Truman Lake Manor Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowry City, Missouri.
- Location
- 600 East 7th St, Lowry City, Missouri 64763
- CMS Provider Number
- 265431
- Inspections on file
- 17
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Truman Lake Manor Inc during CMS and state inspections, most recent first.
The facility failed to timely report suspected abuse, neglect, or theft and did not ensure that the results of its investigations were reported to the proper authorities. This uncorrected citation is linked to a complaint investigation and references prior survey events that also identified problems with timely reporting and communication of investigation outcomes.
A deficiency was cited for the facility’s ongoing failure to respond appropriately to all alleged violations. The citation remains uncorrected and is associated with prior survey events and a complaint investigation, indicating repeated noncompliance with requirements to address reported concerns, though no specific resident details are provided.
The facility failed to follow its abuse reporting policy when a resident with paranoid schizophrenia and moderate cognitive impairment alleged that another resident was sexually assaulting them, using explicit verbal statements and gestures. An LPN documented the allegation and concluded it was impossible based on the other resident’s apparent condition and the belief it was a hallucination, did not notify administration, and did not report the allegation to the state. DHSS records confirmed no report was made. Staff interviews revealed inconsistent understanding of required time frames and processes for reporting abuse allegations, while leadership stated that such allegations should be reported to administration immediately and to the state within two hours.
A resident with schizophrenia, moderate cognitive impairment, delusions, and verbal behavioral symptoms made a specific verbal allegation of sexual abuse by another resident, including describing the act with a hand gesture. An LPN documented the allegation and told the resident the act was impossible and that racial slurs were not tolerated, but did not perform or document a resident assessment, did not initiate or document any protective measures, and only relayed the information in shift report. The medical record contained no further assessment, notifications, or follow-up related to the allegation, and facility leadership later stated they were unaware of the report and that no required abuse investigation with interviews and chart review had been completed or submitted.
The facility failed to ensure that the newly appointed Medical Director, Physician A, was actively involved in implementing care policies and coordinating medical care. Despite agreeing to the role, Physician A had not signed a formal contract and had not participated in QAPI meetings, as confirmed by the Director of Nursing and the Administrator. This lack of involvement contravened the facility's policies, which require the Medical Director to oversee physician services and participate in quality improvement efforts.
A resident in a memory care unit had an unsecured bottle of Brukinsa, a cancer medication, in their room, contrary to facility policy requiring secure storage. The resident, who was cognitively intact and chose the unit for a private room, had no dementia diagnosis. Staff acknowledged the medication should not have been left unsecured, posing a risk to other wandering residents.
The facility failed to store and prepare food according to professional standards, leading to potential contamination. Observations revealed improperly sealed, labeled, and dated food items, use of dented cans, inadequate hand hygiene, improper dishwashing, and an unclean ice machine. Staff interviews confirmed these practices were not consistently followed.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Multiple staff members, including CNAs and the Administrator, did not wear appropriate PPE while assisting or conversing with residents on the designated COVID hall. COVID-positive staff were observed not wearing PPE, contrary to the facility's policy and CDC guidelines.
The facility failed to notify a resident's physician of significant changes in the resident's condition following the death of the resident's spouse and the discontinuation of an anti-anxiety medication. The resident exhibited increased emotional distress and behavioral changes, but staff did not document or report these changes to the physician as required by facility policies.
The facility failed to ensure a clean and homelike environment for two residents whose rooms had cracked and missing floor tiles. One resident, who uses an electric wheelchair, reported the issue had persisted for over two years, while another resident with COPD and OCD had a bathroom floor in disrepair. Maintenance was aware but had not yet completed the necessary repairs.
A facility failed to document an order change and perform dressing changes as ordered for a resident with a G/J-tube, resulting in routinely saturated dressings and potential risk of infection. The DON admitted to forgetting to enter the new order into the electronic medical record, leading to the deficiency.
The facility failed to follow care plans for transferring a resident and did not implement planned fall interventions for another resident. One resident, who required a mechanical lift, was manually transferred without a gait belt, and another resident, assessed as a fall risk, did not have a fall mat in place while in bed, leading to unsafe conditions.
A resident with bipolar disease, vascular dementia, and reduced mobility experienced a 10-day delay in receiving antibiotic treatment for a UTI due to the facility's failure to follow up with the physician after abnormal urinalysis results. Staff acknowledged difficulties in reaching the physician and admitted that they should have continued to call daily until a response was received.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by administering Lasix outside of ordered parameters and not providing the required potassium supplement. Despite specific blood pressure thresholds and the need for potassium on days Lasix was given, staff repeatedly administered Lasix when the resident's blood pressure was too low and failed to administer potassium.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse, neglect, or theft and to report the results of the related investigation to the proper authorities. The citation remains uncorrected and is associated with a complaint investigation identified as #2787573. The report references prior, related examples of the same or similar deficient practice documented under event IDs 1DFDCA-H1 and 1DFDCA-H2, with specified exit dates, indicating that surveyors previously identified issues with timely reporting and communication of investigation outcomes to appropriate agencies. No additional clinical or resident-specific details are provided in this report excerpt.
Ongoing Failure to Respond Appropriately to Alleged Violations
Penalty
Summary
A deficiency was cited related to the facility’s failure to respond appropriately to all alleged violations. The citation remains uncorrected and is linked to prior survey findings identified under event ID 1DFDCA-H1 and event ID 1DFDCA-H2, as well as a specific complaint investigation (Complaint #2787573). The report indicates that surveyors previously identified similar issues during earlier events, and the current citation reflects ongoing noncompliance with requirements to address and respond to alleged violations, but it does not provide additional clinical or resident-specific details.
Failure to Report Resident’s Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of possible abuse was immediately reported to management and within two hours to the State Survey Agency, as required by its Abuse Investigation and Reporting policy. The policy, revised July 2017, required that all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be promptly reported to local, state, and federal agencies and that abuse or serious bodily injury be reported no later than two hours after the allegation. Despite this, the allegation made by one resident was not reported to the Department of Health and Senior Services (DHSS), and there was no documentation that facility administration was notified. The resident involved had been admitted with diagnoses including paranoid schizophrenia and had a quarterly MDS indicating moderate cognitive impairment, delusions, and verbal behavioral symptoms directed at others. On the night in question, an LPN documented that the resident returned from the emergency room and was yelling and screaming, stating that the "N word" next door was putting his penis in the resident’s buttocks. The LPN further documented that the resident used a hand gesture to describe the alleged sexual act. The LPN noted that the other resident was asleep and believed at the time that this resident was unable to get out of bed unassisted, and explained to the resident that the allegation was impossible and that racial slurs were not tolerated. The progress note did not include any notifications to administration or external authorities regarding this allegation of possible abuse. In a subsequent interview, the LPN stated that he/she did not think the allegation should be reported because of the resident’s diagnosis of paranoid schizophrenia and believed it was a hallucination, and therefore did not notify the Administrator. Other staff interviews showed inconsistent understanding of reporting requirements: some CNAs and nurses stated that abuse allegations should be reported to the charge nurse, DON, Administrator, and to the state within two hours, while one CNA believed the state should be notified within 24 hours, and one LPN was unsure whether the allegation should be reported to the state. The ADON and Administrator both stated that abuse allegations should be taken seriously, reported to administration immediately, and reported to the state within two hours, and acknowledged that this resident’s allegation should have been treated as possible abuse and reported and investigated, which did not occur.
Failure to Investigate and Protect Resident After Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate and document an allegation of abuse and to document steps taken to protect a resident following that allegation. Facility policy on Abuse Investigation and Reporting required that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown origin be promptly reported and thoroughly investigated, with the Administrator assigning an investigator and the investigation including review of documentation, medical records, and interviews with the reporter, resident, witnesses, staff, and others. The policy also required private interviews and written, signed, and dated witness statements. Despite these requirements, when a resident with paranoid schizophrenia, moderate cognitive impairment, delusions, and verbal behavioral symptoms alleged that another resident was putting his penis in the resident’s buttocks, the responsible LPN only documented the allegation and a brief interaction with the resident, without initiating or documenting any investigative steps or protective measures. The resident’s progress note described the resident yelling and making a specific sexual abuse allegation, including a hand gesture indicating penetration, and the LPN’s response that the alleged perpetrator was asleep and that the act was impossible, along with a statement that racial slurs and name calling were not tolerated. There was no documentation of a physical assessment, notifications, or further follow-up related to the sexual abuse allegation in the electronic medical record. The LPN later stated that no assessment was completed, that the allegation was reported only in shift report, and that the resident would have been moved and monitored if the LPN had believed the allegation was credible. The Administrator and ADON reported that they were unaware of the allegation, that an assessment and investigation with staff and resident interviews and chart review should have occurred, and that investigations should be completed within five days, but no investigation report had been submitted to the state agency as of the surveyor’s review date.
Lack of Active Medical Director Involvement
Penalty
Summary
The facility failed to employ a medical director who was actively involved in the implementation of care policies and coordination of medical care. Physician A, who agreed to be the Medical Director on July 1, 2024, had not signed a formal contract and was not aware of his responsibilities. The facility did not ensure that Physician A participated in completing or updating the facility assessment or attended the Quality Assessment and Assurance (QAA) Committee meetings. Interviews with the Director of Nursing and the Administrator confirmed that Physician A had not attended any QAPI committee meetings since assuming the role. The facility's policy outlined that the Medical Director should oversee physician services, review practitioner credentials, and participate in quality improvement efforts, among other responsibilities. However, the lack of a formal contract and the absence of participation in QAPI meetings indicated a failure to adhere to these policies. The facility census was 70, but the report does not provide specific details about the impact on individual residents or their medical conditions.
Unsecured Medication Poses Risk in Memory Care Unit
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident on the memory care unit had an unsecured and unattended bottle of medication in their room. The medication, Brukinsa, is a prescription drug used to treat chronic lymphocytic leukemia and has serious potential side effects, including fatal hemorrhage and infections. The facility's policy requires medications to be stored securely and only accessible to authorized personnel, but this was not adhered to in this instance. The resident involved was admitted after back surgery and chose to stay in the secured care unit for a private room, despite not having a diagnosis of dementia. The resident was cognitively intact but required staff supervision for various activities. The resident's room was cluttered, and the medication was left unsecured on the sink counter, posing a risk to other residents who frequently wandered into rooms. Staff, including an LPN and the Director of Nursing, acknowledged the medication should not have been left in the room and recognized the potential risk to other residents. The facility's policies on medication storage and administration were not followed, leading to this deficiency. The unsecured medication was accessible to wandering residents, creating a potential hazard in the secured care unit.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards, leading to potential contamination. Observations revealed that food items in the refrigerator and freezer were not sealed, labeled, or dated. This included various items such as french toast sticks, sausage patties, ground meat, sliced American cheese, and a turkey breast. Staff interviews confirmed that food should be dated and sealed, and any undated items should be discarded. However, these practices were not consistently followed, as evidenced by repeated observations over several days showing the same issues with food storage. Additionally, the facility did not properly handle dented cans, which were found on shelves alongside other food items. Dented cans of cream of mushroom soup, apple fruit filling, tapioca pudding, black beans, and whole potatoes were observed. Despite the facility's policy to set aside and discard dented cans, these were used in meal preparation, posing a risk of contamination. Staff interviews indicated awareness of the policy, but the Dietary Manager admitted to using a dented can of tapioca pudding due to insufficient supply. The facility also failed to adhere to proper hand hygiene and dishwashing protocols. Observations showed that staff did not wash hands or change gloves between different food preparation tasks, and did not properly clean and sanitize equipment between uses. For instance, a cook was observed using the same gloves to handle various food items and equipment without washing hands or changing gloves. The blender used for pureeing food was only rinsed with hot water between uses, without proper washing or sanitizing. Furthermore, the ice machine was found to have white substances and black spots, indicating inadequate cleaning. Staff interviews revealed inconsistencies in cleaning responsibilities and documentation, with maintenance staff admitting to not documenting the cleaning of the ice machine.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Multiple staff members, including CNAs and the Administrator, did not wear appropriate PPE while assisting or conversing with residents on the designated COVID hall. Observations and interviews revealed that staff who tested positive for COVID-19 were not wearing PPE, contrary to the facility's policy and CDC guidelines. The facility's policy required the use of N95 masks, gowns, gloves, and eye protection for staff working on the COVID unit, but this was not adhered to by COVID-positive staff. The Administrator and several CNAs were observed not wearing PPE while serving meals and interacting with residents on the COVID unit. The Administrator, who had tested positive for COVID-19, stated that staff working on the COVID hall did not have to wear PPE if they were positive for COVID-19. This practice was confirmed by multiple staff members, including CNAs and LPNs, who believed that COVID-positive staff did not need to wear PPE while working on the COVID unit. The Director of Nursing/Infection Preventionist confirmed that the facility had multiple residents test positive for COVID-19 and created a COVID unit instead of isolating each resident to their room. The facility policy required staff to wear N95 masks throughout the facility and additional PPE when working on the COVID unit. However, the Director of Nursing/Infection Preventionist stated that COVID-positive staff did not have to wear PPE if they worked on the COVID unit, which was a deviation from the facility's policy and CDC guidelines.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's physician of significant changes in the resident's condition following the death of the resident's spouse and the discontinuation of an anti-anxiety medication. The resident, who had severe cognitive impairment and a history of Alzheimer's disease, type two diabetes, and depression, experienced increased emotional distress and behavioral changes after the medication was stopped. Despite these changes, staff did not document or report the resident's condition to the physician as required by the facility's policies on medication tapering and changes in a resident's condition. The resident's progress notes indicated multiple instances where the resident exhibited tearfulness, paranoia, and refusal to eat, yet there was no documentation of physician notification. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed that not all staff were aware of the medication change or the resident's recent behavioral changes. The staff acknowledged that the physician should have been notified of these changes, but this did not occur. The Director of Nursing and the Social Service Director both confirmed that significant life events and changes in behavior should be documented and reported to the physician. The facility's failure to follow these protocols resulted in a deficiency, as the resident's physician was not informed of the resident's spouse's death or the subsequent behavioral changes, which could have impacted the resident's care and treatment plan.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment for residents, specifically in the cases of two residents whose rooms had cracked and missing floor tiles. Resident #1, who has paraplegia and uses an electric wheelchair, reported that the tiles in their room had been broken and missing for over two years. The resident expressed concerns about the inability to properly clean the floor. Housekeeping staff confirmed the issue had been reported to maintenance several months ago, but the tiles had not been replaced due to the unavailability of matching tiles from the 1980s. The Maintenance Supervisor acknowledged the need to relocate the resident to repair the floor but had not yet done so. The Administrator confirmed that the resident would need to be moved to another room for the repairs to be completed. Resident #7, who has COPD and obsessive-compulsive disorder, also had cracked and missing floor tiles in their bathroom. The resident stated that the bathroom floor had been in disrepair for a while and expressed a desire for it to be fixed. The Maintenance Supervisor was unaware of the issue until it was brought to his attention during the survey. Staff interviews revealed that broken tiles were commonly reported to maintenance, but repairs were slow due to the age of the building and the need to complete repairs in stages. The Director of Nursing and the Administrator acknowledged the ongoing issues with broken and missing tiles in resident rooms. The Administrator mentioned that some tiles had been replaced and that he had consulted with a company about using an epoxy pour for bathroom floors instead of re-tiling. Despite these acknowledgments, the facility had not yet addressed the specific deficiencies in the rooms of Resident #1 and Resident #7, leading to an environment that was not clean or homelike for these residents.
Failure to Document and Perform Dressing Changes
Penalty
Summary
The facility failed to provide care in accordance with standards of practice when staff did not document an order change and complete dressing changes as ordered for one resident. Resident #59, who had diagnoses including chronic pancreatitis, chronic kidney disease, COPD, and hypertension, required daily dressing changes for a G/J-tube. Despite a new order to change the dressing twice per day due to increased drainage and signs of infection, this order was not documented in the resident's medical record, leading to the resident having routinely saturated dressings. Observations over several days showed the resident's G/J-tube dressing to be saturated, and interviews with the resident and staff confirmed that the dressing was not being changed as frequently as needed. The resident expressed discomfort and concern about potential infection due to the wet dressings. Staff interviews revealed that while some were aware of the saturated dressings, the new order for twice-daily changes was not communicated or documented properly. The Director of Nursing admitted to forgetting to enter the new order into the electronic medical record, which resulted in the failure to perform the necessary dressing changes. The Administrator also confirmed that staff are expected to follow physician orders and document them immediately in the electronic medical record. This lapse in documentation and care led to the resident experiencing discomfort and potential risk of infection due to the saturated dressings.
Failure to Follow Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to maintain an environment free of safety hazards by not following the care plan for transferring a resident and not implementing planned fall interventions for another resident. Resident #52, who was care planned to need a mechanical lift for transfers, was manually transferred by two CNAs without using a gait belt. The resident, diagnosed with dementia and psychotic disorder, was observed being transferred from a wheelchair to a bed with the CNAs placing their hands under the resident's arms, which is against the facility's policy. Interviews with the CNAs and other staff revealed inconsistencies in understanding and following the care plan, with some staff believing the resident could bear weight despite the care plan indicating the need for a mechanical lift due to the resident's stiffness and inability to bear weight safely. The Director of Nursing and the Administrator confirmed that the resident should have been transferred using a mechanical lift as per the care plan for both the resident's and staff's safety. The facility also failed to implement planned fall interventions for Resident #46, who was assessed as a fall risk. The resident, diagnosed with conversion disorder with seizures, muscle weakness, lack of coordination, and reduced mobility, had a physician's order for fall mats to be in place while in bed. However, observations showed that the fall mat was not in place on multiple occasions, and the resident was found on the floor next to the bed without the fall mat in place. Interviews with CNAs, LPNs, and the DON confirmed that the fall mat should have been used whenever the resident was in bed, as indicated in the care plan. The Administrator also stated that staff should follow the fall interventions put in place for residents at risk of falling. These deficiencies highlight the facility's failure to adhere to care plans and safety protocols, resulting in unsafe conditions for the residents. The lack of proper transfer techniques and failure to implement fall prevention measures directly contradict the facility's policies and the residents' care plans, putting the residents at risk of injury.
Delay in Treatment for UTI Due to Lack of Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with a positive urine culture received timely follow-up care, resulting in a delay in treatment for a urinary tract infection (UTI). Resident #32, who had diagnoses including bipolar disease, vascular dementia, and reduced mobility, was found to have abnormal urinalysis results on 02/06/24. Despite the results indicating a significant infection, the staff only faxed the results to the physician and did not receive a response or new orders until 02/16/24, leading to a 10-day delay in starting the antibiotic treatment. The resident's medical record showed no documentation of follow-up actions taken by the staff to obtain a timely response from the physician during this period. Interviews with the facility's staff, including LPNs, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the physician preferred to receive results via fax and was difficult to reach at times. The staff acknowledged that they should have continued to call the physician daily until a response was received. The DON and the Administrator both expressed that they expected the antibiotic order to be obtained much sooner and that the nurses should have communicated more effectively to ensure timely treatment. The delay in obtaining the antibiotic order was attributed to a lapse in follow-up and communication among the nursing staff and the physician.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs, specifically in the case of one resident who was administered Lasix outside of the ordered parameters and was not given the required potassium supplement. The resident, who had a history of cardiac issues including the presence of a cardiac pacemaker, atrial fibrillation, and hypertension, was prescribed Lasix with specific blood pressure parameters and a potassium supplement to be administered on the same days as the Lasix. However, staff repeatedly administered Lasix even when the resident's blood pressure readings were outside the prescribed parameters and failed to administer the potassium supplement on those days. The resident's Medication Administration Record (MAR) for February and March 2024 showed multiple instances where the resident's blood pressure was below the required threshold, yet Lasix was still administered. Additionally, the potassium supplement was not given on any of these occasions. Interviews with various staff members, including a Certified Medication Technician (CMT), a Registered Nurse (RN), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the resident's physician, confirmed that the staff did not follow the physician's orders regarding the administration of Lasix and potassium. The staff acknowledged that they should have held the Lasix when the resident's blood pressure was below the specified parameters and should have administered the potassium supplement on the days Lasix was given. The Director of Nursing and the resident's physician both emphasized the importance of adhering to the physician's orders to prevent potential complications related to the resident's heart condition and electrolyte balance. The facility's failure to follow these orders resulted in a deficiency in the resident's care regimen.
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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