Northwood Hills Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Humansville, Missouri.
- Location
- 800 N Arthur St, Humansville, Missouri 65674
- CMS Provider Number
- 265381
- Inspections on file
- 20
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northwood Hills Care Center during CMS and state inspections, most recent first.
The facility failed to ensure that three nurse aides completed CNA training and obtained certification within four months of employment. NA I, NA P, and NA Q were not certified, with NA I providing direct care despite failing the skills test. The DON and Administrator acknowledged the requirement for certification within four months and the need to remove uncertified aides from the floor.
The facility failed to maintain food safety and sanitation standards, with issues in food storage, labeling, and dishwasher operation. Observations showed unclean ice machine vents, outdated food, and improper dishwasher temperature checks. Staff interviews revealed confusion over cleaning responsibilities and a lack of training in using sanitizer test strips.
The facility failed to maintain a clean and homelike environment, with deficiencies observed in shower rooms, sitting areas, and resident bathrooms. Residents reported unclean conditions, including black mold and broken tiles in shower rooms, and grime buildup and urine odors in bathrooms. Staff interviews revealed that cleaning routines were not effectively addressing these issues, and temporary repairs were insufficient. A contractor was needed for a permanent solution.
The facility failed to provide written transfer notices to residents or their representatives for hospital transfers, affecting four residents. Notices were either not documented as provided or not sent, despite being prepared. Staff typically notified families by phone, but written notices were not mailed, contrary to federal regulations.
The facility failed to provide bed-hold notices to four residents upon their transfer to the hospital, as required by their policy. Interviews and record reviews showed that the necessary written information regarding the duration of the bed hold and the reserve bed payment policy was not communicated to the residents or their representatives. Staff typically notified families by phone about the transfer but did not include bed-hold information.
The facility did not adhere to approved menus and serving sizes, affecting residents' nutritional needs. Dietary staff used incorrect portion sizes and did not follow recipes for pureed meals, relying on personal judgment instead. The Registered Dietician confirmed that staff should follow menu guidelines, but inconsistencies in meal preparation were observed.
The facility failed to maintain food at safe and appetizing temperatures, with hot foods served below the required 135°F and cold foods above 41°F. Residents reported meals as consistently cold and unpalatable. Staff interviews revealed a lack of knowledge about proper food temperatures, and the facility's policy on food temperature control was not followed.
The facility failed to maintain an effective infection control program by not screening staff for TB as required and improperly handling residents' cigarettes. Four staff members did not complete the TB skin test before resident contact, and staff counted cigarettes by touching them with bare hands, causing resident discomfort. The facility's DON and Administrator acknowledged these deficiencies.
A resident with multiple mental health diagnoses was spoken to in a threatening manner by a staff member, who informed the resident that staff had the right to press assault charges after an incident where the resident pinched and swung at a nursing aide. The facility's policy emphasizes treating residents with dignity and respect, and staff interviews indicated that threatening residents with charges is inappropriate.
The facility failed to provide trauma-informed care for two residents with PTSD, as staff did not identify, assess, or care plan for their specific needs. One resident, a Vietnam War Veteran, exhibited aggressive behaviors, but the care plan lacked interventions for PTSD triggers. Another resident with PTSD and other mental health conditions showed anxiety and resistive behaviors, yet staff were unaware of the PTSD diagnosis. The facility lacked a policy on Trauma Informed Care, leading to a deficiency in managing residents with trauma-related conditions.
The facility failed to follow standards of practice for bed rail use for two residents, neglecting timely assessments, physician orders, and informed consent. One resident with quadriplegia had grab bars without documented alternatives or risk assessments, while another cognitively impaired resident used a grab bar without documented consent. Staff interviews revealed inconsistencies in policy implementation.
The facility failed to accommodate the food allergies and preferences of two residents. One resident, allergic to carrots, continued to receive them despite communicating the allergy. Another resident's family requested no red dye products, but the resident was still served Kool-Aid with red dye. Staff interviews revealed a lack of awareness and communication regarding these dietary needs.
Failure to Ensure CNA Certification Within Four Months
Penalty
Summary
The facility failed to ensure that three nurse aides, identified as NA I, NA P, and NA Q, completed a certified nurse aide (CNA) training program and obtained certification within four months of employment. The facility's policy requires that nurse aides meet training requirements, including a state-approved training and competency program, and be certified within four months of employment. However, NA P was rehired as a Non-Certified Aide in Training and had no completion date for the training class. NA Q completed the training class but was not certified as a CNA, and NA I completed the training but failed the skills portion of the certification test. Observations and interviews revealed that NA I was providing direct care to residents despite not being certified, as they had failed the skills portion of the test and had not rescheduled it due to distance and cost. LPN R confirmed that NA P had moved to an activities position, NA I was rescheduling the test, and NA Q had failed the knowledge portion of the test but had rescheduled it. The Director of Nursing and the Administrator both acknowledged that nurse aides should be certified within four months and should not work on the floor if certification is not obtained within that timeframe.
Facility Fails to Maintain Food Safety and Sanitation Standards
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Summary
The facility failed to ensure proper food storage, preparation, and service, leading to potential contamination risks. Observations revealed that the ice machine vents, air vents, and a standing fan were not kept free of lint, debris, and grime. Additionally, the facility did not label and date refrigerated food properly, nor did it dispose of outdated food. The kitchen's cleanliness was compromised with visible grease and grime on walls and dead bugs in light fixtures. Interviews with dietary staff indicated a lack of clarity regarding cleaning responsibilities, with maintenance and dietary staff unsure of their specific duties. The facility also failed to adhere to food labeling and handling standards. Observations in the walk-in cooler showed unlabeled and outdated food items, such as a tub of salsa-like substance without a date and tuna casserole and shredded chicken with expired use-by dates. Interviews with dietary aides and the dietary manager revealed inconsistencies in understanding the proper labeling and storage of prepared foods, with some staff unaware of the correct expiration timelines. Furthermore, the facility did not ensure the dishwasher operated at the recommended temperature and chemical solution levels. Staff were unfamiliar with the use of sanitizer test strips and the required minimum temperatures for the dishwasher's wash and rinse cycles. The dietary manager and registered dietician were also unaware of the correct procedures for testing and logging dishwasher temperatures and sanitizer levels. This lack of training and knowledge among staff contributed to the failure to maintain proper sanitation standards in the kitchen.
Facility Fails to Maintain Clean and Safe Environment
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Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple deficiencies observed in the shower rooms, sitting areas, and resident bathrooms. The shower rooms were reported by residents to be unclean, with black mold and broken tiles present. Observations confirmed these reports, revealing loose tiles, a dark substance lining the baseboards, and insecure grab bars. Residents expressed concerns about the cleanliness and safety of these areas, with some noting that the conditions had persisted for several years. In the sitting areas of the 200/400 halls, blankets were used to absorb water leakage from the shower rooms, and the baseboards were detached, exposing a corroded substance. The resident bathrooms were also found to be inadequately cleaned, with grime buildup on sinks and mirrors, and a strong odor of urine in some toilet areas. Residents reported that the staff did not clean these areas frequently enough, and observations confirmed the presence of grime and odors. Interviews with staff, including CNAs, CMTs, and the housekeeping manager, revealed that while daily cleaning routines were in place, they were not effectively addressing the issues. The maintenance director acknowledged attempts to repair the showers and baseboards, but these were only temporary solutions. The administrator confirmed that a contractor was needed for a more permanent remodel, which was scheduled to begin in December.
Failure to Provide Written Transfer Notices
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Summary
The facility failed to ensure that residents or their representatives were notified in writing of each transfer to a hospital, as required by federal regulations. This deficiency was identified for four residents. For Resident #81, the notice of transfer was addressed to the resident's representative and signed by facility staff, but there was no signature or indication that the notice was actually provided to the representative. Similarly, for Resident #67, the notice was addressed and signed by staff, but again, there was no evidence that it was provided to the representative. Resident #45, who was their own responsible party, was transferred to the hospital without any documented written notice of the transfer. The Director of Nursing confirmed that no transfer notification was sent for this resident. Resident #12 was transferred to the emergency room, and while a notice was prepared, there was no signature or indication that it was provided to the representative. Interviews with facility staff revealed that the standard practice was to notify the family or guardian by phone of the reason for the transfer, but no written information was mailed. The Administrator stated that the transfer notice should be faxed to the guardian or sent with the resident, indicating a discrepancy between the facility's policy and actual practice. This lack of proper documentation and communication regarding resident transfers to hospitals constitutes a failure to comply with federal regulations, which require timely written notification to residents and their representatives.
Failure to Provide Bed-Hold Notices Upon Hospital Transfer
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Summary
The facility failed to provide bed-hold notices to four residents upon their transfer to the hospital, as required by their policy. The policy mandates that a bed-hold notice be given upon admission and again at the time of transfer to the hospital or during a therapeutic leave. However, for Residents #81, #67, #45, and #12, there was no documentation or evidence that such notices were provided at the time of their hospital transfers. This oversight was confirmed through interviews and record reviews, which showed that the necessary written information regarding the duration of the bed hold and the reserve bed payment policy was not communicated to the residents or their representatives. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, revealed that the standard practice was to notify the family or guardian by phone about the reason for the transfer, but not about the bed-hold policy. The Administrator acknowledged that the bed-hold policy should have been faxed to the guardian or sent with the resident, but this was not done. The lack of documentation and communication regarding the bed-hold policy for these residents indicates a failure to adhere to the facility's established procedures.
Failure to Follow Approved Menus and Serving Sizes
Penalty
Summary
The facility failed to adhere to approved menus and serving sizes, compromising the nutritional needs of residents. Observations revealed that dietary staff did not follow the specified portion sizes for mechanically altered and pureed meals. For instance, on a specific date, residents were supposed to receive two-fifths of a cup of pureed ham and one-half cup of pureed vegetables, but staff used one-third cup scoops instead. Additionally, staff did not measure portion sizes for regular diets, such as spaghetti and meat sauce, relying instead on visual estimation. Interviews with dietary staff indicated a lack of adherence to menu guidelines, with staff often relying on personal experience rather than consulting the menu or recipes. The facility also lacked a policy for preparing pureed meals, and staff did not use recipes for pureeing food. Dietary staff used inconsistent methods, such as varying amounts of gravy and broth, to achieve the desired consistency for pureed meals. The Registered Dietician confirmed that staff should follow menu spreadsheets for serving sizes and that pureed meals should include all menu items, such as bread, which was not being served. The absence of standardized recipes and reliance on staff judgment rather than established guidelines contributed to the deficiency in meeting residents' nutritional needs.
Deficiency in Food Temperature and Palatability
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Summary
The facility failed to ensure that food served to residents was palatable and maintained at safe and appetizing temperatures. Observations revealed that food temperatures were consistently below the required standards, with hot foods such as ham, scalloped potatoes, and scrambled eggs measuring significantly below the minimum 135 degrees Fahrenheit. Cold foods like yogurt were also not maintained at the required temperatures, measuring above the 41 degrees Fahrenheit guideline. The food was described as mushy, cool, and lacking flavor, with residents reporting that meals were consistently cold and unpalatable. Interviews with residents and staff highlighted ongoing issues with food quality and temperature. Residents, who were cognitively intact and independent with eating, expressed dissatisfaction with the meals, describing them as cold and unappetizing. Staff interviews revealed a lack of knowledge regarding the correct food temperatures and procedures for maintaining them. Dietary aides admitted to not knowing the required temperatures for food service, and the Director of Nursing was unaware of the complaints about cold food. The facility's policy on food temperature control was not adhered to, as evidenced by the test tray temperatures and resident complaints. The policy required hot foods to be held at a minimum of 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. However, the food served was consistently outside these parameters, and staff were not adequately trained or informed about the necessary standards. The dietary manager and registered dietician acknowledged the issues with food temperatures and the need for improvement in maintaining the required standards.
Infection Control Deficiencies in TB Screening and Cigarette Handling
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Summary
The facility failed to maintain an effective infection control program by not screening all staff for tuberculosis (TB) as required. Specifically, four staff members, including two registered nurses, a licensed practical nurse, and a speech therapist, did not complete the first step of the two-step Tuberculin (TB) skin test before having contact with residents. The facility's policy and Missouri state regulations require that new employees and volunteers working ten or more hours per week obtain a Mantoux PPD two-step tuberculin test within one month prior to starting employment. However, the records showed delays in administering and reading the TB tests for these staff members, with some tests being conducted over a month after their hire dates. Additionally, the facility did not adhere to proper infection control practices when staff members counted residents' cigarettes by touching them with bare hands. This practice was observed during multiple instances where staff, including certified nurse aides, handled cigarettes without using hand sanitizer or gloves. Residents expressed discomfort with this practice during a resident council meeting, noting that staff touched their cigarettes eight times per day. Interviews with various staff members, including the housekeeping manager and registered nurses, revealed that staff were aware of the need to use hand sanitizer or gloves but did not consistently follow these practices. The facility's Director of Nursing and Administrator acknowledged the deficiencies in TB testing and cigarette handling practices. They were unaware of the reasons for the delays in TB testing and the improper handling of cigarettes. The Administrator mentioned that staff were required to count cigarettes due to past issues with residents smoking too many or complaints of missing cigarettes, but emphasized that staff should not touch each cigarette and could visually count them instead.
Resident Threatened with Assault Charges by Staff
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Summary
The facility failed to ensure that a resident was treated with dignity and respect when a staff member spoke to the resident in a threatening manner. The incident involved a resident with multiple diagnoses, including chronic PTSD, generalized anxiety disorder, major depressive disorder, paranoid schizophrenia, dementia, and Alzheimer's disease. The resident was dependent on staff for various needs due to cognitive deficits and physical limitations. According to the resident's care plan, staff were instructed to converse with the resident calmly and intervene as necessary to protect the rights and safety of others. On a specific date, the resident was involved in an incident where they were reported to have pinched and swung at a nursing aide. A registered nurse then approached the resident and informed them that the staff had the right to press assault charges, which was perceived as a threat. Interviews with staff, including the DON and the Administrator, revealed that staff should not threaten residents with assault charges and should instead redirect and notify appropriate personnel of problem behaviors. The nurse involved in the incident believed they were providing educational information rather than making a threat.
Failure to Provide Trauma-Informed Care for Residents with PTSD
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Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD, as staff did not identify, assess, or care plan for their specific needs related to this condition. Resident #72, who had a history of PTSD as a Vietnam War Veteran, exhibited aggressive behaviors such as hitting staff and throwing objects. Despite these incidents, the resident's care plan was not updated to include interventions or strategies to manage PTSD-related triggers. Interviews with staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis and triggers, indicating a gap in the facility's approach to trauma-informed care. Similarly, Resident #6, who also had a diagnosis of PTSD along with other mental health conditions, did not have a care plan addressing PTSD or its triggers. The resident displayed anxiety and resistive behaviors, yet staff were unaware of the PTSD diagnosis and did not implement specific interventions to address potential triggers. Interviews with staff highlighted a lack of knowledge about the resident's PTSD and the importance of trauma-informed care planning. The facility did not have a policy related to Trauma Informed Care, which contributed to the deficiency in providing appropriate care for residents with PTSD. Staff interviews revealed a general lack of understanding and training regarding trauma-informed care, as well as an absence of documentation and care planning for residents with PTSD. This deficiency indicates a systemic issue in the facility's approach to managing residents with trauma-related conditions.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to adhere to standards of practice regarding the use of bed rails for two residents, Resident #77 and Resident #70. For Resident #77, the facility did not complete timely assessments or reassessments of side rail use, failed to obtain a physician's order prior to the use of side rails, and did not secure full informed consent before implementing side rail use. The resident, who was cognitively intact but dependent on staff for all activities of daily living due to quadriplegia, was observed with grab bars in the up position on multiple occasions. However, the care plan did not address the use of grab bars, and there was no documentation of alternatives attempted or risk versus benefit assessments conducted prior to their use. For Resident #70, the facility also failed to obtain informed consent prior to the use of side rails. The resident, who had severe cognitive impairment and was dependent on staff for most activities, was observed using a grab bar for bed mobility. Although a physician's order was eventually obtained, the facility did not document who provided verbal consent for the use of the grab bar. The care plan included the use of a grab bar for safety and mobility, but the facility did not document a formal reevaluation of the necessity of the side rails. Interviews with various staff members, including nurse assistants, certified nurse assistants, registered nurses, and the Director of Nursing, revealed inconsistencies in the understanding and implementation of policies regarding side rail use. Staff members were unsure about the assessment process for side rails, and there was a lack of clarity about who was responsible for obtaining informed consent and conducting risk assessments. The facility's policy required attempts to use alternatives before installing bed rails, correct installation and maintenance, and regular assessments, but these procedures were not consistently followed for the residents involved.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, and preferences of its residents, as evidenced by the experiences of Resident #36 and Resident #38. Resident #36, who was admitted with allergies to penicillin and sulfa antibiotics, reported being allergic to carrots. Despite this, staff continued to serve him cooked carrots, even after he communicated his allergy. The resident's meal ticket listed carrots as an allergy/dislike, but this information was not reflected in the care plan or physician order sheet. Interviews with staff, including CNAs, LPNs, and dietary personnel, revealed a lack of awareness and communication regarding the resident's food allergies and preferences. Resident #38, diagnosed with type II diabetes mellitus, dysphasia, vascular dementia, and Alzheimer's disease, was also affected by the facility's failure to honor food preferences. The resident's family had requested that the resident not be served red dye products, such as Kool-Aid, and instead be given ice water at every meal. Despite these requests being communicated during care plan meetings, the resident continued to receive Kool-Aid with red dye, and water was not consistently provided. Staff interviews indicated that while some were aware of the family's request, others, particularly new staff, were not informed. The facility's policies on food allergies, intolerances, and preferences were not effectively implemented, leading to these deficiencies. The Director of Food and Nutrition Services and other staff members failed to ensure that residents' dietary needs and preferences were accurately documented and communicated. This lack of coordination and communication among staff members resulted in residents receiving food items that did not align with their documented allergies and preferences, compromising their satisfaction and potentially their health.
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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