Putnam County Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Unionville, Missouri.
- Location
- 1814 Oak Street, Unionville, Missouri 63565
- CMS Provider Number
- 265826
- Inspections on file
- 16
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Putnam County Care Center during CMS and state inspections, most recent first.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was insufficient to ensure resident safety.
The facility did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a failure to meet required notification standards.
An Administrator disclosed a resident's change in code status from full code to DNR to a family member who was not the DPOA, and did so in a public setting at a golf course. This disclosure led to confusion and was acknowledged by the Administrator as a violation of both the resident's privacy and the facility's privacy policy, which require confidentiality of all resident health information.
Surveyors found that the facility did not ensure services were provided in accordance with professional standards of quality. The report did not specify the actions or omissions that led to this deficiency, nor did it provide details about the residents involved.
Staff did not follow proper infection control procedures while providing catheter care to two residents, including failing to change gloves and perform hand hygiene after perineal care and before catheter care, and improperly positioning urinary drainage bags above bladder level, resulting in observed backflow of urine and increased risk of infection.
A resident with severe cognitive impairment and a history of falls was left unattended in a raised bed without fall interventions in place, leading to a fall that resulted in a fatal head injury and hip fracture. Staff failed to implement care-planned interventions, contributing to the incident.
The facility failed to maintain a sufficient surety bond to protect the personal funds of 15 residents, as required by their policy. The bond was $10,000, while the required amount was at least $10,500 based on the average monthly balance. The Administrative Assistant responsible for the bond had not reviewed it in the past year, leading to this deficiency.
A resident with dementia and a history of wandering intruded into other residents' rooms, compromising their privacy. Despite a care plan to redirect the resident, they continued to disturb others by taking items and urinating in inappropriate places. Residents reported distress and used locks to prevent entry. Staff struggled to monitor the resident effectively, leading to repeated privacy invasions.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing specific medical needs. A resident with edema did not have this condition reflected in their care plan, despite physician orders for ace wraps. Another resident's care plan lacked guidance on managing multiple medications, including mood stabilizers and anti-coagulants. Additionally, a resident's care plan did not address the presence or care of a urinary catheter, leaving staff without necessary instructions.
The facility failed to update care plans for four residents, leading to deficiencies in addressing weight loss, choking episodes, and fall prevention. A resident with Parkinson's disease experienced significant weight loss and choking, but their care plan lacked necessary interventions. Another resident with dementia had multiple falls not documented in their care plan. Additionally, a resident with vitamin B12 deficiency and muscle wasting had significant weight loss without care plan updates, and a resident with diabetes and hypertension had multiple falls not reflected in their care plan.
A resident with dementia and a history of wandering was inadequately supervised, leading to repeated intrusions into other residents' rooms, causing fear and frustration. Despite having a care plan with interventions like alarm devices and redirection, the facility struggled to monitor the resident effectively, especially during night shifts. Staff and residents reported difficulties and distress due to the resident's behavior, highlighting a failure in implementing the facility's policies on wandering and safety.
The facility failed to ensure eight nurse aides completed their CNA certification within four months of employment, as required by policy. Interviews revealed that some aides had only recently started classes, while others were not enrolled. Staff cited issues with accessing online classes and a deliberate delay in enrollment to assess job retention, leading to non-compliance with certification requirements.
The facility did not offer bedtime snacks to all residents, as confirmed by resident interviews and staff admissions. Although a snack cart was available, it was not actively distributed, and residents had to request snacks. Staff inconsistently provided snacks, with some only offering them to diabetic residents. The DON and administrator acknowledged that snacks should be offered to all residents, indicating a gap between policy and practice.
The facility failed to follow infection control practices, including improper storage of respiratory supplies, inadequate hand hygiene, and PPE use during resident care. Additionally, urinary drainage systems were not kept off the floor, and TB screening for new employees was not completed before resident contact.
A facility failed to follow infection control practices for a resident with a urinary catheter, leading to potential urinary tract infections. The resident's care plan lacked documentation of the catheter and preventive measures. Observations showed the catheter drainage bag touching the floor, contrary to policy. Staff interviews confirmed this practice should be avoided to prevent contamination.
The facility failed to lock medication and treatment carts, leaving them unattended, and did not properly manage expired medications. A resident with Alzheimer's was at risk due to an unlocked cart, and an LPN admitted to forgetting to lock it. An expired medication was found in the medication room, indicating lapses in medication management procedures.
A resident with an indwelling urinary catheter experienced urinary retention with abnormal urine characteristics, but staff failed to notify the physician or document the condition. Despite facility policies requiring prompt notification and documentation, the LPN did not complete the necessary communication forms or inform the physician. The resident was later hospitalized with urosepsis, highlighting a breakdown in communication and assessment procedures among staff.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
The facility failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This deficiency was identified based on the lack of timely communication to all required parties when significant events impacting the resident occurred. The report specifically notes the absence of prompt notification following incidents or changes that had a direct effect on the resident's well-being or living situation.
Administrator Disclosed Resident's Code Status in Public, Violating Privacy Policy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records when the Administrator disclosed the resident's change in code status from full code to Do Not Resuscitate (DNR) to a family member who was not the resident's Durable Power of Attorney (DPOA), and did so in a public setting. The disclosure occurred while the Administrator was at a golf course, where the resident's family member and another unrelated individual were present. The Administrator informed the family member of the resident's change in code status, which led to a misunderstanding that the resident had experienced a code event. The family member subsequently shared this information with others and went to the facility, only to find the resident awake and confused. The resident's DPOA later stated that they did not want the resident's medical information shared with anyone else, emphasizing that the Administrator should not have disclosed the change in code status to other family members or in a public place. The Administrator acknowledged that she should not have shared the resident's personal medical information with anyone other than the DPOA, recognizing that this action violated both the resident's privacy and the facility's privacy policy. The facility's policy and federal law require that all resident information be kept confidential and only disclosed in accordance with privacy regulations.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the care and services delivered did not consistently adhere to accepted professional standards. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
Staff failed to utilize appropriate infection control techniques during the provision of care for two residents with indwelling urinary catheters. Observations revealed that certified nurse assistants (CNAs) performed perineal care on residents who were incontinent of bowel without changing their soiled gloves or performing hand hygiene before proceeding to catheter care. Specifically, after cleaning fecal matter, CNAs continued to handle the catheter tubing and perform catheter care with the same contaminated gloves, contrary to facility policy and standard infection control practices. Both residents involved had significant medical histories, including dependence for bed mobility and toileting, indwelling urinary catheters, and persistent bowel incontinence. Laboratory results for these residents indicated abnormal urinalysis findings and positive urine cultures for bacterial infections, with physician orders for antibiotics and ongoing catheter use. During care, staff also failed to maintain proper positioning of the urinary drainage bags, at times placing them above the level of the bladder, which resulted in observed backflow of urine into the catheter tubing. Interviews with staff and facility leadership confirmed that the expected practice was to change gloves and perform hand hygiene after perineal care and before catheter care, and to keep catheter bags below bladder level. However, staff did not consistently follow these protocols during observed care, directly leading to the identified deficiencies in infection control and catheter care.
Failure to Prevent Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate oversight and prevent injury for a resident who was dependent on staff for transfers and bed mobility and had a history of falls. The resident, who had severe cognitive impairment and required substantial assistance for bed mobility, fell out of bed on two occasions prior to the incident in question. Despite these previous falls, the facility did not evaluate or implement new interventions to prevent further falls. On the day of the incident, staff were preparing to transfer the resident out of bed for breakfast. The bed was raised, and the fall mat was removed from the floor. One CNA left the room to retrieve a mechanical lift, while the other CNA remained in the room but turned away from the resident to tidy up. During this time, the resident rolled out of bed and sustained a head injury and a hip fracture, which ultimately led to the resident's death. Interviews with staff revealed that the resident was supposed to have a low bed, fall mat, and pillows in place when in bed, but these interventions were not in place at the time of the fall. The staff's actions, including leaving the resident unattended and not implementing the care-planned interventions, directly contributed to the resident's fall and subsequent injuries.
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond to protect the personal funds of 15 residents held in the resident fund account. The facility's policy requires a surety bond to be at least one and a half times the average monthly balance of the residents' personal funds. However, the facility's surety bond, dated March 2, 2021, was only $10,000, while the required amount, based on the average monthly balance from September 2023 to September 2024, was calculated to be at least $10,500. The current ledger amount was $8,775.60, indicating a shortfall in the bond coverage. During an interview, the Administrative Assistant, who is responsible for managing the resident trust fund and obtaining the surety bond, admitted to not reviewing the bond in the past year. This oversight contributed to the facility's failure to ensure the bond was adequate to cover the residents' funds, as required by their policy. The facility census at the time was 55, highlighting the potential impact on a significant number of residents.
Resident Privacy Compromised by Wandering Resident
Penalty
Summary
The facility failed to ensure personal privacy for multiple residents due to the actions of a resident diagnosed with dementia and identified as a wanderer. This resident, who had a history of wandering prior to admission, frequently intruded into other residents' rooms, which was documented in the facility's records. Despite the resident's care plan indicating that they should be redirected and removed from other residents' rooms as needed, the resident continued to wander into rooms, taking items, urinating in inappropriate places, and disturbing other residents. Numerous residents reported incidents involving the wandering resident entering their rooms without permission. These incidents included the resident taking personal items, urinating in trash cans, and invading personal space, which caused distress among the residents. Some residents resorted to using child safety locks or other barriers to prevent the wandering resident from entering their rooms. Interviews with residents revealed a consistent pattern of unwanted intrusions, which they found troubling and upsetting. Staff interviews indicated that while efforts were made to monitor the wandering resident, they were not always successful in preventing the resident from entering other residents' rooms. The Director of Nursing acknowledged the resident's history of wandering and the challenges in managing their behavior. The facility's failure to adequately address the wandering behavior resulted in repeated invasions of privacy for multiple residents, as confirmed by both staff and resident interviews.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for three residents, which led to deficiencies in addressing their specific medical needs. Resident #22, who was admitted with a diagnosis of edema, did not have this condition identified in their baseline or comprehensive care plan. Despite observations of significant edema and physician orders for ace wraps, the care plan did not reflect these needs, nor did it provide guidance for staff on managing the condition. Resident #31, diagnosed with a left femur fracture, chronic pain syndrome, and schizoaffective disorder, was prescribed multiple medications, including mood stabilizers, anti-depressants, and anti-coagulants. However, the care plan lacked directions for staff regarding the use and potential side effects of these medications, leaving a gap in the management of the resident's complex medical regimen. Resident #47's care plan did not address the presence or care of a urinary catheter, despite documentation and observations confirming its use. The care plan failed to include necessary instructions for catheter care, which was also not reflected in the mini care plan. Interviews with staff revealed reliance on care plans for guidance, highlighting the importance of accurate and comprehensive documentation, which was not provided in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans of four residents to reflect their current care needs, as identified during a survey. Resident #26, who has Parkinson's disease and malnutrition, experienced significant weight loss over six months and had episodes of choking. Despite these issues, the resident's care plan did not include interventions for weight loss or therapeutic treatments. Interviews with CNAs revealed that the resident had been switched to a pureed diet temporarily due to choking episodes, but the care plan was not updated to reflect these changes. Resident #38, diagnosed with dementia, had a history of falls that were not documented in the care plan. The resident's care plan, revised in September 2024, did not include any fall prevention interventions despite the resident having multiple falls since admission. The care plan failed to reflect the resident's fall history, which included incidents in August 2024, March 2024, and November 2023. Resident #44, who suffers from vitamin B12 deficiency and muscle wasting, experienced a significant weight loss of over 13% in six months. However, the care plan did not address weight loss or include therapeutic treatments. Similarly, Resident #48, with type 2 diabetes and hypertension, had multiple falls that were not updated in the care plan. The MDS/Care Plan Coordinator acknowledged the issues with missing care plan updates, including falls and weight loss, and noted problems with the facility's matrix system.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia, identified as Resident #51, who exhibited wandering behavior. This resident, who had a history of wandering prior to admission, was observed entering other residents' rooms, causing distress among them. The resident's care plan included strategies such as equipping the resident with an alarm device and redirecting them as needed, but these measures were not effectively implemented. Observations showed the resident wandering unsupervised, attempting to access the medication room, and entering other residents' rooms, which led to fear and frustration among the other residents. Interviews with staff and residents revealed that the facility struggled to monitor Resident #51 effectively, especially during night shifts when staffing was limited. Staff members reported difficulties in keeping track of the resident, who often wandered into other residents' rooms, sometimes urinating in inappropriate places like trash cans. Residents expressed fear and frustration over the intrusions, with some feeling unable to protect themselves due to physical limitations. The facility's policies on wandering and behavioral assessment required identifying residents at risk and implementing interventions to ensure their safety. However, despite these policies, the facility did not adequately supervise Resident #51, leading to repeated incidents of wandering and intrusion into other residents' spaces. The Director of Nursing and the administrator acknowledged the challenges in supervising the resident and mentioned attempts to address the issue, such as installing safety knobs on doors, but these measures were insufficient to prevent the incidents.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that eight nurse aides completed a state-approved nurse aide training program within four months of their employment, as required by their policy. The nurse aides in question, identified as NA B, NA D, NA N, NA R, NA S, NA T, NA U, and NA V, were found to have no current CNA certification despite being employed for more than four months. Interviews with the nurse aides revealed that some had started CNA classes only recently, while others were not enrolled at all. The facility's policy mandates that nurse aides must complete the training program and competency evaluation within four months of hire, or they may face termination or reassignment to non-nursing roles. Interviews with facility staff, including the Human Resources/Administrative Assistant, Director of Nursing, and the Administrator, highlighted systemic issues in the enrollment and completion of CNA classes. The HR/Administrative Assistant mentioned difficulties accessing the online CNA class website, while the Director of Nursing indicated that the HR director was responsible for setting up these classes. The Administrator acknowledged awareness of the issue, stating that the facility delayed enrolling employees in CNA classes to ensure job retention before investing in their training. This approach led to non-compliance with the regulatory requirement for timely certification of nurse aides.
Failure to Offer Bedtime Snacks to All Residents
Penalty
Summary
The facility failed to offer bedtime snacks to all residents, as observed and reported by both residents and staff. During a group interview, 20 out of 20 residents stated that bedtime snacks were not offered, and staff did not come around to offer snacks in the evenings or at bedtime. Some residents mentioned that snacks were sometimes available at the nurse's station on a cart, but they had to ask for them. Observations confirmed the presence of a snack cart filled with various items, but it was not actively distributed to residents. Interviews with staff revealed inconsistencies in the distribution of bedtime snacks. A Certified Nurse Aide (CNA) mentioned that snacks were only passed to diabetic residents, while another CNA stated that although a cart of snacks was available, staff did not proactively offer them to all residents. The Director of Nursing and the administrator both acknowledged that CNAs should offer bedtime snacks to all residents, indicating a gap between policy and practice. This deficiency highlights a failure to adhere to the facility's policy of providing adequate nutrition and accommodating residents' needs and preferences regarding snack distribution.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices, particularly in the handling and storage of respiratory care supplies. Observations revealed that nasal cannula oxygen tubing for two residents was not stored in a plastic bag when not in use, as per facility policy. In one instance, the tubing was found on the floor and later used by the resident, indicating contamination. Additionally, the facility did not have specific orders regarding the changing or storage of respiratory equipment for these residents. The facility also failed to ensure proper hand hygiene and the use of personal protective equipment (PPE) during resident care. Staff members were observed not washing hands or changing gloves between dirty and clean tasks, and not wearing gowns when required by enhanced barrier precautions. This was noted during wound care and other high-contact activities for several residents. Furthermore, the facility did not ensure that urinary drainage systems were kept off the floor, as observed with one resident whose catheter tubing was repeatedly found touching the floor. Additionally, the facility did not follow its policy for tuberculosis (TB) screening for new employees. Three employees had their Tuberculin Skin Tests (TST) administered and read after they had already begun resident contact, contrary to the policy that requires testing before the first day of contact. Interviews with staff indicated a lack of clear responsibility for ensuring TB tests were completed as required, contributing to this oversight.
Infection Control Lapse in Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed to prevent urinary tract infections for a resident with a urinary catheter. The resident's urine culture report indicated significant bacterial presence, and an antibiotic was prescribed. However, the resident's care plan did not document the presence of a urinary catheter or include interventions to prevent urinary tract infections. Observations revealed that the resident's urinary catheter drainage bag frequently touched the floor, which is against the facility's policy and infection control practices. Interviews with staff, including a CNA, LPN, and the interim Director of Nursing, confirmed that no part of a urinary drainage system should touch the floor due to contamination risks. Despite this, the resident's catheter drainage bag was observed resting on the floor on multiple occasions, indicating a lapse in adherence to infection control protocols. The facility's policy on urinary catheter care, revised in August 2022, emphasizes keeping catheter tubing and drainage bags off the floor to prevent complications, including infections.
Medication Storage and Expired Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in multiple instances of unlocked and unattended medication and treatment carts. Observations revealed that a treatment cart was left unlocked and unattended near the nurse's station and in the hallway, with no staff in sight. This occurred despite the presence of a resident diagnosed with Alzheimer's disease, who was at risk of wandering into potentially dangerous areas. The Licensed Practical Nurse (LPN) admitted to forgetting to lock the cart while attending to a resident's blood sugar check and insulin administration. Additionally, the facility did not properly manage expired medications. An observation of the medication room found an open bottle of oyster shell calcium that had expired several months prior. The Certified Medication Technician (CMT) explained the process for handling expired medications, which involved placing them in a designated bin for destruction or return to the pharmacy. However, the expired medication was not appropriately managed, indicating a lapse in the facility's medication management procedures. The Director of Nursing confirmed that medication carts should be locked when unattended and that expired medications should be discarded or returned to the pharmacy.
Failure to Notify Physician and Document Urinary Status Leads to Urosepsis
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an indwelling urinary catheter, leading to a severe health deficiency. The resident, who had a history of urinary retention, an enlarged prostate, and urinary tract infections, experienced an episode of urinary retention with tea-colored urine and a foul odor. Despite these abnormal findings, the staff did not notify the physician or document the resident's urinary status, which is a violation of the facility's policies. The resident was later admitted to the hospital with urosepsis, a life-threatening condition. The facility's policies require prompt notification of the physician and detailed documentation of any changes in a resident's condition, especially when there are signs of a urinary tract infection or catheter complications. However, the staff failed to adhere to these protocols. The LPN on duty did not complete the necessary SBAR communication form or notify the physician of the resident's abnormal urinary findings. Additionally, there was a lack of communication and follow-up among the staff regarding the resident's condition, which contributed to the delay in addressing the issue. Interviews with various staff members revealed a breakdown in communication and assessment procedures. Several staff members noticed changes in the resident's condition, such as lethargy, pus around the catheter, and decreased urine output, but these observations were not effectively communicated to the charge nurse or physician. The Director of Nursing and the Administrator acknowledged that the staff should have acted more quickly and communicated the resident's condition to the physician to prevent the progression of the urinary tract infection and subsequent hospitalization.
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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