Hilltop At Blue River, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Missouri.
- Location
- 10425 Chestnut Dr, Kansas City, Missouri 64137
- CMS Provider Number
- 265597
- Inspections on file
- 36
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hilltop At Blue River, The during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment was forced out of bed by a CMT despite expressing a desire to remain in bed due to pain. The CMT disregarded the resident's refusal, used excessive force, and failed to notify the charge nurse as required. The incident was witnessed by an OTA and left the resident feeling uneasy and diminished.
A resident with moderate cognitive impairment and a diagnosis of dementia was admitted for rehab, but the facility failed to recognize and facilitate the financial POA's authority, instead redirecting the resident's social security income to a facility-controlled account and rejecting valid POA documentation, despite repeated attempts by the POA to clarify their role.
The facility consistently failed to provide adequate weekend nursing staff, resulting in repeated shortages of CNAs, CMTs, and nurses, as documented in staffing records and confirmed by staff interviews. A resident requiring two-person assistance with a mechanical lift reported frequent delays in care, including late transfers out of bed and missed or delayed meals. Staff described being unable to complete scheduled care tasks, such as bathing and feeding, due to insufficient staffing on weekends.
The facility did not use appropriate liquids or seasonings when preparing pureed carrots and chicken, resulting in bland and unappetizing meals for residents on pureed diets. Additionally, staff failed to monitor and maintain safe serving temperatures for foods such as carrots and ham, with some items served below the required temperature. These deficiencies were confirmed by both the cook and the Dietary Manager, who noted that recipes and temperature checks were not properly followed.
Surveyors found that kitchen equipment and surfaces, including the dishwasher, toaster, convection oven, well cookers, and floors, were not properly cleaned, with visible food debris and grease present. Dietary staff and the manager confirmed that cleaning protocols were not consistently followed, and deep cleaning was delayed, potentially affecting all residents receiving meals from the kitchen.
Two residents with dementia did not receive individualized, goal-directed activity plans that reflected their interests and abilities. Despite care plans specifying preferred activities and the need for one-to-one engagement, both residents were frequently left without meaningful activities, not invited to scheduled events, and lacked documented individualized interventions. Staff interviews and observations confirmed that activities were mostly group-based and not tailored to the residents' cognitive and physical needs.
A resident with cognitive impairment and hemiplegia was found smoking in their room and storing cigarettes and a lighter, despite facility policy requiring secure storage and supervised smoking in designated areas. Another resident from a secure unit accessed hazardous materials, including a board with nails and rocks, during a smoking break in an area near broken equipment, leading to a physical altercation and police intervention. Staff interviews revealed inconsistent supervision and lack of enforcement of smoking policies, resulting in unsafe conditions.
A resident with Alzheimer's disease and swallowing difficulties, who was at risk for weight loss, was not consistently served the physician-ordered pureed diet with large portions. Observations and staff interviews revealed that the resident often received regular portion sizes and non-pureed desserts, contrary to the diet card and care plan. Dietary and nursing staff did not consistently verify or communicate the correct diet orders, resulting in the resident not receiving the prescribed nutrition.
Several residents did not receive appropriate respiratory care due to missing or incomplete nebulizer equipment, improperly fitted CPAP masks, and unsanitary storage of oxygen and suction equipment. Residents with COPD and sleep apnea experienced delays in receiving necessary treatments, and oxygen delivery items were not maintained or stored according to facility policy, as evidenced by undated tubing, masks, and water jugs, and equipment placed directly on the floor.
A resident with significant dental issues, including only one remaining tooth and ongoing mouth pain, did not receive necessary dental care, extractions, or dentures despite repeated requests and staff awareness. Facility staff failed to document the dental needs, make appropriate referrals, or ensure dental appointments were scheduled, resulting in the resident not receiving routine or emergency dental services as required by policy.
A resident with a foot wound and recent IV antibiotic therapy did not have Enhanced Barrier Precautions (EBP) implemented as required, despite physician orders and facility policy. Staff provided high-contact care without gowns or gloves, and there was no EBP signage or PPE available at the resident's door until the issue was identified. Staff interviews revealed a lack of communication and awareness regarding the need for EBP for this resident.
A resident was found to have Melatonin and Tylenol stored in their room and was self-administering these medications without a physician order or documented assessment of their ability to do so. Staff were unaware of the medications' presence, and the required interdisciplinary evaluation and documentation for self-administration were not completed, contrary to facility policy.
Resident's Right to Dignity Violated by Forced Transfer from Bed
Penalty
Summary
A Certified Medication Technician (CMT) failed to honor a resident's right to self-determination and dignity by forcing the resident out of bed against their will. The resident, who had diagnoses including COPD, spondylosis, anemia, hyperlipidemia, and left-sided hemiplegia, was moderately cognitively impaired and reported increased leg pain on the day of the incident. Despite the resident's clear verbal refusal to get out of bed and participate in therapy, the CMT insisted, placed pants on the resident while they resisted, and physically moved the resident from a supine position to a wheelchair. An Occupational Therapist Assistant (OTA) witnessed the event and confirmed that the resident expressed a desire not to participate in therapy due to pain. The OTA observed the CMT using excessive force and commented on the roughness of the interaction. The resident later reported feeling uneasy and diminished by the experience, stating that the CMT spoke loudly and disregarded their wishes, which made them feel small and uncomfortable. During interviews, the CMT acknowledged being familiar with the facility's resident rights policy but admitted to not notifying the charge nurse when the resident refused to get out of bed. The CMT stated that they were concerned about medication administration and the resident's position but did not follow proper protocol for handling refusals. The Social Services Designee and the facility Administrator both confirmed that the resident's rights were not honored, and the incident was documented as a violation of the resident's right to dignity and choice.
Failure to Honor Resident's Power of Attorney for Financial Decisions
Penalty
Summary
The facility failed to ensure that a resident's designated power of attorney (POA) was able to exercise financial decision-making rights on behalf of the resident. The resident, who was moderately cognitively impaired with diagnoses including dementia and muscle wasting, was admitted to the facility for short-term rehabilitation. The admission agreement and facility policies recognized the rights of resident representatives to manage financial matters, but the facility did not properly acknowledge or facilitate the POA's authority during the resident's stay. Upon admission, the facility did not have documentation of the POA, despite the family member (Family Member A) presenting as the financial POA and being listed as such on the admission sheet. The facility staff claimed there was no family contact and no POA on file, and subsequently arranged for the resident's social security direct deposit to be changed to an account under facility control. This occurred even though the POA document, appointing Family Member A as attorney-in-fact for financial and legal matters, was drafted months prior and later presented to the facility. Communication between the family and facility staff revealed confusion and lack of recognition of the POA, with the Social Services Director rejecting the completed POA paperwork and requesting a new document. Interviews with facility staff indicated that there was difficulty contacting family members and uncertainty regarding the resident's capacity and wishes. The resident was described as providing conflicting information and expressing uncertainty about admission decisions. Despite the POA's attempts to clarify their status and manage the resident's finances, the facility proceeded with financial arrangements without proper involvement or consent from the POA, contrary to facility policy and the resident's rights.
Failure to Provide Sufficient Weekend Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends to meet the care needs of all residents, as evidenced by multiple documented staffing shortages across several months. Payroll Based Journal (PBJ) data submitted to CMS repeatedly triggered for excessively low weekend staffing, and daily staffing sheets from January through June 2024 showed frequent and significant shortfalls in the number of Certified Nursing Assistants (CNAs), Certified Medication Technicians (CMTs), and nurses scheduled for weekend shifts. On numerous occasions, the facility was short by several CNAs per shift, with some shifts missing as many as eight CNAs. There were also instances where documentation of staffing was missing entirely for certain days. Interviews with staff, including the Staffing Coordinator, CNAs, and a Registered Nurse, confirmed that the facility was regularly short-staffed on weekends. Staff reported being asked to work extra shifts, and managers sometimes worked on the floor, although there was no documentation to verify this. Staff described delays in resident care, such as assistance with getting out of bed, bathing, and feeding, particularly for residents requiring two-person assistance or mechanical lifts. The Director of Nursing (DON) was not aware of the PBJ staffing triggers and did not monitor PBJ reports, relying instead on the Staffing Coordinator to notify them of shortages. There was no documentation of managerial assistance with nursing tasks during shortages. One resident with a history of traumatic brain injury, lack of coordination, heart failure, and muscle weakness, who required a mechanical lift and two staff for transfers, reported that on many weekends there was not enough staff to assist with getting out of bed in a timely manner. The resident stated that they often remained in bed until the afternoon, missing breakfast, and that meals were sometimes served late when staffing was insufficient. Staff interviews corroborated that care tasks, including scheduled baths and timely transfers, were delayed or missed due to inadequate staffing on weekends.
Failure to Ensure Palatable Pureed Foods and Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain the nutritive value and palatability of pureed foods for residents on pureed diets, as well as to ensure that food was served at safe and appetizing temperatures. During meal preparation and service, pureed carrots and pureed chicken were prepared using only water as the liquid, rather than broth, chicken base, or milk as specified in the facility's recipes. Both the cook and the Dietary Manager confirmed that the pureed foods were bland, lacked seasoning, and did not taste like the intended food items. The cook was unaware of the requirement to use broth or other flavor-enhancing liquids and had not reviewed the recipe prior to preparation. Additionally, the facility did not consistently monitor or record food temperatures before serving. Observations showed that the temperatures of certain food items, such as carrots and ham, were below the acceptable serving temperature, with ham slices measured at 104°F and carrots at 111°F. The Dietary Manager acknowledged that food temperatures were not taken before service on the day in question, contrary to facility policy. These failures potentially affected all residents receiving pureed diets and those consuming food outside the kitchen.
Failure to Maintain Kitchen Cleanliness and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple instances of uncleanliness and food debris in the facility's kitchen, including yellowish, dried food debris on the outside of the dishwasher, spilled cereal debris on and around a tray and the floor, and a toaster with dried food debris and grease on both the exterior and internal roller mechanism. The convection oven was found with baked-on grease and debris on the knobs, panel, front, and sides, as well as thick, greasy debris on the top and backsplash. The well cookers had dried food debris on the outside, and the kitchen floor throughout was soiled with food debris and stains that appeared to have accumulated over time. Interviews with dietary staff and the Dietary Manager confirmed that cleaning protocols were not consistently followed. Staff acknowledged that equipment such as the wells, toaster, and stove were not being cleaned as required after each meal or on a weekly deep-cleaning schedule. The Dietary Manager also noted that the floors were dirty and awaiting cleaning by an outside vendor, while dietary staff were only sweeping and mopping at the end of the day. These lapses in cleaning and maintenance potentially affected all residents who consumed food prepared in the kitchen, with a facility census of 140 residents.
Failure to Provide Individualized Activity Plans for Residents with Dementia
Penalty
Summary
The facility failed to ensure individualized, goal-directed activity plans that incorporated the interests and abilities of two residents with dementia. Both residents had documented cognitive impairments and required varying levels of assistance with daily activities. Despite care plans outlining specific preferences and interventions, such as enjoyment of music, church services, socializing, and outdoor activities, observations and interviews revealed that these preferences were not consistently addressed or implemented in daily programming. For one resident with Alzheimer's disease, hemiplegia, and significant memory loss, the care plan included a variety of preferred activities and required one-to-one or in-room activities when unable to attend group events. However, observations showed the resident was often left in common areas without engagement, not invited to scheduled activities, and did not receive documented one-to-one activities as required. Staff interviews confirmed a lack of individualized engagement, with most activities being group-based and little evidence of tailored interventions for the resident's cognitive and physical limitations. The second resident, diagnosed with dementia and agitation, was noted to have a strong preference for music, animals, outdoor activities, and group participation. Despite this, the resident was frequently observed wandering the unit without engagement in activities, and staff primarily redirected the resident or provided snacks rather than meaningful activity involvement. Documentation of one-to-one activities was minimal, and staff interviews indicated that such individualized activities were rarely provided. Activity staff and CNAs acknowledged the challenges in engaging the resident but did not consistently implement or document individualized interventions as outlined in the care plan.
Failure to Prevent Smoking Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to resident smoking practices and supervision. One resident with a history of stroke, hemiplegia, and moderate cognitive impairment was found to have smoking materials, including cigarettes and a lighter, in their room and admitted to smoking in the restroom, contrary to facility policy. The resident was aware of the rules prohibiting smoking and storage of smoking materials in resident rooms, and staff confirmed that the resident had previously been found smoking in their room. Despite the facility's policy requiring smoking materials to be stored securely by staff and only used in designated areas under supervision, both the resident and their roommate had smoking materials in their room, and there was no documentation of progressive disciplinary action as outlined in the facility's policy. Another resident, who resided on a secure unit due to dementia and other psychiatric diagnoses, was involved in an incident during a supervised smoking break. The resident obtained a 2x4 board with nails, rocks, and other potentially hazardous items from the area near the designated smoking section, which was located close to a maintenance garage with broken equipment and accessible debris. The resident attempted to bring the board into the building, became physically aggressive, and required intervention from staff and police. Observations confirmed that the smoking area was not fenced off and that residents could access hazardous materials, with staff and maintenance acknowledging that residents were able to wander away from the designated area and obtain dangerous items during smoking breaks. Interviews with staff, including CNAs, RNs, and the DON, revealed inconsistent supervision during smoking breaks and a lack of awareness regarding residents' movements and access to hazards. Staff reported that hospitality aides were responsible for monitoring residents from the locked unit during smoking breaks, but there was evidence that residents were able to leave the designated area unsupervised. Maintenance staff also noted that hazardous materials were accessible and that they had previously found rocks in resident rooms. The facility's failure to enforce its smoking policy, supervise residents adequately, and maintain a hazard-free smoking area resulted in unsafe conditions for residents.
Failure to Provide Physician-Ordered Diet Texture and Portion Size
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, hemiplegia, muscle wasting, and a cognitive communication deficit, who was at risk for weight loss, did not receive the physician-ordered pureed diet with large portions as specified on the resident's diet card. Observations on multiple occasions showed the resident was served regular portion sizes instead of large portions, and was also given a regular dessert instead of a pureed dessert. The resident's care plan and physician's orders clearly indicated the need for a pureed diet with large portions, but these instructions were not consistently followed by dietary staff. Certified Nursing Assistants (CNAs) and the Dietary Manager confirmed that the resident was supposed to receive large portions and pureed desserts, but this was not routinely provided. CNAs reported that the dietary staff rarely served large portions and did not always check the diet cards for accuracy. On one occasion, a CNA had to page dietary staff to correct the dessert and portion size after noticing the error. The Dietary Manager acknowledged the mistake and stated that the kitchen staff should have followed the diet card instructions. The Director of Nursing (DON) stated that the expectation was for the resident's physician-ordered diet to be followed and for nursing staff to document meal consumption and any concerns about the resident's diet order. However, the DON was not made aware of the resident not receiving the correct diet until after the deficiency was identified. The lack of adherence to the prescribed diet and portion size for the resident with significant health concerns led to the deficiency.
Deficiencies in Respiratory Care Equipment Provision and Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in the provision and maintenance of respiratory equipment. One resident with a diagnosis of COPD did not have access to a complete nebulizer setup for several days, despite having a physician's order for nebulizer treatments. The resident repeatedly requested the missing mouthpiece and tubing after being moved to a new room, but staff did not provide the necessary components or a replacement nebulizer until several days later. Observations confirmed the absence of the required parts, and interviews with the resident and roommate corroborated that the equipment was incomplete and requests for assistance were not addressed in a timely manner. Another resident with obstructive sleep apnea was observed multiple times sleeping with a CPAP mask that was not properly fitted, resulting in oxygen leaking from the sides of the mask. The resident reported difficulty keeping the mask on due to facial hair and stated that the CPAP mask and nebulizer mouthpiece had never been cleaned. Staff interviews indicated awareness of the challenges with mask placement but did not document any interventions to ensure the mask was correctly positioned or that the equipment was maintained according to policy. Additionally, two residents with respiratory conditions had oxygen and suction equipment that was not stored in a sanitary manner. Observations revealed that oxygen tubing, masks, and suction machine tubing were not dated to indicate when they had last been changed, and equipment such as humidifier water jugs and suction machines were stored directly on the floor and not in protective bags. These practices were inconsistent with the facility's own policies, which require weekly changes of oxygen delivery items, proper storage in clean, dry places, and dating of equipment to ensure timely replacement.
Failure to Provide Required Dental Care and Services
Penalty
Summary
The facility failed to ensure that a resident received necessary dental care, including both routine and emergency services, as required by facility policy. The resident, who had a history of severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency, was observed to have only one remaining tooth and reported ongoing mouth pain and difficulty eating. Despite the resident's requests to have the remaining tooth and broken fragments extracted and to be fitted for dentures, there was no documentation of dental services being provided, no dental appointments scheduled, and no orders for dental care in the resident's medical record. Staff interviews revealed that certified nursing assistants were aware of the resident's dental issues and difficulties with eating, but had not communicated these concerns to nursing staff. The registered nurse interviewed was unaware of the resident's dental condition and confirmed that there was no documentation or orders for dental care. The director of nursing acknowledged that the resident should have been assessed for dental needs upon admission, and that missing teeth should have been documented and addressed in the care plan, but this was not done. Facility policy required oral assessments upon admission and as needed, documentation of adverse oral conditions, and referral for dental services, including arranging appointments and transportation. However, the resident's care plan and assessments did not address the broken or missing teeth, and the resident had not seen a dentist in over a year. The lack of follow-through on dental referrals and absence of documentation resulted in the resident not receiving the necessary dental care, including extractions and dentures, as requested and indicated by their condition.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound and IV Therapy
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a foot wound and recent intravenous (IV) antibiotic therapy, as required by their infection prevention and control program. The resident had a history of stroke with paralysis, diabetes, peripheral vascular disease, and was totally dependent on staff for all activities of daily living. The care plan and physician's orders indicated the need for EBP, including the use of gowns and gloves during high-contact care activities due to the presence of a vascular wound and recent IV access. Despite these documented requirements, multiple observations over several days revealed that there was no EBP signage or personal protective equipment (PPE) available at the resident's door. Staff, including CNAs, were observed providing direct care such as repositioning, checking for incontinence, and changing linens without wearing gowns or gloves. Interviews with staff confirmed a lack of awareness that the resident required EBP, and that no communication had occurred to inform them of the need for these precautions. Staff also reported that EBP signage and PPE were typically used for residents with wounds or medical devices, but in this case, these measures were not in place until after the deficiency was identified. The Director of Nursing confirmed that the protocol required assessment and implementation of EBP, including signage and PPE, for residents with wounds or devices. However, the EBP was not in place for this resident until it was brought to the attention of the facility, despite the resident having a wound and recent IV therapy. The lack of EBP implementation was due to a failure in communication and adherence to established infection control protocols.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician order for self-administration of medication at bedside and did not evaluate or document a resident's ability to self-administer medication. One resident, who was cognitively intact and had diagnoses including insomnia, scoliosis, and spondylosis, was found to have bottles of Melatonin and Tylenol stored in the bottom drawer of their nightstand. The resident reported that their family had provided the medications and that staff were unaware of their presence. The resident had been taking the Tylenol for pain and Melatonin for sleep, including doses from both their own supply and what was provided by the facility. Staff interviews revealed that medication technicians and nurses were not aware that the resident had medications in their room, and there was no current order or assessment permitting self-administration. The facility's policy required an interdisciplinary assessment and a physician order before allowing residents to self-administer medications or store them at bedside, but this process was not followed for the resident in question. Staff also indicated that medications had previously been found and removed from the resident's room, but no formal assessment or documentation was completed. The Director of Nursing and other staff confirmed that the resident did not have an order or assessment for self-administration and that the presence of medications in the resident's room was not known until it was brought to their attention. The psychiatric nurse practitioner stated that no resident should have medications at bedside without an assessment, and expected staff to supervise all medication administration. The facility census at the time was 137 residents, and this deficiency was identified for one sampled resident out of twelve reviewed.
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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