Ozarks Methodist Manor, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Marionville, Missouri.
- Location
- 205 South College,, Marionville, Missouri 65705
- CMS Provider Number
- 265594
- Inspections on file
- 18
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ozarks Methodist Manor, The during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and known behavioral issues became combative during toileting care and bent a CMT's finger back, after which the CMT bent the resident's fingers back and made a retaliatory comment. A CNA witnessed this interaction, believed it could be abuse, but did not report it to a nurse or management at the time, instead discussing it later with another CNA and only informing an LPN the following day. As a result, the allegation was not reported to facility leadership or to the State Survey Agency within the required two-hour timeframe, despite staff interviews confirming they understood that suspected abuse must be reported immediately.
A resident with cognitive impairment and multiple medical conditions had $40 taken from their wallet without consent after returning from the hospital. The money, which was typically given weekly for personal use, was confirmed present by the guardian and then left unattended in the resident's room. When a family member arrived shortly after, the money was missing. Despite an internal investigation and staff interviews, the facility was unable to determine what happened to the funds, resulting in a deficiency for failing to protect the resident from misappropriation.
Two residents in the facility experienced significant weight loss, with one losing 9.60% in a month and another 19.38% over five months. The facility failed to notify the RD or update care plans to address these changes. Observations and staff interviews revealed inadequate communication and documentation regarding the residents' nutritional status, leading to unaddressed weight loss and poor intake.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, affecting all 58 residents. Staffing sheets showed no RN coverage on several dates, confirmed by interviews with staff. The facility had more LPNs than RNs, leading to scheduling issues.
The facility failed to ensure the Dietary Manager met the required training and certification, affecting all 58 residents receiving meals. The DM, employed for two years, was not certified and had not completed Serv-Safe courses. Despite being enrolled in classes since 2023, she struggled to finish them. The RD, aware of the DM's lack of certification, spent limited time precepting her in the facility.
The facility did not conduct an annual review of its Infection Prevention and Control Program (IPCP), leading to outdated policies and disorganization in the IPCP binder. Interviews revealed that the IPCP had not been reviewed since June, and there was no documentation of recent reviews. This oversight risked adverse events for all 58 residents.
The facility did not ensure a clean environment as bathroom exhaust vents in shared and private bathrooms were found covered in dust, dirt, and debris. The Environmental Services staff confirmed the vents had not been cleaned in two months, contrary to the facility's policy of weekly dusting and quarterly vacuuming.
The facility failed to transmit completed MDS assessments to CMS within the required time frames for several residents, due to a misunderstanding of transmission requirements by the ADON/MDSC and DON. The facility's policy did not address MDS data transmission, contributing to the oversight. Residents affected had diagnoses such as dementia, PTSD, and anxiety disorder.
The facility failed to develop comprehensive care plans for three residents, neglecting to include necessary interventions for conditions such as schizophrenia, bipolar disorder, intellectual disability, skin lesions, catheter use, and hospice care. Interviews with staff confirmed these omissions, highlighting inconsistencies in care plan development.
The facility failed to develop comprehensive care plans for several residents, omitting critical diagnoses, treatments, and interventions. A resident's care plan lacked documentation for schizophrenia, bipolar disorder, and intellectual disability, as well as antipsychotic medication use. Another resident's care plan did not address a skin lesion or urinary catheter management. Additionally, a resident admitted to hospice care did not have a corresponding care plan. Staff interviews confirmed these omissions and the need for complete care plans.
The facility failed to serve meals consecutively to all residents at the same table, resulting in a resident being left without a meal while their tablemates ate. This occurred on two separate occasions, with the resident having to wait for staff to notice the oversight. The Dietary Manager was unaware of the dining room protocols and admitted there was no training for staff serving meals.
A facility failed to complete a significant change assessment within 14 days for a resident admitted to hospice care. The resident, with a history of heart disease, diabetes, and myocardial infarction, began hospice care, but no significant change MDS assessment was conducted. The MDS Coordinator was unaware of the hospice admission, and the DON confirmed the assessment should have been completed.
A resident at an LTC facility developed a pressure ulcer on the right heel, which deteriorated due to the facility's failure to update the care plan and implement appropriate interventions. Despite being at high risk for pressure ulcers, the resident's care plan was not updated to include necessary interventions such as floating heels or using a Broda chair. The ulcer progressed from Stage 3 to Stage 4, with exposed bone and tendon, due to inadequate documentation and inconsistent application of care strategies.
A facility failed to ensure physician progress notes were documented in the EMR for a resident with multiple diagnoses, including severe cognitive impairment. Staff interviews revealed ongoing issues with obtaining and placing these notes into resident records, resulting in incomplete documentation.
A facility failed to conduct an ongoing review for antibiotic stewardship for a resident who received multiple antibiotics over several months. The resident, admitted with acute vaginitis and UTI, was prescribed various antibiotics, but their use was not properly logged or reviewed as required by the facility's policy. The DON, responsible for the antibiotic stewardship program, acknowledged the oversight, and the Administrator confirmed the need for adherence to guidelines.
The facility did not accurately post daily nurse staffing information, failing to document the resident census, nurse licensing status, and actual hours worked. Key staff, including the DON and Administrator, were unaware of these requirements.
Failure to Timely Report Witnessed Allegation of Possible Abuse
Penalty
Summary
The facility failed to ensure that an allegation of possible abuse was reported immediately to management and within two hours to the State Survey Agency as required by policy. A cognitively impaired resident with Alzheimer's disease, known verbal and physical behaviors, and a care plan addressing potential physical aggression and resistance to care was involved. During toileting and incontinence care, the resident became combative and bent a CMT's finger back. In response, the CMT bent the resident's fingers back and stated, "you like that" or "how does that feel," which a CNA witnessed and believed could be abuse. The CNA who witnessed the incident did not report it to a nurse or management at the time it occurred. Instead, the CNA discussed the event with another CNA later during a lunch break and was advised to report it to the LPN. The CNA went home after the shift and did not report the allegation until the following day during the next shift, resulting in the facility notifying the DON, Administrator, and State Survey Agency the day after the alleged abuse occurred. Interviews with multiple staff, including CNAs, CMTs, nurses, the DON, and the Administrator, confirmed that staff were aware of the requirement to report suspected abuse immediately, and the DON and Administrator stated they expected all staff to report allegations of abuse without delay.
Failure to Safeguard Resident Funds Resulting in Misappropriation
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of personal funds when $40 was taken from the resident's wallet without their knowledge or consent. The resident, who had diagnoses including mild cognitive impairment, general anxiety disorder, major depressive disorder, traumatic brain injury, and a history of falls, typically received $40 weekly from the facility for personal use, which was then given to a family member for purchases and outings. The resident's care plan did not address concerns related to maintaining or safeguarding their money. On the day of the incident, the resident returned from the hospital accompanied by their guardian, who confirmed the presence of $40 in the resident's wallet. The wallet was placed on a table in the resident's room by a CNA after the resident showed the money to the guardian. Shortly after the guardian left, the resident's family member arrived and discovered the money was missing from the wallet. Multiple staff, including CNAs and an LPN, were present in the area during this time, and the wallet was left unattended in the resident's room for a period. Interviews with staff and the resident indicated that no one witnessed the removal of the money, and the resident could not recall when the money disappeared. The facility conducted an investigation, including interviews and statements from staff, the resident, the guardian, and the family member. The investigation was unable to determine what happened to the money, and the funds were not recovered. The incident was reported to the Ombudsman and local police, but the facility's failure to ensure the resident's money was safeguarded and accounted for resulted in a deficiency related to the misappropriation of resident property.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately address significant weight loss and poor intake for two residents, leading to a deficiency in nutritional care. Resident #14 experienced a severe weight loss of 9.60% in less than a month, with no documented notification to the Registered Dietitian (RD) or physician regarding the weight loss or reduced meal intake. The resident's care plan was not updated to reflect these changes, and there was no evidence of a nutritional assessment being conducted to address the weight loss. Observations showed the resident was not consuming adequate amounts of food, and staff interviews revealed a lack of communication and documentation regarding the resident's nutritional status. Resident #228 experienced a weight loss of 19.38% over five months, with similar issues of inadequate documentation and communication. The resident's care plan was not updated to reflect the significant weight loss until several months later, and there was no evidence that the RD was notified of the weight loss. The resident's nutritional status was not reassessed, and there were no documented interventions to address the weight loss until the resident was admitted to hospice services. Interviews with staff indicated a lack of awareness and action regarding the resident's nutritional needs. The facility's policies on weight assessment and intervention were not followed, as significant weight changes were not promptly communicated to the RD or addressed in the residents' care plans. The RD was not made aware of the residents' weight loss in a timely manner, and there was a lack of multidisciplinary effort to address the nutritional deficiencies. The deficiency highlights a failure in the facility's processes for monitoring and addressing residents' nutritional needs, leading to unaddressed weight loss and poor intake for the affected residents.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to consistently have a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, between July 4, 2024, and December 30, 2024. This deficiency was identified through a review of the facility's staffing sheets, which revealed that there was no RN coverage on several specific dates within this period. Interviews with the Central Supply, Human Resources Director, Director of Nursing, and the Administrator confirmed the lack of RN coverage on these days. The facility had more licensed practical nurses than registered nurses, which contributed to the inability to schedule an RN for the required hours, affecting all 58 residents residing in the facility.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met the required training, certification, and/or experience as mandated by state regulations. The DM, who had been employed at the facility for two years, was not certified and had not completed any Serv-Safe courses. Although she had been enrolled in classes since 2023, she had not been able to complete them. The Registered Dietitian (RD), who was aware of the DM's lack of certification, was present at the facility two days a month for approximately 16 hours, spending most of her time precepting the DM in her courses. This deficiency had the potential to affect all 58 residents who received meals in the facility.
Failure to Review and Update Infection Prevention Program
Penalty
Summary
The facility failed to conduct an annual review and update of its Infection Prevention and Control Program (IPCP), which is necessary to align with changing national standards. This deficiency was identified through a review of the facility's Infection Prevention binder, which was found to be disorganized with policy pages out of order or missing. The binder contained outdated policies, including a COVID-19 prevention policy from March 2020 and undated documents that did not specify the frequency of IPCP reviews. Interviews with the Infection Preventionist and the Administrator revealed that the IPCP policies had not been reviewed since June, and there was no documentation to confirm when the last review occurred. The Administrator was uncertain about the review process and could not provide evidence of the IPCP being discussed in quality assurance meetings. This oversight had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, affecting all 58 residents in the facility.
Failure to Maintain Clean Bathroom Vents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for residents by not ensuring the cleanliness of bathroom exhaust fan vents. Observations revealed that the exhaust vents in the shared bathrooms of several residents were covered in layers of fuzzy, gray dust, dirt, and debris. Additionally, the exhaust vent in a private bathroom was found to be covered in stringy cobweb-like fibers and similar debris. During interviews, the Environmental Services/Plant Director and Assistant confirmed the unclean state of the vents and acknowledged that they needed vacuuming. It was noted that the vents were last cleaned approximately two months prior, despite the facility's policy requiring weekly dusting and quarterly vacuuming of vents.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that completed Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) system within the required time frames for four residents. The facility's policy did not address the transmission of MDS data to the CMS system, which contributed to the oversight. The CMS 2024 Resident Assessment Instrument (RAI) Manual requires that comprehensive assessments be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments within 14 days of the MDS Completion Date. However, the facility did not adhere to these requirements for several residents, including those with diagnoses such as dementia, PTSD, anxiety disorder, and depression. The Assistant Director of Nursing/MDS Coordinator (ADON/MDSC) was responsible for completing the MDS, while the Director of Nursing (DON) was responsible for signing and transmitting the assessments. The ADON/MDSC was under the impression that comprehensive or quarterly assessments should not be submitted to prevent unauthorized access to residents' protected health information, and was unaware that all completed assessments needed to be transmitted. Similarly, the DON believed that only entry, prospective payment system (PPS), and discharge assessments needed to be transmitted, and was not aware of the requirement to transmit initial, annual, or significant change assessments. This misunderstanding led to the failure to transmit the required assessments for the residents in question.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychological needs. For one resident, the care plan did not include necessary interventions for schizophrenia, bipolar disorder, intellectual disability, or the use of antipsychotic medication. Despite the resident's diagnoses and the recommendations from the Pre-Admission Screening and Resident Review (PASARR), the care plan lacked measurable goals and interventions related to these conditions. Interviews with the Social Services Director, MDS Coordinator, and Director of Nursing confirmed that these diagnoses and medication side effects should have been included in the care plan. Another resident's care plan was deficient in addressing skin lesions and the use of an indwelling urinary catheter. The resident had severely impaired cognition, open skin lesions, and used a catheter, but the care plan did not include interventions for these issues. Observations noted a large scabbed area on the resident's chin and the presence of a catheter, yet the care plan lacked strategies for monitoring and managing these conditions. The Assistant Director of Nursing/MDS Coordinator acknowledged the missing information and the need for these issues to be included in the care plan. A third resident, who was admitted to hospice care, did not have hospice services included in their care plan. Despite a physician's order for hospice admission and the resident being cognitively intact, the care plan failed to reflect the receipt of hospice services. The Assistant Director of Nursing admitted to inconsistencies in care plan development and recognized that hospice services should have been incorporated into the care plan, detailing the facility's responsibilities and interventions.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for six residents, which included necessary measurable goals and interventions. For Resident 231, the care plan did not document diagnoses of schizophrenia, bipolar disorder, or intellectual disability, nor did it include the use of antipsychotic medication and its side effects. Despite recommendations from the PASRR/ID assessment for services like physical therapy and drug therapy monitoring, these were not incorporated into the care plan. Interviews with the Social Services Director, MDS Coordinator, and Director of Nursing confirmed the expectation that these diagnoses and treatments should be included in the care plan. Resident 11's care plan was also incomplete, lacking documentation for a skin lesion on his chin and the use of a moisture barrier, as well as the management of an indwelling urinary catheter. Observations noted the presence of a scabbed area on the resident's chin, and the EMR indicated the lesion was being monitored, but this was not reflected in the care plan. The Assistant Director of Nursing acknowledged the missing information and the need for the care plan to include monitoring and physician notification for changes in the skin lesion. For Resident 10, the care plan did not address the resident's admission to hospice care, despite a physician's order and the resident's significant change in status MDS indicating hospice care. The Assistant Director of Nursing admitted to inconsistencies in care plan documentation and recognized the need for hospice care to be included in the care plan, outlining the facility's responsibilities and interventions.
Failure to Serve Meals Consecutively at Resident Tables
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents during meal service by not serving all residents at the same table consecutively. On two separate occasions, a resident was left without a meal while their tablemates were served, leading to the resident feeling forgotten and hungry. On the first occasion, three residents at a table were served their meals at 5:25 P.M., but the fourth resident was not served until 5:43 P.M., despite raising their hand to get the staff's attention. On the second occasion, the same resident was again left without a meal while their tablemates were served at 12:22 P.M., and was only served at 12:30 P.M. when a staff member noticed the oversight. The Dietary Manager, responsible for meal service, was unaware of the dining room protocols and admitted that there was no training for staff serving meals. This lack of awareness and training contributed to the oversight, resulting in the resident being left without a meal on multiple occasions. The facility's policy, which states that meals should be provided to all residents sitting at the table at the same time, was not followed, leading to the deficiency in treating residents with dignity and respect.
Failure to Complete Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days for a resident who was admitted to hospice services. The resident, who had a history of hypertensive heart disease, diabetes, and myocardial infarction, began hospice care on November 20, 2024. However, the facility did not conduct a significant change Minimum Data Set (MDS) assessment following this change in the resident's condition. The last MDS assessment was a quarterly one completed on November 12, 2024. During interviews, the MDS Coordinator stated she was unaware of the resident's transition to hospice care, and the Director of Nursing confirmed that a significant change MDS should have been completed within 14 days of the resident's change to hospice care.
Failure to Update Care Plan Leads to Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development and deterioration of a pressure ulcer on the resident's right heel. Initially, the resident was assessed as being at risk for pressure ulcer development, with a Braden Scale score indicating moderate to high risk. Despite this, the care plan was not updated to reflect the new pressure ulcer or to include specific interventions to address the resident's changing condition. The resident's care plan did not incorporate the necessary interventions to manage the pressure ulcer, such as floating heels or using a Broda chair, until several months after the ulcer was first identified. The resident's pressure ulcer was first noted on the right heel, and a treatment plan was initiated. However, the care plan was not updated to include this new development, and the interventions were not adequately documented or implemented. The resident continued to spend significant time in a wheelchair with legs in a dependent position, contributing to the pressure on the wound site. Despite recommendations from the wound care provider to elevate the resident's legs and use Podus boots, these interventions were not consistently applied, and the care plan remained unchanged. As a result of these oversights, the resident's pressure ulcer deteriorated significantly, progressing from a Stage 3 to a Stage 4 ulcer with exposed bone and tendon. The facility staff failed to update the care plan with appropriate interventions in a timely manner, and there was a lack of consistency in implementing the recommended care strategies. The facility's failure to document and update the care plan contributed to the worsening of the resident's condition, highlighting deficiencies in the facility's pressure ulcer management practices.
Incomplete Documentation of Physician Progress Notes
Penalty
Summary
The facility failed to ensure that physician progress notes were documented and available for review in the electronic medical record (EMR) for a resident. The resident, who was admitted with diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, low-tension glaucoma, and osteoporosis, was severely cognitively impaired according to the quarterly Minimum Data Set. During the survey, it was found that there were no physician progress notes documented in the resident's EMR, neither under the Progress Notes tab nor the Miscellaneous tab. Interviews with facility staff revealed that the physician progress notes were not consistently placed into resident records. The Social Service Director confirmed the absence of these notes in the EMR, and the Director of Nursing acknowledged difficulties in obtaining the notes from the physician's dictating company. The Administrator was also unaware of how long this issue had persisted and provided only photo images of the physician's laptop screen as evidence of the notes, which were not available in the EMR. This lack of documentation resulted in incomplete resident records.
Failure in Antibiotic Stewardship Review
Penalty
Summary
The facility failed to conduct an ongoing review for antibiotic stewardship for a resident who received multiple antibiotics over several months. The facility's policy on antibiotic stewardship, revised in December 2016, mandates that all clinical infections treated with antibiotics undergo review by the infection preventionist (IP) or designee. However, the resident was not listed on the Infection Control Line Listing log for antibiotic stewardship review for the months of August, September, November, and December 2024. The log sheets were incomplete, missing critical information such as resident room numbers, dates of labs/pathogen, date/symptoms, and predisposing factors. The resident, admitted with diagnoses including acute vaginitis and urinary tract infection (UTI), was prescribed and administered various antibiotics from August to December 2024. Despite the facility's policy requiring documentation and review of antibiotic regimens, the resident's antibiotic use was not properly logged or reviewed. During interviews, the Director of Nursing (DON), who also served as the IP, acknowledged that the resident should have been on the log and that there was no policy she was aware of for following the McGeer criteria or protocols for reviewing antibiotic stewardship. The Administrator confirmed that the DON was responsible for the antibiotic stewardship program and that guidelines were to be followed for appropriate ordering of antibiotics.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was accurately posted to reflect the actual staff hours for the care of 58 residents. Observations from January 6 to January 9 revealed that the Daily Nursing Roster was posted at various times without documenting the daily resident census, the licensing status of the nurses (LPN or RN), or the actual hours worked by the staff. Interviews with the Central Supply and Human Resources Director indicated they were unaware of the requirement to include the resident census and nurse licensing information in the postings. The Director of Nursing, responsible for the postings, was also unaware of the missing documentation. Additionally, the Administrator admitted to not being familiar with the requirements for daily nurse postings.
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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