Kirksville Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirksville, Missouri.
- Location
- 1705 East Laharpe, Kirksville, Missouri 63501
- CMS Provider Number
- 265247
- Inspections on file
- 18
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Kirksville Manor Care Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including buildup of debris, dried substances on surfaces, improper storage of cleaning rags, and rust on storage carts. Staff interviews revealed inconsistent cleaning practices and failure to follow established sanitation protocols, leading to unclean kitchen and dining areas.
A resident with cognitive impairment and behavioral issues was physically struck on the thigh by a CNA during care after the CNA believed the resident intentionally disconnected a feeding tube. Multiple staff confirmed the CNA also referred to the resident as a 'pedophile' in the resident's presence, constituting both physical and verbal abuse.
A resident with a history of stroke and on anticoagulant medication experienced a fall from a wheelchair, resulting in severe pain and shortness of breath. Despite ongoing complaints and a family member's request for re-evaluation, the physician was not notified for over 10 hours. The resident was later diagnosed with a hemothorax and multiple fractures in the ER.
A resident at risk for falls sustained severe injuries after a fall in the facility. The facility failed to develop a care plan with fall prevention interventions, complete a thorough post-fall assessment, or notify the DON. The fall was not communicated to the oncoming shift or the on-call physician, delaying evaluation and treatment.
The facility did not maintain resident dignity and self-determination for four residents by failing to provide necessary grooming assistance, such as basic haircuts. This issue was identified through observation and interviews, highlighting a lack of support for residents' personal grooming needs.
The facility failed to provide adequate assistance with ADLs for three residents. Staff did not check for incontinence, and a resident's hair was not groomed or pulled back during meals. Another resident did not receive routine showers, impacting their hygiene and comfort.
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed incontinence care, lack of routine showers, slow response to call lights, and inadequate assistance with meals. The facility's census was 51 residents.
A resident on anticoagulant medication fell from a wheelchair and experienced severe pain, but the facility failed to notify the physician of the resident's condition and medication use. Despite ongoing pain and shortness of breath, the resident was not sent for evaluation until the next day, resulting in the discovery of multiple serious injuries. The facility's failure to follow protocols and communicate effectively led to a significant delay in appropriate medical intervention.
A resident with a history of falls and significant health conditions fell from their wheelchair, sustaining serious injuries due to the facility's failure to implement a fall prevention care plan and conduct a thorough post-fall assessment. Staff did not communicate the fall effectively, delaying evaluation and treatment.
The facility failed to treat residents with dignity and respect, as staff made demeaning comments, ignored call lights, and did not promptly assist incontinent residents. A resident reported a staff member's comment about taxes paying for their stay, and another resident was left in a wet state without immediate care. Additionally, a CNA discouraged call light use, upsetting a resident. The administration was unaware of these issues, highlighting a communication breakdown.
The facility failed to provide adequate assistance with ADLs for four residents, leading to deficiencies in care. A resident was observed without glasses during meals, making it difficult to eat, and was left with wet hair after bathing. Another resident was not repositioned or checked for incontinence as required. Staff interviews revealed that incontinence care was often delayed due to workload, despite the care plans indicating the need for regular checks and assistance.
The facility failed to provide adequate nursing staff, resulting in residents not receiving timely incontinence care, showers, or meal assistance. Observations showed residents left in soiled briefs, missing meals, and not receiving scheduled showers. Staff interviews highlighted the challenges of managing care for residents requiring mechanical lifts, with administration attributing issues to inefficient work practices rather than staffing shortages.
The facility failed to accurately review and update its facility-wide assessment, leading to incorrect documentation of residents' needs for assistance with activities of daily living. The new Administrator, unfamiliar with the process, completed the assessment without the required involvement of the Quality Assurance Team or other disciplines, resulting in discrepancies in the reported number of residents needing assistance with toileting and transfers.
The facility failed to post required COVID-19 precaution signage at the entrance and outside a COVID-19 positive resident's room, violating their infection control policy. Despite the resident being in isolation, there was no signage to inform staff or visitors of necessary precautions. Interviews revealed that staff were informed of the positive test, but signage was not posted due to oversight and workload issues.
The facility failed to accurately assess and timely report changes in a resident's condition following a fall, leading to significant swelling, severe pain, and a wound on the knee. Despite the resident's worsening condition and need for narcotic pain medication and antibiotics, the physician was not timely notified, resulting in a hospital admission for urgent evaluation and treatment.
The facility failed to evaluate, implement, and modify interventions to reduce fall risks for a resident, leading to multiple falls and injuries. Additionally, the resident was not safely secured during transport, resulting in further injury. The facility did not conduct necessary evaluations or update the care plan to address fall risks.
Failure to Maintain Sanitary Kitchen Practices and Cleanliness
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen, including dried liquid splashes on the wall near sanitation sinks, a buildup of brown debris on the floor under a sanitation sink, and thick black debris on the baseboard behind the sinks. Additional findings included stained sinks, food particles and liquid splatter on shelving, dried substances on outlet face plates and appliance cords, and a white, dry substance on shelves where clean utensils and trays were stored. Rags used for cleaning dining room tables were stored in a plastic can without being soaked in sanitizing solution, contrary to facility policy. Rust was also present on the sides of a cart used for storing clean items. Interviews with staff revealed inconsistencies in cleaning responsibilities and practices. The night shift was reportedly responsible for sweeping, mopping, and cleaning out the dishwasher food strainer, while dietary staff used cleaning solutions with rags to wipe tables, but the solution and rags were only changed out every evening. The dietary manager and administrator confirmed that cleaning duties were divided among staff, but observations indicated that cleaning and sanitation protocols were not consistently followed, resulting in unsanitary kitchen conditions.
Failure to Protect Resident from Physical and Verbal Abuse by CNA
Penalty
Summary
A resident with moderate cognitive impairment, hemiplegia, and a history of behavioral issues, including sexual and verbal behaviors toward staff, was dependent on staff for all activities of daily living and required extensive assistance. During care, a Certified Nurse Assistant (CNA) became agitated with the resident after the resident's feeding tube opened, resulting in soiling of the bed and the need for additional care. The CNA believed the resident had intentionally disconnected the feeding tube and responded by smacking the resident on the thigh below the buttock. Multiple staff interviews and written statements confirmed that the CNA struck the resident with an open hand during care. Additionally, the same CNA was reported by several staff members to have referred to the resident as a "pedophile" in the resident's presence and in the presence of other staff, which was considered a form of verbal abuse. The resident's next of kin was informed of the incident and reported that the resident nodded affirmatively when asked if anyone had hit them. The facility's abuse policy defined both physical and verbal abuse, including hitting and the use of derogatory terms, as prohibited behaviors. Staff interviews indicated that the CNA had become increasingly hostile and aggressive toward the resident, particularly in response to the resident's behavioral issues. The incident was reported internally, and staff statements corroborated the occurrence of both physical and verbal abuse toward the resident.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide appropriate care and treatment following a fall with injury for a resident with a history of stroke and who was on Xarelto, an anticoagulant medication. The resident experienced a fall from a wheelchair and complained of severe right-sided rib pain, rating it 9 out of 10 on the pain scale. Despite the resident's ongoing complaints of pain and shortness of breath, the physician was not notified, and the resident's condition was not re-evaluated by staff until prompted by a family member approximately 2-1/2 hours after the fall. The resident continued to experience significant pain, described as tearful and in distress when repositioned, yet the physician remained uninformed. Approximately 10-3/4 hours after the fall, the resident's pain persisted at a level of 7 out of 10, and the physician was still not notified. Eventually, the resident was sent to the emergency room due to a high blood potassium level, where they were diagnosed with a large right-sided hemothorax, multiple displaced rib fractures, and a right scapular fracture. The on-call physician was initially informed that the resident had slipped from the wheelchair without injury, following facility procedure, but was not updated on the resident's pain, use of anticoagulant medication, shortness of breath, or the fact that the fall was unwitnessed.
Failure to Prevent Falls and Communicate Post-Fall Information
Penalty
Summary
The facility failed to develop a care plan with interventions to prevent falls for a resident who was at risk for falls and had been admitted after experiencing falls at home. The resident sustained a fall while at the facility, resulting in severe injuries including a large right-sided hemothorax, multiple displaced rib fractures, and a right scapular fracture. Staff did not complete a thorough post-fall assessment or notify the Director of Nursing as required by facility policy. Additionally, the fall was not communicated to the oncoming shift at shift change, nor was pertinent information regarding the fall communicated to the on-call physician, who was unfamiliar with the resident, leading to a delay in evaluation and treatment.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to maintain resident dignity and self-determination for four residents by not providing necessary grooming assistance, specifically basic haircuts. This deficiency was identified through observation and interview, indicating that the staff did not adequately support the residents' personal grooming needs. The facility had a census of 51 residents at the time of the survey.
Failure to Assist with ADLs and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents. Staff did not check for incontinence, which is a critical aspect of resident care. Additionally, one resident's hair was not groomed or pulled back from their face during meals and throughout the day, impacting their comfort and dignity. Another resident did not receive routine showers, which is essential for maintaining personal hygiene. These deficiencies were identified through observation, interviews, and record reviews during the survey.
Inadequate Nursing Staff Leads to Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of five sampled residents. This deficiency was observed through the facility's inability to provide timely incontinence care, routine showers for personal hygiene, and prompt responses to call lights. Additionally, the facility did not have adequate staffing to assist residents out of bed for meals and ensure all residents were served meals. The facility had a census of 51 residents at the time of the survey.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide appropriate care and treatment following a fall with injury for a resident with a history of stroke and who was on Xarelto, an anticoagulant medication. The resident experienced a fall from a wheelchair, which was unwitnessed, and complained of severe right-sided rib pain and shortness of breath. Despite these symptoms, the on-call physician was not informed of the resident's pain, the use of anticoagulant medication, or the unwitnessed nature of the fall. The resident's condition worsened, and it was only after a family member's insistence that the resident was re-evaluated and eventually sent to the emergency room, where multiple serious injuries were discovered. The facility's policy on acute condition changes required that significant changes in a resident's condition, such as increased pain, be reported to a physician. However, the nursing staff failed to adequately assess and communicate the resident's condition to the physician. The resident continued to experience severe pain throughout the night, and the physician was not notified of the resident's ongoing pain or the potential complications due to the anticoagulant medication. The lack of thorough post-fall assessment and communication with the physician contributed to the delay in appropriate medical intervention. Interviews with staff revealed that there was a breakdown in communication and adherence to facility policies. The Director of Nursing and the Administrator both expressed expectations that were not met, including the need for thorough assessment and communication of changes in condition. The on-call physician indicated that with complete information, he would have sent the resident for evaluation immediately after the fall. The failure to follow established protocols and communicate critical information resulted in a significant delay in addressing the resident's injuries, which were ultimately severe enough to necessitate hospice care.
Failure to Implement Fall Prevention Measures and Conduct Thorough Post-Fall Assessment
Penalty
Summary
The facility failed to develop a care plan with interventions to prevent falls for a resident who was at risk for falls and had a history of falls prior to admission. The resident, who had bilateral lower extremity amputations and other significant health conditions, was admitted to the facility after a fall at home. Despite being identified as high risk for falls, the resident's care plan did not address fall prevention, and staff did not complete the fall risk evaluation section for interventions. On the day of the incident, the resident fell from their wheelchair and sustained serious injuries, including a large right-sided hemothorax, multiple displaced rib fractures, and a right scapular fracture. The staff failed to conduct a thorough post-fall assessment, did not notify the Director of Nursing, and did not communicate the fall to the oncoming shift or the on-call physician effectively. This lack of communication and assessment delayed the resident's evaluation and treatment, resulting in significant pain and complications. Interviews with staff revealed a lack of awareness regarding the resident's fall history and the absence of fall prevention interventions. The Director of Nursing and other staff members acknowledged that the fall care plan and interventions should have been implemented upon admission. The facility's failure to follow its policies and procedures for fall prevention and post-fall assessment contributed to the resident's injuries and subsequent decline in health.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat four residents with dignity and respect, as evidenced by staff not speaking respectfully to residents and not promptly responding to an incontinent resident requiring assistance. Resident #2, who had severe cognitive impairment and was dependent on staff for various needs, reported that a staff member made a demeaning comment about taxes paying for the resident's stay. Additionally, the resident's call light was turned off by staff without providing the needed assistance. Resident #1, who shared a room with Resident #2, corroborated the incident and expressed dissatisfaction with the staff's response to call lights and the handling of incontinence pads. Resident #12, who also had severe cognitive impairment and was dependent on staff for toileting, was observed standing in the hallway in a wet state. A Certified Medication Technician (CMT) acknowledged the situation but did not address the resident's needs, leaving it to another staff member to provide care later. This lack of immediate response to the resident's needs further exemplifies the facility's failure to uphold dignity and respect. Resident #18, who was cognitively intact but had verbal behaviors and was frequently incontinent, was told by a CNA not to use the call light excessively. This upset the resident, as confirmed by a family member. Staff O reported that CNA E was rude to residents and discouraged them from using the call light, but no action was taken by the administration despite being informed. The Director of Nursing and the Administrator were unaware of these issues, indicating a communication breakdown within the facility.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, resulting in deficiencies in care. Resident #2, who had severe cognitive impairment and was dependent on staff for various ADLs, was observed without glasses during meals, making it difficult for them to eat properly. Additionally, the resident's hair was left wet after bathing, and they were not repositioned or checked for incontinence as required by their care plan. The resident reported having to yell for a blanket because the call light was out of reach, indicating a lack of attention to their needs. Resident #3, who also had severe cognitive impairment and was dependent on staff for toileting and transfers, was observed sitting in a wheelchair for extended periods without being repositioned or checked for incontinence. Despite the care plan indicating the need for regular checks and assistance, staff interviews revealed that these tasks were not consistently performed due to time constraints and workload. Similarly, Residents #16 and #8, both with severe cognitive impairments and incontinence, were not adequately repositioned or checked for incontinence before meals. Staff interviews confirmed that incontinence care was often delayed until after lunch due to being busy with other residents. The Director of Nursing acknowledged the expectation for routine rounds to include incontinence checks and repositioning but believed there was sufficient staff to meet residents' needs, despite evidence to the contrary.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of several residents who did not receive timely incontinence care, showers, or assistance with meals. Observations and interviews revealed that residents were left in soiled incontinence briefs for extended periods, resulting in skin irritation and discomfort. For instance, one resident was found with a saturated brief and red skin imprints, indicating a lack of timely care. Another resident reported being wet with urine and soiled with feces, with staff confirming that they had not been checked or changed for several hours. The facility's staffing issues also affected residents' ability to receive meals and personal hygiene care. One resident reported missing meals multiple times and waiting hours for assistance with mobility, leading to incontinence episodes. The facility's shower schedule was not adhered to, as evidenced by a resident who did not receive a scheduled shower, resulting in oily and dirty hair. Staff interviews consistently highlighted the challenges of managing care for residents requiring mechanical lifts, which necessitated two staff members, further straining the already limited resources. Interviews with staff, including CNAs and LPNs, consistently pointed to a shortage of staff as the primary reason for the deficiencies in care. Despite the facility's assessment indicating sufficient staffing levels, the reality was that the high number of residents requiring mechanical lifts and extensive care needs overwhelmed the available staff. The facility's administration, however, attributed the issues to inefficient work practices rather than a lack of staff, despite evidence to the contrary. This disconnect between administration and staff perceptions contributed to ongoing care deficiencies, as residents continued to experience delays in receiving necessary care and assistance.
Inaccurate Facility Assessment and Lack of Team Involvement
Penalty
Summary
The facility failed to review and update its facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, last updated on August 1, 2024, was conducted by the Administrator, Director of Nursing (DON), and the Governing Body with the corporation. However, the DON reported having no involvement in completing the assessment, and the Administrator, who was new to the role, admitted unfamiliarity with the process and form. The assessment inaccurately documented that 47 residents were independent with toileting, whereas the DON indicated this was incorrect. Additionally, the assessment understated the number of residents dependent on transfers, with the Administrator acknowledging that the documented number of 13 was incorrect, as 27 residents required mechanical lifts for transfers. Interviews revealed that the Administrator completed the assessment with assistance from the Corporate Administrator but without the required involvement of the Quality Assurance Team or other disciplines. The facility's policy mandates an annual review and update of the facility assessment, involving a team that includes the administrator, medical director, DON, and representatives from various services. The failure to accurately assess and document the residents' needs and the lack of involvement from the necessary team members led to the deficiency in the facility's ability to determine and provide the required resources for resident care.
Failure to Post COVID-19 Precaution Signage
Penalty
Summary
The facility failed to ensure proper signage was posted at the entrance of the building and outside a COVID-19 positive resident's room, which is a violation of their infection prevention and control policy. On observation, there was no signage at the front entrance indicating a COVID-19 outbreak, nor was there any transmission-based precaution signage outside the room of a resident who tested positive for COVID-19. The facility's policy requires visual alerts to be posted to inform staff and visitors of the necessary precautions to prevent the spread of COVID-19. The deficiency involved a resident who was admitted with a fracture of the right femur and later tested positive for COVID-19. Despite the resident being placed in isolation, there was no signage to alert staff or visitors of the precautions needed before entering the room. Interviews with the LPN, Infection Control Nurse, and Director of Nursing revealed that while staff were informed of the positive COVID-19 test, the required signage was not posted due to oversight and workload issues. The Administrator acknowledged the expectation for the facility to adhere to its COVID-19 policy.
Failure to Timely Report Changes in Resident's Condition
Penalty
Summary
The facility failed to accurately assess and timely report changes in condition to the resident's physician for one resident who was admitted following a fall. The day after admission, the resident developed blisters, edema, pain, and bruising to the left knee. Staff did not consistently assess the resident's skin and condition, despite the resident continuing to experience pain requiring narcotic pain medication and receiving antibiotic therapy. The physician was not timely notified of the changes in the resident's condition, leading to a delay in appropriate medical intervention. The resident requested to see their physician 11 days after admission and was subsequently admitted to the hospital with significant swelling from the knee to the toes, severe pain, and a wound on the knee. The facility's policies required prompt notification of the physician for any abnormalities, significant changes in condition, or need to alter medical treatment. However, the facility failed to follow these policies, as evidenced by the lack of documentation and follow-up on the resident's worsening condition. Interviews with staff and review of the resident's medical records revealed multiple instances where the resident's condition was not properly assessed or documented. The facility did not follow up on faxes sent to the physician, and there was no evidence of daily documentation on the resident's blisters and bruising. The resident's condition continued to deteriorate, leading to a hospital admission for urgent evaluation and treatment of a suspected compartment syndrome and infected hematoma.
Failure to Prevent Falls and Ensure Safe Transport
Penalty
Summary
The facility failed to consistently evaluate, implement, and modify interventions to reduce the risk of falls for a resident, leading to multiple incidents of falls and injuries. The resident, who had a history of falls and various diagnoses including altered mental status, muscle weakness, and unsteadiness on feet, was not adequately assessed or provided with a care plan addressing fall risks. Despite multiple falls, the facility did not conduct root cause analyses, update the care plan, or notify the physician and family as required by their policies. The resident experienced several falls within a short period, including incidents where the resident was found on the floor in different locations such as their room and the dining room. These falls resulted in injuries including bruises, skin tears, and reported pain. The facility staff failed to document post-fall evaluations, neurological checks, or any re-evaluation of fall interventions. Additionally, the resident's care plan did not reflect their fall risk or any interventions to prevent future falls. Furthermore, the facility failed to safely secure the resident during transport in the facility van, resulting in the resident sliding out of their wheelchair and onto the floor of the vehicle. This incident was not reported, and no interventions were modified to prevent further falls during transportation. The facility's lack of a policy for securing residents during transport and the staff's inadequate response to the resident's falls and injuries highlight significant deficiencies in the facility's fall prevention and management practices.
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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