Friendship Village Chesterfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterfield, Missouri.
- Location
- 15250 Village View Drive, Chesterfield, Missouri 63017
- CMS Provider Number
- 265121
- Inspections on file
- 19
- Latest survey
- February 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Friendship Village Chesterfield during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and mobility issues was left alone in the bathroom and improperly assisted during transfers, leading to a deficiency in dignity and care. The resident, who required assistance with daily activities, was observed performing personal care without help while a CNA displayed inappropriate behavior. The facility's DON and Administrator reviewed video footage showing the CNAs' actions, which were deemed inappropriate and not in line with care expectations.
The facility failed to prevent accident hazards, resulting in injuries to residents due to improper use of mechanical lifts. One resident suffered a fracture from an inappropriate sit-to-stand lift transfer, and another was improperly connected to a Hoyer lift, causing the wheelchair to lift with the resident seated. Staff did not adhere to protocols requiring two staff members for transfers, leading to unsafe conditions.
The facility failed to properly label and store medications, with expired drugs found in medication rooms and carts. Additionally, medication carts were left unlocked and unattended, posing a risk to residents. Staff interviews revealed a lack of formal auditing processes for expired medications and inconsistent enforcement of cart security protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper PPE use for residents with wounds and COVID-19. Staff did not consistently wear gowns or N-95 masks, and EBP signage was missing. Confusion among staff about EBP requirements and improper mask use during a COVID-19 outbreak were observed.
The facility did not ensure CNAs completed the required 12 hours of annual training. Four CNAs, including a CMT, did not meet the training requirement, with hours ranging from 0 to 11.7. The facility lacked a policy for the training, and staff were expected to complete it independently by their anniversary date.
The facility failed to conduct and document required neurological assessments following unwitnessed falls for two residents, one with Parkinson's and dementia and another with a history of stroke and dementia. Despite the facility's policy, no neuro checks were recorded, even though one resident reported hitting their head. Staff interviews confirmed the absence of documentation, highlighting a lapse in adhering to established procedures.
Two residents in a facility were not provided with necessary assistance for activities of daily living (ADLs), including grooming and personal hygiene. One resident, with multiple sclerosis and dementia, was observed wearing the same stained gown for days and had untrimmed nails, despite expressing a desire for care. Another resident, with upper extremity impairments, reported receiving showers only once a week, contrary to their preference for more frequent showers. Staff interviews confirmed the lack of adherence to expected care routines.
A facility failed to provide necessary dialysis communication forms for a resident receiving hemodialysis. Despite the facility's policy requiring documentation and communication with the dialysis center, no forms were sent with the resident, as confirmed by staff interviews. The resident's care plan did not address hemodialysis treatments, and the DON confirmed the absence of completed communication forms in the medical record.
The facility failed to maintain a medication administration error rate below 5%, resulting in a 12% error rate. Two residents did not receive their prescribed medications due to unavailability on the medication cart and in the emergency kit. The Director of Nursing confirmed that medications should be administered as per physician orders, and if unavailable, staff should document them as not given and administer them at the next appropriate time.
An LPN in a facility was found to have misappropriated Norco, a controlled substance, by falsifying records and signing out excessive amounts for residents who did not request or require it. The issue was discovered when another LPN noticed discrepancies in medication records, leading to an investigation where the LPN confessed to taking the medications for personal use due to addiction.
The facility failed to document the administration and effectiveness of controlled substances for four residents, did not update medication orders on the IPNR, and omitted necessary signatures and dates for received medications. These lapses in documentation and adherence to policies potentially affected all residents with pain medication orders.
The facility failed to maintain a comprehensive system for documenting and reconciling controlled substances, leading to incomplete shift change count sheets and inadequate documentation of medication destruction. This affected residents prescribed controlled substances for pain management, with no clear records of how discontinued medications were handled.
The facility failed to prevent further misappropriation of controlled substances by not suspending an LPN during an investigation. The LPN continued working, leading to further misappropriation involving three residents. The facility also did not conduct a thorough investigation, failing to interview additional staff and residents as required by policy. This oversight had the potential to affect all residents with controlled substance orders.
Resident Dignity and Care Deficiency
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by multiple incidents involving a resident with severe cognitive impairment and mobility issues. The resident, who required staff assistance with mobility and personal care, was left alone in the bathroom while seated on the toilet and again while hovering over the toilet. During these times, a Certified Nurse Aide (CNA) made comments about their dislike of the job and the level of care the resident required. Additionally, during a transfer from the wheelchair to the bed, the resident was not properly assisted and was left with legs hanging off the bed. The resident's medical history included severe cognitive impairment, high blood pressure, orthostatic hypotension, acid reflux, dementia, Parkinson's disease, and depression. The resident required supervision or assistance with various activities of daily living, including toileting hygiene, sit-to-stand transfers, and chair/bed transfers. Despite these needs, the resident was observed performing personal care without staff assistance while a CNA stood in the doorway, clapping hands, snapping fingers, and swaying side to side. The facility's Director of Nursing (DON) and Administrator reviewed video footage provided by the resident's family, which showed inappropriate behavior by the CNAs. The DON noted that the aides were moving too fast and that it was not appropriate for the resident to be left alone on the toilet or for the resident to be transferred in a manner that left their lower half hanging off the bed. The Administrator acknowledged that the behavior of the aides was not appropriate and not in line with the facility's expectations for resident care.
Improper Use of Mechanical Lifts Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, as evidenced by improper use of mechanical lifts, leading to injuries. One resident sustained a minimally displaced sub-acute chip fracture along the anterior surface of the talus, reportedly due to improper handling during a Hoyer lift transfer. The investigation revealed that the resident had been transferred using a sit-to-stand lift, which was inappropriate given the resident's inability to stand safely. Additionally, a CNA admitted to operating the Hoyer lift alone, contrary to the facility's policy requiring two staff members for such transfers. Another incident involved a resident being improperly connected to a Hoyer lift, resulting in the wheelchair being lifted approximately one foot into the air with the resident seated. This incident highlighted a failure to ensure the resident's safety during transfers, as the Hoyer pad was not correctly attached, causing the chair to rise with the resident. The facility's policy mandates that two staff members assist with mechanical lift transfers to prevent such hazards. The facility's documentation and staff interviews revealed a lack of adherence to established transfer protocols, contributing to the unsafe conditions. Staff were not consistently following the care plans and mechanical lift policies, which specify the use of appropriate equipment and the need for two staff members during transfers. The facility's failure to ensure proper training and supervision of staff in using mechanical lifts resulted in preventable injuries to residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the first-floor medication room, several expired medications and biologicals were found, including Milk of Magnesia, Albuterol Sulfate inhalation aerosol solution packets, Covidien Xeroform Occlusive gauze strips, KerraFoam gentle border foam dressings, and Divalproex tablets. Additionally, a Glucagen Hypokit and a punch card for Senokot were found expired on medication carts. Interviews with staff revealed a lack of a formal process for auditing medication carts and rooms for expired medications, with responsibilities vaguely assigned to night shift staff and random audits requested by facility administration. The report also highlighted issues with medication cart security. On multiple occasions, a medication cart on the Grand Unit was observed unlocked and unattended by staff, posing a potential risk to residents, especially those with dementia. A Certified Medication Technician (CMT) was seen leaving the cart unattended while assisting residents, despite the expectation that carts should be locked when not in use. Interviews with staff confirmed that medication carts should be locked when unattended to ensure resident safety. The Director of Nursing (DON) and the facility Administrator both acknowledged the responsibility of staff to audit medication rooms and carts for expired medications and to ensure that medication carts are locked when not in use. However, the report indicates a lack of consistent procedures and enforcement of these expectations, contributing to the deficiencies observed during the survey.
Infection Control Deficiencies in EBP and COVID-19 Precautions
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS. This deficiency was observed in the care of residents with central lines, dialysis access sites, and wounds requiring treatment. Specifically, for two residents, the facility did not display EBP signage outside their rooms, and staff did not wear the required gowns during high-contact care activities. Interviews with staff revealed a lack of understanding and inconsistent application of EBP, with some staff believing that EBP only required glove use, while others were unsure of the requirements. Additionally, the facility did not ensure that staff wore N-95 respirator masks in rooms of residents positive for COVID-19, who were on airborne and droplet precautions. Observations showed that staff entered and exited these rooms without the appropriate PPE, and surgical masks were not worn properly on the first floor, where a COVID-19 outbreak was identified. Interviews with staff and the Director of Nursing confirmed that there was an expectation for surgical masks to be worn at all times on the first floor, but this was not consistently followed. The facility's policies on EBP and COVID-19 precautions were not effectively implemented, leading to lapses in infection control. The Infection Preventionist and other staff members expressed confusion over the application of EBP, particularly regarding wounds, and there was a lack of clear communication and enforcement of PPE requirements. The Administrator and Director of Nursing acknowledged the deficiencies and the need for proper signage and PPE use, but these measures were not consistently applied during the survey period.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of ongoing education annually. This deficiency was identified for four out of five sampled CNAs, including CNA Q, CNA N, Certified Medicine Technician (CMT) R, and CNA P. Specifically, CNA Q, hired on 5/18/23, completed 0 hours of training; CNA N, hired on 3/23/23, completed 3 hours; CMT R, hired on 3/16/09, completed 10.6 hours; and CNA P, hired on 10/2/14, completed 11.7 hours. The facility did not provide a policy related to the 12-hour training requirement. Interviews with the Director of Nursing (DON) and the Administrator revealed that CNAs were expected to complete their training by their anniversary date independently, without reminders.
Failure to Conduct and Document Neuro Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to adhere to its own policies regarding neurological assessments following unwitnessed falls, resulting in a deficiency. Two residents, one with Parkinson's disease and dementia and another with a history of stroke and dementia, experienced unwitnessed falls. Despite the facility's policy requiring immediate neurological checks in such cases, these assessments were not documented for either resident. This oversight occurred even though one resident reported hitting their head during a fall. Resident #41, who has multiple diagnoses including Parkinson's disease and dementia, experienced two unwitnessed falls. On both occasions, the resident's medical records lacked documentation of the required neurological checks. The resident was on a blood thinner, which increases the risk of complications from head injuries, yet no neuro checks were performed or recorded. Similarly, Resident #27, with a history of stroke and dementia, also experienced an unwitnessed fall, and no neuro checks were documented in their medical records. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed the absence of documentation for the required neuro checks. The staff acknowledged the importance of these assessments, particularly for residents on blood thinners or those unable to communicate effectively. Despite this understanding, the facility failed to ensure that neuro checks were completed and documented, as required by their policies, following the unwitnessed falls of these residents.
Deficiencies in Resident Hygiene and ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. Resident #24, who is cognitively intact but has multiple sclerosis, dementia, and depression, was observed over several days wearing the same stained hospital gown and having long, jagged fingernails with a light brown substance underneath. Despite the resident expressing a desire to have their nails trimmed and to be assisted out of bed, staff did not provide the necessary care. Interviews with staff revealed that the resident did not refuse care, yet the expected daily hygiene and grooming tasks were not completed. Resident #11, who is cognitively intact but has impairments in both upper extremities, was also not receiving adequate assistance with ADLs. The resident, who requires some assistance with showering and bathing, reported only receiving showers once a week, despite expressing a preference for more frequent showers. Observations confirmed the resident's hair appeared oily, indicating a lack of regular hygiene care. Staff interviews corroborated the resident's need for assistance with showering, including covering a Quinton catheter, but the facility failed to meet these needs consistently. Interviews with the Director of Nurses and the Administrator highlighted expectations for staff to provide daily nail care, change hospital gowns, and offer assistance with getting residents out of bed. However, these expectations were not met, as evidenced by the observations and resident interviews. The facility's failure to adhere to its own policies and procedures for morning care and hygiene resulted in deficiencies in the care provided to Residents #24 and #11.
Failure to Provide Dialysis Communication Forms
Penalty
Summary
The facility failed to provide necessary pre-assessment and post-assessment communication forms to the dialysis center for a resident receiving hemodialysis. The facility's Hemodialysis Access Policy requires documentation of the hemodialysis access point, condition of the dressing, prior dialysis dates, reports from the dialysis clinic RN, post-dialysis observations, and physician notifications of unusual observations. However, the resident's care plan did not address hemodialysis treatments, and no communication forms were sent with the resident to the dialysis center, as confirmed by interviews with the resident and facility staff. The resident, who was cognitively intact and diagnosed with heart failure, end-stage renal disease, and diabetes, reported attending dialysis sessions three times a week without any accompanying paperwork. Interviews with an LPN and RN revealed that no forms were sent with dialysis residents, except for the physician order sheet on the first day of treatment. The DON confirmed the absence of completed dialysis communication forms in the resident's medical record, indicating a failure to adhere to the facility's policy for dialysis communication.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 12% error rate. This deficiency was identified through observation, interview, and record review, affecting two residents. The facility's policy requires that all personnel administering medications ensure the correct medication, dose, person, administration time, and route. However, during the medication administration process, Certified Medication Technician (CMT) I was unable to administer the prescribed medications to two residents due to their unavailability on the medication cart and in the emergency kit. For Resident #34, the prescribed Refresh Tears eye drops were not available, and CMT I did not administer them on the scheduled day. Similarly, for Resident #9, the prescribed PreserVision eye drops and Thera-M multivitamin were missing, and CMT I did not administer these medications. The Director of Nursing confirmed that medications should be administered as per physician orders, and if unavailable, staff should document them as not given and administer them at the next appropriate time. The failure to administer these medications as ordered contributed to the facility's medication error rate exceeding the acceptable threshold.
Misappropriation of Controlled Substances by LPN
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of controlled substances by a staff member, specifically involving the unauthorized removal of Norco, a pain medication, for four residents. The issue was brought to light when an LPN noticed discrepancies in the medication sign-out records, particularly when another LPN, who was later identified as the perpetrator, was on duty. The LPN in question was observed signing out excessive amounts of Norco for residents, even when they did not request or require it, and often at times when they were unlikely to take it, such as late at night. Upon investigation, it was found that the LPN had been falsifying narcotic records, documenting the administration of Norco to residents who later confirmed they had not received the medication. Interviews with alert residents revealed that they had not been given the medication at the times recorded by the LPN. The facility's Director of Nursing (DON) and Administrator conducted interviews and reviewed video footage, which did not provide evidence of the medication being administered as documented. The LPN eventually confessed to taking the medications for personal use due to an addiction problem. The facility's failure to monitor and verify the accurate administration of controlled substances led to this deficiency. The lack of oversight allowed the LPN to continue the misappropriation over an extended period, affecting multiple residents. The issue was compounded by the fact that the facility's management did not act on initial concerns raised by another LPN until a formal complaint was made, highlighting a gap in the facility's internal controls and reporting mechanisms.
Deficiencies in Controlled Substance Documentation and Pain Management
Penalty
Summary
The facility failed to properly document the administration of controlled substances and the effectiveness of pain medication for four sampled residents. This included not recording the administration of narcotics on the Individual Patient Narcotic Record (IPNR) and the electronic Treatment Administration Record (eTAR). Additionally, the facility did not document the effectiveness of the pain medication after it was administered. This lack of documentation was observed for all four residents who were part of the sample. The facility also failed to update the IPNR when there were changes in medication orders. This oversight was noted in the records of the sampled residents, where the orders for pain medications were not updated to reflect changes in dosage or frequency. Furthermore, the facility did not document the signature of the nurse receiving the controlled medication and the date it was received, which is a critical step in ensuring accountability and compliance with controlled substance regulations. The deficiencies in documentation and record-keeping had the potential to affect all residents with pain medication orders and controlled substance orders. The facility's policies on controlled substances and pain management were not adhered to, as evidenced by the discrepancies in the narcotic records and the lack of documentation on the effectiveness of pain management interventions. These failures highlight significant lapses in the facility's medication management processes, which are essential for ensuring the safety and well-being of residents.
Inadequate Documentation and Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to establish a comprehensive system for the documentation and reconciliation of controlled substances, which are medications regulated by the DEA due to their potential for dependency and abuse. This deficiency was identified through interviews and record reviews, revealing that the facility did not maintain detailed records of the disposition of controlled substances, making accurate reconciliation impossible. Specifically, the facility's controlled substance shift change count sheets were inadequately completed, with only one staff member's initials present in numerous instances across several months. This lack of proper documentation and oversight was noted in the records of three out of three controlled substance shift change count sheets reviewed. Additionally, the facility did not have a system in place to document the destruction of controlled substances adequately. For four sampled residents, there was no documentation on what was done with the remaining controlled medications after they were discontinued. The records showed that medications were marked as discontinued, but there was no accompanying documentation to indicate how these medications were destroyed or disposed of. Interviews with the DON and ADON revealed that the facility relied on a drug buster system for medication destruction but did not document this process, leaving a gap in the accountability and tracking of controlled substances. The deficiency affected residents who were prescribed controlled substances for pain management, including those with conditions such as osteomyelitis, paraplegia, and fractures. The facility's failure to document the destruction of controlled substances and to ensure accurate shift-to-shift counts of these medications posed a risk to all residents with controlled substance orders. The lack of a formal education program for nursing staff on the importance of completing and documenting these counts further contributed to the deficiency, as acknowledged by the ADON and Administrator during interviews.
Failure to Prevent Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent further misappropriation and diversion of controlled substances by not adhering to its policy for suspension during an investigation. An LPN reported alleged violations of misappropriation by another LPN, who was allowed to continue working while the facility investigated the allegations. This resulted in the continued misappropriation of medications for three residents. The facility's policy required immediate suspension of the accused individual to protect residents, which was not followed. Additionally, the facility did not conduct a thorough investigation as required by its policy. The investigation did not include interviews with additional staff and residents who might have been involved or affected by the misappropriation. The facility's policy mandates a comprehensive investigation process, including interviews with all involved parties and a review of relevant documentation, which was not fully executed in this case. The failure to follow the facility's policy for suspension and thorough investigation had the potential to affect all residents with controlled substance orders. The facility's census was 82, indicating a significant number of residents could have been impacted by the misappropriation of medications. The lack of immediate action and comprehensive investigation compromised the safety and well-being of the residents.
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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