Grand River Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Chillicothe, Missouri.
- Location
- 118 Trenton Road, Chillicothe, Missouri 64601
- CMS Provider Number
- 265480
- Inspections on file
- 21
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Grand River Health Care during CMS and state inspections, most recent first.
A resident with dementia, Parkinson’s disease, mood disorder, and a history of verbal and physical behaviors required maximum assistance with ADLs and had a care plan directing staff to avoid power struggles, use a calm approach, and stop and reattempt care later if the resident became abusive. During incontinence care, a NA reported that the DON pulled on the resident despite complaints of pain, then attempted to remove heavily soiled shorts while the resident yelled to be left alone and resisted. The Administrator entered, and per witness accounts, held the resident’s arm tightly while the DON continued trying to remove the shorts and used profanity, including a threat when the resident kicked toward her. The SSD, standing in the hallway, heard the DON use an obscenity toward the resident, and staff later observed multiple small bruises on the resident’s arms and hand, with the resident complaining of arm pain and stating that staff had hurt him/her. Staff interviews revealed confusion about how to report abuse when the alleged perpetrators were the DON and Administrator, and the DON and Administrator were not immediately removed from their roles despite facility policy requiring immediate suspension of employees alleged to have committed abuse.
A resident with dementia, Parkinson’s disease, mood disorder, and frequent verbal/physical behaviors, who required maximum assistance with ADLs, was involved in an incident where the DON pulled on the resident, grabbed and pulled at soiled shorts against the resident’s objections, and used profanity, while the Administrator tightly held the resident’s arm as the resident yelled, slapped, and kicked. A maintenance staff member assisting with care believed the actions were abusive, observed bruising on the resident’s arms later, and left the room and facility after refusing to further participate. The SSD and BOM heard or partially witnessed the episode, including the DON’s profane statement, but were unsure how to report because the alleged perpetrators were their supervisors, and their abuse training only directed them to report to the Administrator. As a result, staff did not immediately report the allegation of abuse to the state survey agency as required by policy.
A resident with severe cognitive impairment and a history of aggressive behavior physically struck another resident on two occasions in the dining hall. Despite staff awareness of the resident's behavioral risks, supervision was inconsistent, and the incidents were not prevented. The affected resident, who had mild cognitive impairment, reported being hit, and staff confirmed the events, but the facility did not implement effective measures to stop the abuse.
A resident with multiple chronic conditions and on hospice care was subjected to verbal and physical abuse by staff during an episode of Bi-Pap mask administration. Staff became frustrated with the resident's refusal to wear the mask, leading a nurse aide to hold the resident's arms down, use profanity, and call the resident 'stupid,' while an LPN yelled at the resident, told them they would die if they did not comply, and physically restrained the resident's hand to force the mask on. Witnesses confirmed the abusive actions, and the resident reported feeling scared and upset by the incident.
A resident with severe cognitive impairment and chronic pain had a full bubble pack of hydrocodone-acetaminophen go missing, with the controlled drug count sheet also unaccounted for and the medication cart found unlocked. Staff interviews revealed inconsistent explanations and improper access to controlled substances by a CMT, who was observed with medications outside the facility and exhibited concerning behavior. The facility could not determine what happened to the missing medication due to poor documentation and lack of secure storage.
A resident with severe cognitive and physical impairments had a bubble pack of hydrocodone-acetaminophen go missing. Although the facility notified the state survey agency and conducted an internal investigation, law enforcement was not contacted as required by policy. The Administrator acknowledged that the missing narcotics should have been reported to authorities, but this was not done.
The facility failed to maintain food safety and kitchen cleanliness standards, with expired and unlabeled food items, improper storage of cups and glasses, uncovered garbage cans, and a lack of dishwasher chemical test logs. Additionally, the kitchen and walk-in cooler were not properly maintained, with dust, debris, and moisture present. These deficiencies were acknowledged by dietary staff and the Administrator.
The facility failed to provide dignified care, as staff were observed vaping in a resident's room, refused a resident's request for medical help, and conducted medical procedures in public areas. Additionally, meals were served on disposable plates, and residents at the same table were not served simultaneously, leading to complaints about unequal treatment.
The facility failed to ensure proper lighting in shared restrooms, affecting 11 rooms. Residents had to cross dark restrooms to reach a light switch, posing a risk for those with gait instabilities. A resident expressed dissatisfaction, and the Maintenance Supervisor confirmed the wiring issue.
The facility did not respect the personal care preferences of two residents, leading to unmet needs. A resident who prefers night showers for privacy was not assisted with shaving, causing discomfort. Another resident, unable to shower due to a cold shower room, felt humiliated and avoided social interactions. Staff interviews confirmed residents should have their preferences met, but this was not the case.
The facility failed to ensure residents had timely access to personal funds on weekends, affecting several residents. Despite a policy allowing access during normal business hours and provisions for weekend requests, residents reported being unable to access funds on Saturdays. Interviews revealed that the Business Office Manager and Administrator were the only ones with access to the safe containing petty cash, and no staff were available on weekends to provide funds. This deficiency impacted residents' ability to manage their financial affairs.
The facility failed to maintain a clean and comfortable environment, with issues such as damaged furniture, peeling paint, and non-functional call lights affecting all residents. The shower room was notably cold, leading to missed showers and discomfort for residents with arthritis. Staff interviews revealed a backlog of repairs and a lack of systematic inspections, contributing to the ongoing deficiencies.
The facility failed to develop and update care plans for two residents, one with PTSD and another on antibiotics. A resident with PTSD was not provided with a care plan identifying triggers, leading to distress during an incident with paramedics and police. Another resident's care plan did not address their code status or antibiotic use. Staff interviews revealed a lack of awareness and training, and the absence of a care plan policy highlights deficiencies in the facility's processes.
The facility failed to provide medications for two residents, leading to a deficiency in care. A resident with multiple diagnoses, including diabetes and schizophrenia, did not have Jardiance and Myrbetriq available, and their insulin order lacked clarity on administration frequency. Another resident with conditions like CHF and dementia was out of Eliquis. The pharmacy's 14-day fill policy contributed to the issue, and the facility was switching pharmacies.
The facility failed to consistently provide fresh water to residents, affecting three individuals with various medical conditions. Observations showed that water pitchers were often empty or lacked ice, and residents expressed dissatisfaction with the inconsistency. Staff interviews revealed that while the night shift sometimes provided fresh ice water, the day shift did not routinely do so, leading to residents having to request it themselves.
The facility failed to provide proper respiratory care by not dating oxygen tubing, allowing it to lie on the floor, and not refilling humidifiers daily. A resident experienced respiratory distress and was sent to the ER. Staff interviews confirmed non-compliance with facility guidelines for oxygen equipment maintenance.
The facility had a medication error rate of 19.23%, affecting several residents due to incorrect administration of eye drops and delayed insulin meals. Additionally, medication availability issues led to residents missing doses of essential medications.
The facility failed to manage and store medications properly, with expired medications and biologicals found in the medication room and cart. Medications were not dated when opened, and personal items like cigarettes and money were improperly stored in the medication cart. Staff interviews revealed non-compliance with facility policies on medication administration and labeling.
The facility failed to administer the required two-step TB screening for seven newly hired employees and did not adhere to proper handwashing and enhanced barrier precautions (EBP) during resident care. Observations showed staff not changing gloves or washing hands between tasks, and Resident #79, with severe cognitive impairment and a documented wound, did not receive care following EBP guidelines. Staff interviews confirmed the lack of adherence to protocols.
A resident with schizophrenia and psychotic disorder threatened another resident over a television dispute, causing fear and distress. Despite having a care plan for managing delusional and aggressive behavior, the resident's actions escalated, leading to police involvement and a court-ordered psychiatric evaluation. The facility sought alternative placement as the resident refused medication and showed no improvement.
A resident with severe cognitive impairment and multiple diagnoses exhibited symptoms of an upper respiratory condition, but the facility failed to notify the physician in a timely manner. The resident showed signs of illness for weeks, yet there was no documentation of physician or guardian contact. Staff interviews revealed that symptoms were reported, but the resident was not isolated due to the lack of a physician's order.
A resident with cognitive impairments and multiple health conditions was verbally and physically abused by a CNA at an LTC facility. The incident occurred when the resident, who was upset about a non-working phone, was prevented from using the nurses' station phone. The CNA grabbed the resident's arm, jerked them back into their wheelchair, and cursed at them, which was witnessed by other staff members. The facility's Administrator acknowledged the failure to protect the resident from abuse.
A resident with severe cognitive deficits and a history of aggressive behaviors was abused by the DON, who used the resident's hand to hit their own face during an altercation. The incident was witnessed by a housekeeping aide and later reported, leading to the DON being placed on leave. The resident expressed feeling unsafe around the DON, and the incident was reported to law enforcement.
A resident with severe cognitive deficits was involved in an alleged abuse incident with the DON, which was not reported within the required timeframe. The resident, who had a history of physical and verbal behaviors, was allegedly hit with their own hand by the DON. The incident was reported late due to staff's fear of repercussions and absence of supervisors, leading to a delay in notifying the Administrator and authorities.
A resident with a history of dementia and mental health conditions was improperly restrained by staff during the administration of an intramuscular injection for aggressive behavior. Despite facility policies against physical restraints, staff members used their bodies to hold the resident down, which was not approved by medical personnel. Interviews revealed a lack of training in restraint use and de-escalation techniques among staff.
A resident with a history of mental health conditions exhibited escalating behaviors, leading to the use of an antipsychotic injection. Despite staff attempts to manage the situation, the resident's behavior worsened, culminating in aggression towards staff. Interviews revealed a lack of formal training in behavior modification, contributing to the deficiency in providing necessary behavioral health care.
Abusive Handling of Resident During Incontinence Care and Failure to Follow Abuse Protections
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse during incontinence care and clothing change. The resident had dementia, Parkinson’s disease, mood disorder, violent behaviors, anxiety, depression, was always incontinent of bowel and bladder, and required maximum assistance with ADLs. The resident’s care plan directed staff to avoid power struggles, explain procedures, maintain a calm, slow approach, stop care and try later if the resident became verbally abusive, not to force tasks, and to allow the resident as much control and decision-making as possible. On the day of the incident, the Maintenance Director/NA began assisting the resident with changing a soiled brief and clothing. The resident refused care from a female CNA, who left the room, and then allowed the Maintenance Director/NA to assist. The DON entered, told the resident he/she needed to get cleaned up, and the resident yelled at the DON to leave. The Maintenance Director/NA obtained the resident’s agreement for the DON to help only with turning in bed. According to the Maintenance Director/NA, the DON pulled on the resident, the resident said it hurt, and the DON told the resident he/she was fine. The resident began pulling and smacking at the DON, who then let go, and the Maintenance Director/NA applied a clean brief. The Maintenance Director/NA noted the resident’s shorts were heavily soiled and obtained the resident’s agreement to change them, but stepped away briefly to check laundry. During this time, the DON began grabbing and pulling on the resident’s shorts. The resident grabbed the shorts with one hand, yelled for the DON to get out and leave him/her alone, and slapped at the DON with the other hand. The Administrator entered the room, and per the Maintenance Director/NA, the DON told the Administrator/CMT/CNA to grab the resident. The Administrator then held the resident’s arm tightly by the hand and elbow while the resident kicked and screamed. The Maintenance Director/NA reported that the resident kicked toward the DON’s face and that the DON responded by saying, “kick me again motherfucker and see what happens.” The Maintenance Director/NA told them to stop, refused to hold the resident’s arms, left the room, and then left the facility. The SSD reported hearing the resident yelling and, from the hallway, heard the DON say, “kick me again motherfucker and see what happens.” The SSD saw the Maintenance Director/NA exit the room stating he/she wanted no part of it. The SSD and BOM both stated they had received abuse training that instructed them to report to the Administrator but did not address what to do if the Administrator was the alleged perpetrator, and they were initially unsure how to proceed. The SSD later learned from the Maintenance Director/NA that the Administrator held the resident down by the arm while the DON cursed at the resident and ripped off the resident’s shorts. The resident later complained of arm pain and refused to allow staff to examine the arm. Observation showed multiple dime-sized, light-yellow discolorations (bruises) on the resident’s forearms and hand, and the resident indicated the bruised area while stating, “they hurt me here.” An x-ray of the right arm and hand showed no fractures. The facility’s abuse policy prohibited verbal, mental, or physical abuse, including holding someone down or grabbing a resident by the arms or legs, and required immediate suspension of any employee alleged to have committed abuse, but the DON and Administrator continued to provide oversight for residents until the following day.
Failure to Immediately Report Alleged Abuse Involving DON and Administrator
Penalty
Summary
Failure to immediately report an allegation of abuse occurred when staff did not promptly notify the state survey agency after an incident involving a cognitively impaired resident with dementia, Parkinson’s disease, mood disorder, violent behaviors, anxiety, and depression. The resident required maximum assistance with ADLs and had frequent verbal and physical behaviors. On the date of the incident, the Maintenance Director, who was also a nurse aide, was assisting the resident with a brief change when the DON entered and told the resident he/she needed to get cleaned up. The resident yelled at the DON to leave, but eventually agreed to allow the DON to help turn him/her. The DON pulled on the resident, the resident complained of pain, and the DON responded that there was nothing wrong with the resident. The resident began yelling and smacking at the DON, who then let go. The Maintenance Director observed that the resident’s shorts were heavily soiled and obtained the resident’s agreement to be changed. The DON then began grabbing and pulling on the resident’s shorts while the resident held onto them with one hand and yelled for the DON to leave him/her alone, simultaneously slapping at the DON with the other hand. The Administrator entered the room, and at the DON’s direction, grabbed the resident by the hand and elbow and held the arm tightly while the resident kicked and screamed. The resident kicked toward the DON’s face, and the DON responded by saying, “kick me again motherfucker and see what happens.” The Maintenance Director told the DON and Administrator to stop and leave the resident alone, refused to hold the resident’s arms when instructed by the Administrator, and then left the room and the facility. The next day, the Maintenance Director noted small bruises on the resident’s arms that had not been present during bathing the previous day. Multiple staff members witnessed or overheard parts of the incident but did not immediately report the allegation of abuse to the state agency as required by facility policy. The SSD heard the resident yelling and, from the hallway, heard the DON say “kick me again motherfucker and see what happens,” and saw the Maintenance Director exit the room stating he/she wanted no part of it. The SSD and BOM both reported uncertainty about how to report abuse when the alleged perpetrators were the DON and Administrator, noting that their abuse training video instructed them to report to the Administrator but did not address what to do if the Administrator was involved. The Maintenance Director, SSD, and BOM delayed external reporting, and the allegation was not immediately reported to the state survey agency within the required time frames outlined in the facility’s Abuse Prohibition Protocol Manual.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had severe cognitive impairment and a history of aggressive behaviors, struck the resident on two separate occasions. The resident who committed the acts had diagnoses including psychotic disorder, obsessive compulsive disorder, and dementia, and was known to become agitated, yell, and hit others when frustrated. Despite these known behaviors, the resident was not always supervised, and incidents occurred in the dining hall where the resident hit another resident on the arm. Documentation shows that staff and management were aware of the resident's behavioral tendencies, but the supervision and interventions in place were insufficient to prevent repeated physical contact. The resident who was struck had mild cognitive impairment and required substantial assistance with activities of daily living. On both occasions, the resident reported being hit in the dining room, and staff assessed for injuries, finding none. The incidents were documented in nursing progress notes, and notifications were made to the administrator, guardian, and provider. However, there was no evidence of consistent or effective measures to prevent further occurrences, as the same pattern of behavior recurred, and staff interviews indicated that the aggressive resident was sometimes left unsupervised. Interviews with staff and other residents confirmed that the aggressive resident had a pattern of yelling, hitting, and threatening others, and that staff were aware of the risk but did not always provide adequate supervision. Residents reported feeling the need to avoid the aggressive resident, and staff acknowledged that residents have the right not to be hit by anyone. The facility's failure to provide sufficient supervision and protection allowed repeated physical abuse to occur, violating the policy that each resident should be free from abuse and harm.
Resident Subjected to Verbal and Physical Abuse During Bi-Pap Administration
Penalty
Summary
Facility staff failed to protect a resident from verbal and physical abuse during an incident involving the use of a Bi-Pap mask for respiratory support. The resident, who was on hospice care with diagnoses including heart failure, hypertension, schizophrenia, and chronic respiratory issues, was non-compliant with the Bi-Pap order and required frequent encouragement to use the device. During a period of low oxygen saturation, staff became frustrated with the resident's refusal to wear the Bi-Pap mask. A nurse aide admitted to holding the resident's arms down, cussing at the resident, and calling them 'stupid' while demanding the mask be worn. The aide also punched a pillow near the resident's head, which frightened the resident. Another staff member, an LPN, was reported to have yelled at the resident, told them they would die if they did not comply, and physically held the resident's hand down to force the mask on, despite the resident's expressed wishes to refuse the treatment. Multiple interviews confirmed that the resident was subjected to both verbal and physical abuse by staff during this event. The resident reported feeling upset and scared, stating that staff forced them down and used harsh language. Witnesses, including another nurse aide, corroborated that the LPN and nurse aide both yelled at the resident and used physical force to restrain the resident and apply the Bi-Pap mask. The staff involved acknowledged their actions, with the nurse aide admitting to cussing and restraining the resident, and the LPN admitting to holding the resident's hand and using a loud voice. The incident occurred in the context of the resident's oxygen saturation dropping to dangerously low levels, but staff actions were not in accordance with facility policy, which prohibits the use of restraints and mandates respect for residents' rights to refuse care. The facility's own investigation verified the allegations of abuse and neglect, based on eyewitness statements and staff interviews. The investigation found that the staff involved did not follow established protocols for handling non-compliance and instead resorted to abusive and coercive measures. The resident's right to refuse care was not honored, and the staff's actions resulted in the resident experiencing both physical and emotional distress.
Misappropriation of Controlled Medication Due to Inadequate Security and Documentation
Penalty
Summary
A resident with severe cognitive impairment, vascular dementia, major depressive disorder, pain, and anxiety was dependent on a wheelchair and required significant assistance with daily activities. The resident was on a scheduled pain medication regimen, including hydrocodone-acetaminophen, a Schedule II controlled substance. According to medication administration records and pharmacy delivery receipts, there were discrepancies in the number of hydrocodone-acetaminophen tablets available for the resident, with a full bubble pack of medication found missing from the facility. The controlled drug count sheet for the missing medication was also not located, and the controlled drug box inside the medication cart was observed to be unlocked. Staff interviews and record reviews revealed inconsistent accounts regarding the handling and destruction of the resident's controlled medications. A Certified Medication Technician (CMT) was reported to have access to and to have passed controlled drugs, despite facility policy changes and concerns raised by nursing staff. The CMT provided conflicting explanations about the missing medication, at times stating that the Director of Nursing (DON) and Administrator had destroyed the drugs, and at other times denying involvement. Other staff members, including the Business Office Manager and nurses, reported observing the CMT with medications outside the facility and noted unusual behavior, such as drowsiness and pre-setting medications, which was against facility policy. Despite multiple staff statements and an internal investigation, the facility was unable to conclusively determine the fate of the missing controlled medication. There was no documentation of proper destruction, and the medication could not be accounted for through standard procedures. The lack of secure storage, inconsistent medication handling practices, and inadequate documentation led to the misappropriation of the resident's property, specifically the loss of a controlled substance prescribed for pain management.
Failure to Report Missing Narcotics to Law Enforcement
Penalty
Summary
The facility failed to report the misappropriation of a resident's narcotic medication to both the state survey agency and local law enforcement as required by policy. On 3/11/25, staff became aware that a bubble pack containing 30 tablets of hydrocodone-acetaminophen, a controlled substance prescribed for severe pain, was missing for a resident with severe cognitive impairment, chronic pain, and multiple physical dependencies. The investigation revealed conflicting accounts among staff regarding the destruction or disappearance of the medication, with the Director of Nursing and Administrator denying any involvement in destroying the drugs. The facility did notify the state survey agency and conducted an internal investigation, but law enforcement was not contacted at any point. The resident involved had significant medical needs, including vascular dementia, major depressive disorder, chronic pain, and required substantial assistance with daily activities. Despite facility policy mandating immediate reporting of suspected crimes to law enforcement, the Administrator chose not to contact authorities, citing the time elapsed since the medication went missing. Interviews confirmed that the Administrator was responsible for the investigation and acknowledged that the missing narcotics should have been reported to law enforcement, but this step was not taken.
Deficiencies in Food Safety and Kitchen Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food storage and labeling. Observations revealed expired food items, such as baking cocoa and baking powder, and numerous food packages without open or received dates, including soy sauce, parsley flakes, and chocolate fudge icing. Interviews with dietary staff, including the Dietary Aid, Dietary Manager, Dietician, and Administrator, confirmed that opened food should be labeled with the date opened, and expired items should be discarded. However, these practices were not consistently followed, leading to the presence of expired and unlabeled food items in the facility. Additionally, the facility did not maintain proper storage practices for cups and glasses, which were observed stored upright and uncovered on beverage carts and trays. This practice was contrary to the expectations of the dietary staff and the Administrator, who stated that cups and glasses should be stored face down to ensure cleanliness. Furthermore, the facility failed to cover garbage cans when not in use, as required by the Waste Disposal policy, and did not maintain a log for dishwasher chemical tests, which is necessary for ensuring proper sanitation. The facility also exhibited deficiencies in kitchen cleanliness and maintenance. Observations noted dust accumulation on vents, dirty floors with stains and debris, and unpainted spackled walls. The walk-in cooler was found to have a leaking ceiling and a wet floor, with a towel placed inside the doorway. These conditions were acknowledged by the dietary staff and Administrator, who agreed that the kitchen and walk-in cooler should be clean and free of dust, debris, and moisture. Despite requests, the facility did not provide policies regarding dietary services, kitchen cleaning, and maintenance, indicating a lack of formal guidelines to address these issues.
Lack of Dignified Care and Professionalism in Resident Treatment
Penalty
Summary
The facility failed to ensure staff cared for residents in a dignified and professional manner, as evidenced by several incidents. A resident with severe cognitive impairment and multiple diagnoses, including schizophrenia and PTSD, reported that a nursing assistant (NA) was rude, gave a dirty look, and was vaping in the resident's room. The NA refused the resident's request to look at their urine and instead redirected the resident back to bed. The NA admitted to having a vaping pen in hand during the incident. Additionally, the facility did not maintain privacy for residents during medical procedures. Two residents had their blood sugar levels checked and insulin administered in a public common area, in view of other residents. This practice was acknowledged by staff as inappropriate, as such procedures should be conducted in private to maintain resident dignity. Furthermore, the facility served meals on Styrofoam plates with plastic utensils to residents eating in their rooms, which was against the facility's policy of using regular dishware. Residents in the dining room were not served meals simultaneously at the same table, leading to complaints about unequal treatment and cold food. These actions demonstrate a lack of adherence to professional standards and resident rights policies.
Inadequate Lighting in Shared Restrooms
Penalty
Summary
The facility staff failed to provide reasonable accommodation for residents' needs by not ensuring proper lighting in shared restrooms. Observations revealed that in 11 out of 30 rooms, residents had to enter a dark restroom and traverse the space to reach a light switch on the opposite side to illuminate the room. This setup posed a risk, especially for residents with potential gait instabilities. During interviews, a resident expressed dissatisfaction with the situation, noting the inconvenience of having to cross the restroom in the dark at night. The Maintenance Supervisor confirmed that the wiring allowed only one switch to turn on the light, but was unsure why it was designed that way.
Failure to Respect Resident Preferences for Personal Care
Penalty
Summary
The facility failed to respect and facilitate resident self-determination by not adhering to the shower preferences of two residents. Resident #3, who is cognitively intact and prefers to shower at night for privacy, was not assisted with shaving according to his/her preference. The resident expressed discomfort with having long facial hair, which made him/her feel unkempt. Despite the resident's care plan indicating a preference for privacy during showers and self-care, staff interviews revealed inconsistencies in following these preferences, with some staff unaware of the resident's usual grooming habits. Resident #2, also cognitively intact, requires assistance for showers and has multiple diagnoses, including heart and kidney disease, diabetes, and dementia. The resident reported not having showered in over a week due to the shower room being too cold, which caused pain. This lack of showering led to feelings of humiliation and avoidance of social interactions, such as dining with others. Interviews with staff, including the DON, confirmed that residents should be able to shower whenever they want, yet Resident #2's requests were not fulfilled, highlighting a failure in meeting the resident's personal care needs.
Residents Unable to Access Personal Funds on Weekends
Penalty
Summary
The facility staff failed to ensure that residents had timely access to their personal funds on weekends, affecting four of the twelve sampled residents. The facility's policy, revised in August 2019, stated that residents or their legal representatives should have reasonable access to personal funds during normal business hours, and if funds were needed for the weekend, they should be requested on Friday. However, interviews with residents revealed that they were unable to access their funds on Saturdays, leading to frustration and inconvenience. Resident #1, with intact cognition and diagnoses including hypertension, diabetes, and Parkinson's disease, expressed difficulty in accessing funds on Saturdays. Similarly, Resident #4, with diagnoses of hypertension, anxiety disorder, and schizophrenia, and Resident #6, with intact cognition and multiple diagnoses including dementia and schizophrenia, reported being unable to access funds on weekends. Resident #15, also with intact cognition and multiple diagnoses, expressed a desire for weekend access to funds to avoid forgetting during the week. During a group interview, five out of nine residents confirmed the inability to access funds on weekends, needing to request them during the week. The Business Office Manager (BOM) stated that petty cash is kept in a safe, accessible only by her and the Administrator, and confirmed that residents cannot access funds on weekends due to the absence of staff with access to the safe. The Administrator acknowledged that staff ask residents on Fridays if they need funds for the weekend, but residents should be able to access their money on weekends. This deficiency highlights a failure to honor residents' rights to manage their financial affairs as stipulated by the facility's policy.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, affecting all residents. Observations revealed numerous maintenance issues, including misaligned and damaged furniture, peeling paint, broken laminate, and non-functional call lights. The shower room was particularly problematic, with temperatures recorded as low as 65.7 degrees Fahrenheit, which residents found too cold, especially during a local cold spell. This led to some residents missing showers due to discomfort and exacerbated conditions such as arthritis. Interviews with staff and residents highlighted the extent of the issues. Residents expressed dissatisfaction with the cleanliness and temperature of the shower room, with some reporting that the cold exacerbated their arthritis. The Maintenance Supervisor acknowledged the backlog of repairs and the lack of a systematic inspection process, relying instead on staff to report issues. The facility's maintenance log showed incomplete repairs, and the Administrator confirmed that the current state of the facility did not meet the expected standards for resident comfort and safety. The facility's failure to address these maintenance issues resulted in an environment that did not meet the regulatory standards for a safe, clean, and homelike setting. The lack of a proactive maintenance strategy and the reliance on staff to report issues contributed to the ongoing deficiencies. The Administrator's acknowledgment of the problems indicates awareness but highlights the need for a more structured approach to facility upkeep.
Inadequate Care Plans for Residents with PTSD and Antibiotic Use
Penalty
Summary
The facility failed to develop and update care plans consistent with the specific conditions and needs of two residents. Resident #11, who has severe cognitive impairment and multiple diagnoses including PTSD, was not provided with a care plan that identified triggers or interventions for managing behaviors. During an incident in the dining room, the presence of paramedics and police officers, which are known triggers for the resident, caused significant distress. The staff did not remove the resident from the area, exacerbating the situation. Interviews revealed a lack of awareness and training regarding PTSD among staff, and the resident's care plan did not reflect the necessary information to manage their condition effectively. Resident #26's care plan was also found to be inadequate. The resident, who has memory problems and requires assistance with daily activities, was on a prophylactic antibiotic regimen and had a full code status. However, the baseline care plan did not address the resident's code status or the use of antibiotics. Interviews with staff indicated that these omissions were not in line with expectations, as the care plan should have included this critical information to ensure proper care and communication among staff. The facility's failure to provide comprehensive and updated care plans for these residents highlights deficiencies in the assessment and documentation processes. The lack of a policy regarding care plans further underscores the need for improved procedures to ensure that residents' specific needs and conditions are adequately addressed in their care plans.
Medication Availability and Order Clarity Deficiency
Penalty
Summary
The facility failed to ensure that medications were available for two residents, leading to a deficiency in the quality of care provided. Resident #15, who has diagnoses including diabetes mellitus, depression, high blood pressure, schizophrenia, and COPD, did not have their prescribed medications, Jardiance and Myrbetriq, available on February 26, 2025. The Certified Medication Technician (CMT) noted the absence of these medications and informed the Charge Nurse. Additionally, the sliding scale insulin order for Resident #15 lacked clarity on the frequency of administration, which was acknowledged by a Registered Nurse during a subsequent interview. Similarly, Resident #6, who has diagnoses including congestive heart failure, dementia, anxiety, depression, bipolar disorder, and schizophrenia, was also affected by the unavailability of their prescribed medication, Eliquis, on the same date. The CMT documented the absence of Eliquis and notified the Charge Nurse. The Director of Nursing and the Administrator were later informed that the pharmacy only filled certain medications for 14 days, which contributed to the residents running out of their medications. The facility was in the process of switching pharmacies to address this issue.
Inconsistent Provision of Fresh Water to Residents
Penalty
Summary
The facility failed to ensure that residents had fresh water at their bedside, which was easily accessible, affecting three of the twelve sampled residents. Resident #15, who had a diagnosis of constipation, diabetes mellitus, depression, high blood pressure, schizophrenia, and COPD, was observed with an almost empty water pitcher without ice. The resident expressed that staff did not consistently provide fresh ice water and felt forgotten. Resident #22, with intact cognitive skills and diagnoses including psychotic disorder, COPD, and diabetes mellitus, also had a water pitcher that was half full without ice. The resident reported that the staff provided a clean cup with ice at 3:30 A.M., but it melted by the time they woke up, requiring them to get fresh ice water themselves. Resident #26, who had memory problems and required assistance with transfers, was observed with an almost empty water pitcher without ice and expressed a desire for fresh ice water each shift. Interviews with staff revealed inconsistencies in the distribution of fresh ice water. Certified Medication Technician A mentioned that the night shift passed fresh ice water, but was unsure about the day shift. Registered Nurse B confirmed that the day shift did not routinely pass fresh ice water, and it was only provided upon request. Nurse Aide B and the Director of Nursing stated that staff were supposed to pass fresh ice water every shift. However, RN A acknowledged that the day shift did not pass fresh ice water often enough, and it was inconsistent, with several residents requesting fresh ice water during the day.
Improper Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for residents by not adhering to their own Cleaning (Sanitizing) Guidelines for oxygen equipment. Observations revealed that oxygen tubing was not dated and was found lying on the floor for several residents, including Resident #17, #22, #79, and #129. Additionally, humidifiers were not refilled daily with distilled water, and nebulizer machines were placed directly on the floor. These actions were contrary to the facility's policy, which required oxygen tubing to be dated and changed weekly, and humidifiers to be refilled every 24 hours. Resident #129, who had no documented care plan or physician orders for oxygen, experienced respiratory distress with an oxygen saturation of 82% and was subsequently sent to the emergency room. Resident #22, who had a diagnosis of COPD and required oxygen during the day, had oxygen tubing dated from 11 days prior and a nearly empty humidifier bottle. The resident's oxygen concentrator was also observed to have dried white debris on it. Resident #17, diagnosed with heart failure and high blood pressure, was found with undated oxygen tubing on the floor and a humidifier bottle with insufficient water, while being short of breath. Resident #79, with moderately impaired cognition and active diagnoses of diabetes and manic depression, had undated nebulizer and oxygen tubing on the floor. Interviews with staff, including a Certified Medication Technician, Nurse Aide, and the Director of Nursing, confirmed that the oxygen and nebulizer tubing should not be on the floor, should be dated, and that the humidifiers should be filled with distilled water. The staff acknowledged that these practices were not being followed, leading to the deficiencies observed.
Medication Administration Errors and Policy Deviations
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 19.23% with five errors out of 26 opportunities. This affected four residents, including one who received an incorrect number of eye drops and another who did not receive their insulin in a timely manner after administration. The facility's policies on medication administration were not followed, as evidenced by the incorrect application of eye drops and the timing of insulin administration. One resident was prescribed Cyclosporine eye drops, but the Certified Medication Technician (CMT) administered two drops in one eye instead of the prescribed one drop, and did not apply lacrimal pressure for the recommended duration. Another resident was prescribed Brimonidine eye drops, and while the correct number of drops was administered, the lacrimal pressure was not applied for the full minute as required by the facility's policy. These deviations from the prescribed orders and facility policy contributed to the medication errors. Additionally, a resident prescribed Novolog insulin did not receive their meal within the recommended time frame after insulin administration, which is crucial to prevent low blood sugar. The facility also faced issues with medication availability, as certain medications were only filled for 14 days, leading to residents running out of necessary medications. This was noted in the case of a resident who did not receive their prescribed Jardiance and Myrbetriq due to the pharmacy's dispensing limitations.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and biologicals, as evidenced by the presence of expired medications and biologicals in the medication room and cart. Observations revealed expired sterile water bottles, a burn relief can, and a bowel prep kit, among others. Additionally, some medications, such as Lorazepam and Morphine Sulfate, were not dated when opened, and an opened vial of Influenza vaccine lacked a date. The medication refrigerator contained a recalled health shake and was not properly maintained, with a yellow and brown dried substance inside the door and excess ice in the freezer. The facility also failed to ensure that personal items such as residents' cigarettes and money were not stored in the medication cart. Observations showed that several residents had money stored in envelopes within the cart, with discrepancies in the amounts recorded and present. Cigarettes were found in zip lock bags without names, and loose tobacco was present in the drawer. Additionally, a pair of hearing aids was found in the medication room without identification. Interviews with staff, including RN A and RN B, revealed a lack of adherence to policies regarding the dating and disposal of medications, as well as the inappropriate storage of personal items. The Director of Nursing acknowledged these deficiencies, noting that expired medications should be destroyed, and personal items should not be stored in the medication cart. The facility's policies on medication administration and labeling were not followed, contributing to the deficiencies observed.
Deficiencies in TB Screening and Infection Control Practices
Penalty
Summary
The facility failed to ensure the required two-step tuberculosis (TB) screening test was administered upon hire for seven newly hired employees. The facility's policy mandates a tuberculin skin test during pre-employment procedures, with a second test if the initial result is 0-9mm. However, records showed that employees from various departments, including housekeeping, CNA, activities, maintenance, transportation, laundry, and LPN, did not complete the TB skin test process. Interviews with the Business Office Manager, Director of Nursing, and Administrator confirmed that the two-step testing should have been performed and recorded. The facility also failed to adhere to proper handwashing protocols and enhanced barrier precautions (EBP) during resident care. Observations revealed that a housekeeper cleaned multiple rooms without changing gloves or washing hands, and a maintenance supervisor and CNA did not wash hands between tasks. Interviews with staff indicated a lack of consistent training on hygiene precautions, with some staff not using hand sanitizer due to skin irritation concerns. Resident #79, who had severe cognitive impairment, limited mobility, and a documented wound, did not receive care in accordance with EBP guidelines. The resident's care plan did not address the use of EBP, and during wound care, staff used gloves but did not follow EBP protocols. Interviews with staff involved in the resident's care acknowledged the oversight in using EBP during peri care and wound treatment. The Director of Nursing confirmed that EBP should have been used during these care activities.
Resident Threatens Harm to Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a resident threatened harm to another resident. The incident involved a resident with a history of schizophrenia and psychotic disorder, who exhibited delusional and verbally aggressive behavior. This resident threatened another resident in the dining room over a disagreement about the television, causing fear and distress to the threatened resident. The facility's records show that the resident who made the threat had a care plan addressing their delusional and aggressive behavior, which included strategies such as maintaining a calm environment, setting limits, and providing one-on-one counseling. Despite these measures, the resident's behavior escalated to the point of making threats and displaying a butter knife in a menacing manner. The facility staff attempted to manage the situation by ordering a one-on-one supervision and contacting emergency services, but the resident refused to cooperate with transportation for a psychiatric evaluation. The facility's response included contacting the police and the resident's guardian, but the police did not detain the resident as no crime had been committed. The guardian was advised to seek a court order for the resident's psychiatric evaluation. The facility eventually obtained a court order to transfer the resident to a psychiatric hospital, but the hospital reported that the resident refused medication and had not shown improvement. The facility was in the process of seeking alternative placement for the resident.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident with severe cognitive impairment and multiple diagnoses, including diabetes, high blood pressure, dementia, anxiety, and depression. The deficiency occurred when staff did not notify the physician of the resident's change in condition in a timely manner. The resident exhibited symptoms of an upper respiratory condition, such as a cough, eye drainage, and nasal discharge, which were not documented in the nursing progress notes. Additionally, there was no record of the physician or guardian being contacted about these changes. Observations revealed that the resident was symptomatic for a couple of weeks, with visible signs of illness, yet continued to be in common areas with other residents. Interviews with staff indicated that the resident's symptoms were reported to the charge nurse, and a flu test was eventually conducted. However, the physician was not contacted promptly, and the resident was not isolated due to the lack of a physician's order. The Director of Nursing acknowledged that the physician should have been contacted when symptoms appeared, and documentation should have been maintained regarding the symptoms and physician's guidance.
Resident Abuse by CNA at LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with multiple diagnoses, including mood disorder, depression, Parkinsonism, and anxiety disorder, who required moderate to substantial assistance with activities of daily living. The resident, who had difficulty making themselves understood due to cognitive impairment and unclear speech, was involved in an altercation with CNA A after becoming upset when they thought the restroom door was going to be closed on them. The situation escalated when the resident attempted to use the phone at the nurses' station, claiming the phone in the resident phone room was not working. CNA A, along with another nursing aide, tried to prevent the resident from going behind the nurses' station desk. During this confrontation, CNA A was reported to have grabbed the resident's arm, jerked them back into the wheelchair, and cursed at them while kicking at the wheelchair. This behavior was witnessed by two laundry aides and the Activity Director, who noted a red mark on the resident's arm. The Administrator was informed of the incident and expressed that residents have the right to be free from abuse and should be treated with respect. The Administrator also stated that the staff should have allowed the resident to use the phone at the nurses' station and informed the charge nurse of the resident's agitation. The report highlights a failure in the facility's responsibility to ensure residents are free from abuse, as outlined in their Abuse Prohibition policy.
Resident Abuse by Director of Nursing
Penalty
Summary
The facility failed to protect a resident from abuse when a staff member, specifically the Director of Nursing (DON), forcibly used the resident's own hand to hit their face multiple times. This incident involved a resident with severe cognitive deficits, as indicated by a Brief Interview of Mental Status (BIMS) score of 99, and a history of physical and verbal behaviors, as well as rejection of care. The resident also had diagnoses including mood disorder, violent behavior, generalized anxiety, Parkinson's disease, and pain. The incident occurred when the resident locked themselves in an activity room and began exhibiting aggressive behaviors. The situation escalated when the housekeeping aide attempted to remove the resident from the room, leading to the resident hitting and kicking. The DON intervened, and during the altercation, the resident hit the DON, knocking off their glasses and scratching their face. In response, the DON grabbed the resident's arm and used it to hit the resident's own face while yelling at them. This action was witnessed by the housekeeping aide, who later reported the incident to their supervisor. The Social Service Director (SSD) intervened by calming the resident and removing them from the situation. The resident expressed feeling unsafe around the DON, who was subsequently placed on leave. The incident was reported to law enforcement, and a complete skin assessment showed no bruises or abrasions on the resident's face. The facility's abuse prohibition policy mandates immediate reporting of such incidents, highlighting a failure in adherence to these protocols.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of potential physical abuse involving a resident in a timely manner, as required by state law. The incident involved a resident with severe cognitive deficits and a history of physical and verbal behaviors, who locked themselves in an activity room. When a Housekeeping Aide attempted to remove the resident, the resident became physically aggressive. The Director of Nursing (DON) intervened and allegedly used the resident's own hand to hit their face while yelling at them. The resident expressed feeling unsafe around the DON, and the incident was not reported to the appropriate authorities within the required two-hour timeframe. The Housekeeping Aide did not report the incident immediately due to the absence of their supervisor and fear of repercussions, as the DON had previously exhibited rude behavior towards other residents. The Aide eventually reported the incident to the Administrator a few days later, who was not present at the facility on the day of the incident. The delay in reporting was compounded by the Housekeeping Supervisor's failure to escalate the report to the Administrator. The Social Services Director also delayed reporting the incident to the Administrator, contributing to the facility's failure to comply with mandatory reporting requirements.
Improper Use of Physical Restraints During Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by an incident involving a resident who was restrained by staff members during the administration of an intramuscular injection. The resident, who had a history of dementia and other mental health conditions, exhibited aggressive behaviors towards staff, prompting the administration of medication. However, during the process, staff members used their bodies to physically restrain the resident by wrapping their arms around the resident to prevent movement, which is against the facility's policy on physical restraints. The resident involved in the incident had a complex medical history, including bipolar disorder, psychosis, major depressive disorder, and dementia, among other conditions. The resident's care plan highlighted confusion, paranoia, and forgetfulness, and emphasized the importance of allowing the resident to express emotions and participate in activities that increase self-esteem. Despite these guidelines, the resident was physically restrained by staff during a behavioral episode, which involved yelling and aggressive actions towards staff. Interviews with staff and medical personnel revealed that the use of physical restraint was not in line with the facility's policies. The Medical Director and Psychiatric Nurse Practitioner both indicated that holding a resident down for an injection is a form of restraint and should not be practiced. Additionally, staff members involved in the incident admitted to restraining the resident and acknowledged a lack of training in restraint use, behavior modification, and de-escalation techniques. The facility's administrator confirmed that staff had been previously instructed not to hold residents down for medication administration, highlighting a gap in adherence to established protocols.
Inadequate Behavioral Health Interventions Lead to Medication Use
Penalty
Summary
The facility failed to provide adequate behavioral health interventions for a resident who exhibited behaviors that escalated to a catastrophic reaction, resulting in the use of an antipsychotic medication injection. The resident, who had a history of bipolar disorder, psychosis, major depressive disorder, and other mental health conditions, was observed to have verbal outbursts and wandering behaviors. On the day of the incident, the resident was loud and disruptive, and despite staff requests to lower their voice, the resident continued to yell profanities and exhibited aggressive behavior. The resident's behavior escalated when they were found sitting on the floor, requesting assistance to use the bathroom. Despite staff attempts to calm the resident and assist them, the resident became increasingly agitated, flinging their walker and threatening staff. The situation culminated in the resident slapping a staff member, leading to the administration of an intramuscular injection of Haldol, as ordered by a psychiatric Nurse Practitioner. The facility's policy required alternative interventions to be implemented and recorded prior to the use of medication, but it appears these steps were not adequately followed. Interviews with staff revealed a lack of formal training in behavior modification and handling outbursts. Staff members reported relying on the Charge Nurse or DON when behaviors were uncontrollable, indicating a gap in staff preparedness to manage such situations effectively. The facility's failure to provide necessary behavioral health care and services, as outlined in their policies, contributed to the escalation of the resident's behavior and the subsequent use of medication.
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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