical records of the affected residents lacked documentation of such notifications. Specifically, Resident #22 was discharged and readmitted without any written notification of the bed hold policy. Similarly, Resident #36 experienced multiple discharges and readmissions without receiving the required notification, and Resident #47's records also lacked documentation of bed hold policy notification upon discharge and readmission. Interviews with facility staff revealed a lack of awareness and understanding of the bed hold notification process. The Social Services Director (SSD) admitted to only providing bed hold information at the time of admission and was unaware of the requirement to do so upon each discharge for hospital or therapeutic leave. An LPN expressed unfamiliarity with the bed hold policy, assuming it was the responsibility of the SSD. The facility administrator believed that the discharging nurse was responsible for completing the bed hold notification and stated that staff had been in-serviced on this process, but was unaware that it was not being consistently implemented.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that Level I Pre-Admission Screening and Resident Review (PASRR) evaluations were completed for two residents, both of whom were residing in Medicare and/or Medicaid certified units. The PASRR is a federally mandated screening process designed to evaluate individuals for serious mental illness or intellectual disabilities to ensure appropriate placement and care. The facility's policies did not include a policy for PASRR, and the Director of Nursing was unsure who was responsible for completing these evaluations. The administrator acknowledged responsibility for completing PASRR evaluations but could not locate the completed screenings for the two residents in question. Resident #8 was assessed with moderate cognitive impairment and had diagnoses of anxiety disorder, depression, and schizophrenia. The resident was receiving antipsychotic, antianxiety, and antidepressant medications, yet their medical record lacked a Level I Pre-Admission Screening or PASRR Level II screen. Similarly, Resident #26, who was cognitively intact and diagnosed with anxiety disorder, depression, and PTSD, also did not have the required PASRR evaluations in their medical record. Both residents were receiving relevant medications, indicating the necessity for such screenings to ensure their needs were being met appropriately.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility staff failed to ensure that call lights were within reach for three residents, leading to a deficiency in the accessibility of the call system. Resident #10, who was severely cognitively impaired and dependent on staff for activities of daily living and transfers, was observed multiple times with the call light either on the floor or hung on the wall behind the bed, making it inaccessible. Similarly, Resident #27, who was legally blind and required substantial assistance, was found in a wheelchair with the call light placed on the bed or hung on the wall, out of reach. Resident #40, also severely cognitively impaired and dependent on staff, was repeatedly observed with the call light on the floor beside the bed, not within reach. Interviews with facility staff, including a CNA, an LPN, the Director of Nursing, and the administrator, confirmed that call lights should always be within reach of residents to prevent falls and ensure they can request help. Despite this understanding, the staff was unable to explain why the call lights were not accessible to the residents in question. The facility's policy mandates that call lights be accessible to residents at all times, yet observations indicated a failure to adhere to this policy, resulting in a deficiency in resident care.
Inadequate Access to Resident Trust Funds on Weekends
Penalty
Summary
Facility staff failed to ensure residents had appropriate access to their trust fund accounts on weekends. The facility's Resident Trust Policy, dated February 2, 2024, and the Admission Packet both indicated that residents could access their personal possessions and funds only during regular business hours, Monday through Friday. During an interview, the Corporate Business Office Manager confirmed that the corporation policy restricted access to business hours and was unsure of the regulations regarding access outside these hours. The Administrator acknowledged awareness of the regulation but mentioned that the issue of weekend access had never arisen, and if necessary, a nurse could cover money for a resident, with reimbursement from the facility's petty cash later.
Incomplete Facility Assessment for Staffing and Resident Care Needs
Penalty
Summary
The facility failed to develop a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated 01/20/24, was incomplete, lacking details on the number of licensed nurses and direct care staff per resident, as well as assistance with activities of daily living. The facility census was 53, with specific care needs including oxygen therapy, tracheostomy care, BIPAP/CPAP, behavioral health care, injections, dialysis, ostomy care, and hospice care. During an interview, the Administrator acknowledged her responsibility to update the facility assessment but was unaware that it had not been updated. She mentioned that a new assessment would be implemented by the corporation that recently took over.
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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