St James Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint James, Missouri.
- Location
- 415 Sidney Street,, Saint James, Missouri 65559
- CMS Provider Number
- 265225
- Inspections on file
- 23
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at St James Living Center during CMS and state inspections, most recent first.
Staff did not notify a resident's physician after the resident was found lethargic and unresponsive, received Narcan for a suspected overdose, and was transferred to the hospital. Despite facility policy requiring physician notification and documentation, the physician was not informed, and there was no record of contact or response.
Facility staff did not initiate an investigation after a resident overdosed on Benzodiazepines and Opiates, received Narcan, and was transferred to the hospital. Despite policy requiring immediate and thorough investigation of such incidents, neither the Administrator nor the DON were fully informed or took action to investigate, resulting in no documentation or analysis of the event.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A Certified Medication Technician misappropriated Lorazepam by signing out and documenting administration to two residents without proper authorization, including after a physician had discontinued the medication for one resident. The CMT falsified records and removed medications that were not present at the time of administration, as discovered through a narcotics count and staff report.
The facility failed to maintain a safe and clean environment, with observations of unclean and poorly maintained areas, including cracked toilet seats, chipped paint, and damaged floors. Residents reported dissatisfaction with unfinished maintenance work and the presence of flies in their rooms. The maintenance director acknowledged a backlog of repairs, but no work orders were submitted for many issues. Additionally, windows in resident rooms were sealed shut, preventing them from being opened.
The facility staff failed to update comprehensive care plans for several residents, leading to deficiencies in care. A resident's care plan did not address oxygen use, despite a physician's order for continuous therapy. Another resident's plan lacked information on a new depression diagnosis and antidepressant use. Other residents had incomplete care plans regarding behaviors, wandering risks, weight loss, and ADL needs. The MDS Coordinator admitted to overlooking these updates, and the DON confirmed the omissions.
Facility staff failed to ensure safe hydraulic lift transfers for two residents by not keeping the lift's base open for stability, as required by policy. Observations showed residents swaying dangerously during transfers, and interviews revealed staff were not properly trained on the lift's operation.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, as required. The Payroll Based Journal report showed multiple days with no RN hours in early 2024. Interviews revealed staffing challenges, with the DON often being the only RN available and working doubles on weekends. The facility did not use agency staff and struggled to hire RNs, despite efforts like job fairs and sign-on bonuses.
Facility staff failed to follow infection control procedures, including Enhanced Barrier Precautions, during resident care. A resident with an indwelling catheter did not receive care with the required gown and gloves. Additionally, two residents did not receive proper hand hygiene and glove changes during perineal care. The facility also failed to comply with its TB control policy, allowing several employees to start work before completing the required PPD test.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives before hospital transfers. This issue was identified for four residents through interviews and record reviews, which showed a lack of documentation in their medical records. Staff interviews revealed confusion and lack of responsibility regarding the bed hold notification process, with the DON noting previous staff unawareness of the requirement.
Facility staff did not complete Significant Change in Status Assessments (SCSA) for three residents who experienced notable changes in their conditions, including increased assistance needs, cognitive decline, weight loss, and new diagnoses. The MDS Coordinator and DON were unaware of the requirements for conducting these assessments, leading to the oversight.
Facility staff failed to accurately document the MDS for three residents, leading to deficiencies. A resident's significant weight loss was not recorded, another was incorrectly coded for restraint use, and a third was inaccurately documented as receiving hypnotic and anticoagulant medications. The MDS Coordinator admitted to errors and a lack of full training.
The facility failed to post and retain required daily nurse staffing information, including staff numbers and hours worked, for both licensed and unlicensed staff. Observations showed missing or outdated postings, and interviews revealed a lack of awareness from the DON and administrator about these requirements.
Facility staff failed to ensure oncoming and off-going staff members verified and reconciled the narcotic count as accurate at each shift change. A review of the Narcotic Inventory Sheet for October 2023 showed multiple instances where staff did not document or record a signature to signify the count had been completed. Interviews with the Assistant DON, an LPN, and the Administrator confirmed that staff are expected to count narcotics with two nurses every shift and sign the narcotic count sheet.
Facility staff failed to prevent the misappropriation of a resident's narcotic medications when a CNA took the medication without authorization. The incident involved a cognitively intact resident with a diagnosis of pain in the right hip and hypertrophic osteoarthropathy, who was receiving scheduled and as-needed pain medication, including oxycodone 10 mg tablets. The CNA accessed the medication cart, administered the medication without proper authorization, and subsequently fled the facility. The CNA was terminated following an investigation.
Failure to Notify Physician After Resident Overdose and Narcan Administration
Penalty
Summary
Facility staff failed to notify a resident's physician after the resident experienced a significant change in condition, specifically lethargy, pinpoint pupils, and unresponsiveness, which led staff to suspect an overdose and administer Narcan. The resident, who had a history of seizures and was assessed as alert and cognitively intact on the baseline care plan, was subsequently transferred to a local hospital for evaluation. Documentation showed that staff are required to report changes in condition to the DON and physician, and to document any physician contact and response. Despite these requirements, there was no documentation that the physician was notified of the incident. Interviews with the administrator, DON, and the physician confirmed that the physician was not informed, and the physician stated that he was unaware of the overdose and had not adjusted the resident's medications as a result. The charge nurse reported faxing a nonemergent line but did not call the physician, and there was no confirmation that the fax was received. The facility's policy and care plan expectations for physician notification were not followed in this case.
Failure to Investigate Resident Overdose Incident
Penalty
Summary
Facility staff failed to conduct an investigation after a resident experienced an overdose involving Benzodiazepines and Opiates, resulting in the administration of Narcan and subsequent transfer to a hospital. The facility's investigation policy requires prompt and thorough investigation of such incidents, including interviews, assessments, and root cause analysis. However, review of the resident's medical record revealed no documentation of an investigation following the event. The resident, who was alert, cognitively intact, and on chronic opiate therapy for cancer-related pain, was found lethargic, with pinpoint pupils and unresponsive, prompting staff to administer Narcan and call emergency services. Interviews with facility leadership revealed that the Administrator was only partially informed about the incident and did not initiate an investigation due to lack of full details. The DON was not aware of the incident at all and stated that an investigation should have been started to rule out medication errors, the need for medication adjustments, or possible abuse. The absence of an investigation following the overdose event was contrary to the facility's own policy and expectations.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Misappropriation of Resident Medications by CMT
Penalty
Summary
Facility staff failed to prevent the misappropriation of medications for two residents. A Certified Medication Technician (CMT) was found to have signed out and documented the administration of Lorazepam to both residents without proper authorization or, in some cases, after the medication had been discontinued by the physician. For one resident, the CMT continued to sign out and document administration of Lorazepam even after the physician had discontinued the order, and for the other resident, the CMT signed out and documented doses that were not present in the medication cup at the time of administration. These actions were discovered following a report from a Certified Nurse Aide (CNA) who had evidence of the CMT stealing medications, prompting an immediate narcotics count by the Director of Nursing (DON). The review of medication administration records, controlled drug receipt forms, and physician orders revealed discrepancies between the medications signed out and those actually administered or present. The CMT had pre-popped medications and falsified records to indicate administration that did not occur, resulting in the wrongful use and misappropriation of resident medications without consent. Both residents involved had documented needs for or histories of antianxiety medication, with one assessed as moderately cognitively impaired and the other as cognitively intact.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous observations of unclean and poorly maintained areas. Observations included dried stains on walls, cracked and stained toilet seats, dirty bathroom walls, chipped paint, and damaged floors held together with duct tape. Residents expressed dissatisfaction with the unfinished maintenance work, such as incomplete painting and exposed drywall debris. The maintenance director acknowledged a backlog of repairs due to a previous lack of a maintenance director, but no work orders had been submitted for many of the observed issues. Additionally, the facility failed to provide an environment free of pests, as multiple residents were observed with flies in their rooms and on their food. Residents reported the presence of flies to staff, but no effective action was taken to address the issue. The maintenance director and administrator were aware of the flies but had not received reports from staff or taken steps to resolve the problem. The pest control company was contacted but reportedly stated there was nothing they could do. The facility also had issues with sealed windows in resident rooms, which prevented residents from opening them. The maintenance director was aware of the sealed windows, which were closed during the pandemic, but the administrator was not informed of this issue. The lack of a written policy for maintenance and the absence of a system for reporting environmental concerns contributed to the facility's failure to address these deficiencies effectively.
Deficiencies in Comprehensive Care Plan Updates
Penalty
Summary
The facility staff failed to ensure comprehensive care plans were updated for several residents, leading to deficiencies in care. For instance, Resident #2's care plan did not address their oxygen use, despite a physician's order for continuous oxygen therapy. The MDS Coordinator admitted to overlooking this aspect, and the Director of Nursing (DON) confirmed that oxygen use should be included in the care plan. Similarly, Resident #8's care plan lacked information on their new diagnosis of depression and the use of antidepressant medication. The care plan did not include symptoms for staff to monitor or non-pharmacological interventions, nor did it list potential side effects of the medication. The MDS Coordinator acknowledged the oversight, and the DON stated that these elements should have been included in the care plan. Other residents, such as Resident #34, #36, #41, and #45, also had incomplete care plans. Resident #34's care plan did not address their aggressive behaviors, while Resident #36's plan failed to include their wandering and elopement risks. Resident #41's care plan omitted significant weight loss and oxygen use, and Resident #45's plan did not address their ADL needs. In each case, the MDS Coordinator admitted to forgetting to update the care plans, and the DON confirmed that these elements should have been included.
Unsafe Hydraulic Lift Transfers Due to Improper Use
Penalty
Summary
Facility staff failed to provide safe hydraulic lift transfers for two residents, resulting in a deficiency. The facility's policy and the hydraulic lift user manual both require the lift's base to be opened to the maximum width and locked for stability during transfers. However, observations revealed that staff did not adhere to these guidelines. In one instance, two CNAs transferred a resident without keeping the lift's base open, causing the resident to sway dangerously in the sling. The CNAs were unaware of the requirement to keep the lift's legs open for stability, as they had not been trained properly. In another instance, the same CNAs repeated the unsafe practice with a different resident, again closing the lift's legs during the transfer. Interviews with the CNAs revealed a misunderstanding of the lift's operation, with one CNA incorrectly believing that closing the legs was necessary to prevent tripping hazards. The MDS coordinator and the DON confirmed that the lift's legs should remain open during transfers to ensure stability and prevent tipping.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's policies did not include a policy for RN coverage, and the Payroll Based Journal (PBJ) report for Fiscal Year 2024, Quarter 2, showed multiple days with no RN hours. Specific dates in January, February, and March 2024 were identified where the facility did not have an RN present for the required hours. The facility census at the time was 48. Interviews with the Director of Nursing (DON) and the administrator revealed that the facility struggled with RN staffing. The DON, who started in February, was often the only RN available and had to work doubles on weekends. The facility did not use agency nursing staff but relied on corporate RNs to assist when needed. The administrator, who started in May, was unaware of the missing coverage for the quarter and acknowledged the difficulty in hiring RNs, with efforts such as job fairs and sign-on bonuses being implemented to address the issue.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility staff failed to adhere to appropriate infection control procedures, specifically Enhanced Barrier Precautions (EBP), during the care of residents. One resident with an indwelling urinary catheter did not receive care with the required gown and gloves, as observed when a Certified Nursing Aide (CNA) provided catheter care without wearing a gown. The CNA was unaware of the EBP requirements, indicating a lack of training or understanding of the infection control measures necessary for residents with indwelling devices. Additionally, staff failed to perform proper hand hygiene and glove changes during perineal care for two residents. Observations showed that CNAs did not change gloves or perform hand hygiene between dirty and clean tasks, increasing the risk of cross-contamination and infection. Interviews with the CNAs revealed an acknowledgment of the need for hand hygiene but highlighted the absence of hand sanitizer in resident rooms, which contributed to the oversight. The facility also did not comply with its Tuberculosis (TB) control policy, as several employees began working before completing the required first step of the purified protein derivative (PPD) test. The Director of Nursing (DON) and the administrator confirmed that the TB tests were not read before the employees' start dates, which is against the facility's policy. This lapse in protocol was attributed to a change in responsibility for TB screenings after the Assistant Director of Nursing (ADON) left the facility.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives prior to hospital transfers for four out of 23 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the medical records of these residents lacked documentation of such notifications. The facility's policy on the discharge and transfer of residents mandates that staff explain and provide a copy of the bed hold form to the resident or their representative, which was not adhered to in these cases. Interviews with various staff members, including the Business Office Manager, Director of Nursing, Activities Director, and the Administrator, highlighted a lack of clarity and responsibility regarding the bed hold notification process. The Director of Nursing, who assumed the position in late February, noted that prior staff were unaware of the bed hold requirements. The Administrator mentioned that the nursing staff had not been providing the necessary bed hold forms to residents upon transfer, indicating a systemic issue in the facility's adherence to its own policies.
Failure to Complete Significant Change Assessments for Residents
Penalty
Summary
Facility staff failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for three residents, despite significant changes in their conditions. Resident #2 experienced a decline in functional abilities, including increased assistance needs for daily activities, a fall with injury, and the development of an open lesion on the foot. Resident #8 showed both declines and improvements, such as severe cognitive impairment, increased rejection of care, significant weight loss, and new pressure injuries, along with a new diagnosis of depression and the initiation of antidepressant medication. Resident #41 exhibited changes in behavior, increased assistance needs, significant weight loss, and experienced falls, yet no SCSA was completed for these changes. The MDS Coordinator, responsible for completing significant change assessments, admitted to not being aware of the requirements outlined in the Resident Assessment Instrument (RAI) Manual. The coordinator also mentioned working as a charge nurse at times, which may have contributed to the oversight. The Director of Nursing (DON) also expressed a lack of knowledge regarding the criteria for triggering a significant change MDS. This lack of awareness and understanding among key staff members led to the failure to conduct necessary assessments for residents experiencing significant changes in their health status.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility staff failed to document a complete and accurate Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment process. For one resident, a significant weight loss from 254 pounds to 228 pounds was not documented as significant on the MDS, despite acknowledgment from the MDS Coordinator and the Director of Nursing (DON) that it should have been. Another resident was incorrectly coded as using limb restraints, although observations and staff interviews confirmed that restraints were never used. The MDS Coordinator admitted to coding restraints due to bed rail use, which was an error, and noted a lack of full training in the position. Additionally, a third resident was inaccurately coded as receiving hypnotic and anticoagulant medications. The MDS Coordinator mistakenly identified amitriptyline as a hypnotic and aspirin as an anticoagulant, indicating a misunderstanding of medication classifications. The MDS Coordinator acknowledged responsibility for ensuring accurate MDS coding but was unaware of the errors. These inaccuracies highlight a failure in the facility's assessment and documentation processes, as outlined in their policy to adhere to CMS guidelines.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care. The facility also did not retain these records for the required eighteen months. Specific dates were identified where the nurse staffing forms were either not completed or not available, indicating a pattern of non-compliance. Observations on multiple days showed that the daily nurse staff postings were either outdated or missing required information such as shift details and Certified Nurse Aide (CNA) hours. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the requirements for nurse staffing postings. The DON, who took over the responsibility after the Assistant Director of Nursing (ADON) left, admitted to being unaware of the inaccuracies and the failure to save the postings. The administrator, new to the position, was also unaware of the deficiencies in the daily nurse staff postings and was in the process of addressing various operational issues within the facility.
Failure to Verify and Reconcile Narcotic Count at Shift Changes
Penalty
Summary
Facility staff failed to ensure oncoming and off-going staff members verified and reconciled the narcotic count as accurate at each shift change. The facility's Narcotic Count Policy requires that one RN, LPN, or CMT going off duty and one RN, LPN, or CMT coming on duty must count and justify the accuracy of narcotics supply for each individual resident at the change of each shift. However, a review of the Narcotic Inventory Sheet for October 2023 showed multiple instances where staff did not document or record a signature to signify the count had been completed. Specific dates where the count was not documented include all shifts on 10/1/23, 10/7/23, 10/8/23, 10/15/23, 10/28/23, and 10/29/23, among others. This indicates a consistent failure to follow the facility's policy on narcotic counts across multiple shifts and days throughout the month of October 2023. During interviews, the Assistant DON, an LPN, and the Administrator confirmed that staff are expected to count narcotics with two nurses every shift and sign the narcotic count sheet. The DON acknowledged that nurses have developed a bad habit of completing the count but failing to sign the book. The Administrator and DON both expressed the need for in-services with the licensed staff to ensure the counts are completed and signed as required by the facility's policy.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's narcotic medications when a CNA took the medication without authorization. The facility's Abuse Prohibition Policy defines misappropriation as the wrongful use of a resident's belongings or money without consent. The incident involved a cognitively intact resident with a diagnosis of pain in the right hip and hypertrophic osteoarthropathy, who was receiving scheduled and as-needed pain medication, including oxycodone 10 mg tablets. The resident's medication card of 30 oxycodone pills was found missing, and none of the pills had been signed out as given. The incident was reported by an LPN who noticed the missing medication and confronted the CNA, who claimed to have administered the medication to the resident. The CNA could not produce the medication card and subsequently fled the facility. The ADON and Administrator were notified, and an investigation was initiated. The police, the resident's primary care physician, the appropriate state agency, and the resident's responsible party were informed of the misappropriation. The CNA was terminated for the misappropriation of the resident's narcotic medication. Interviews with various staff members revealed that the CNA had accessed the medication cart and administered the medication without proper authorization. The CNA was reported to have acted suspiciously, moving between bathrooms and eventually fleeing the facility. The staff also noted that the nurses had previously left the keys to the medication cart in a drawer at the nurse's station, which allowed the CNA to access the cart. The facility's investigation confirmed the misappropriation, and the CNA was terminated as a result.
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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