Twin Pines Adult Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirksville, Missouri.
- Location
- 1900 S Jamison, Kirksville, Missouri 63501
- CMS Provider Number
- 265198
- Inspections on file
- 12
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Twin Pines Adult Care Center during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity and respect during personal care, environmental management, and staff-resident interactions. A resident with dementia, anxiety, chronic pain, and total dependence for mobility and hygiene was roughly repositioned in bed, causing pain when an incontinence brief pinched the groin; the CNA continued care despite the resident yelling in pain and later dismissed the resident’s complaints. The same resident and spouse reported the CNA being rough during a shower transfer and described a DON-level manager publicly ordering a CNA back to work in the dining room in front of residents and families. Another cognitively intact resident with a hearing deficit reported that night staff played music loudly, refused to lower the volume, and said it could not be turned down because other residents liked it. Staff, including a CMT, were also reported squirting each other with water in the dining room; when a resident became upset and asked them to stop, the CMT handed the resident a squirter and encouraged participation, which the resident declined.
The facility failed to ensure meals were served at an appetizing temperature, as required by its policy specifying hot foods on room trays should be at or above 120°F and that complaints be logged and investigated. Multiple residents who required setup assistance, including cognitively intact and moderately impaired individuals eating in both rooms and the dining room, reported that their food, including soup and breakfast eggs, was frequently cold. CNAs and an LPN acknowledged ongoing resident complaints and described a tray delivery process in which plated, covered trays sat in carts while nursing staff completed report and morning care, leading to food reaching residents at room temperature. A test tray showed entrée and vegetable temperatures below the facility’s preferred minimum, while the Dietary Manager and Administrator stated expectations that food temperatures be checked and maintained but were unaware of or not acting on resident complaints.
A cognitively intact resident with dementia and rheumatoid arthritis experienced multiple changes to colchicine and methotrexate orders, including holding, resuming, dose adjustments, and conversion from PRN to scheduled dosing, without documented notification to the resident or listed emergency contacts as required by facility policy. Additionally, the resident was transferred by ambulance to a hospital for abnormal vital signs with no documentation that family was informed. Family members reported they were not notified of these medication changes or the hospital transfer and only learned of the hospitalization through a third party. An LPN acknowledged nurses were supposed to notify families of significant changes and transfers, while the DON stated staff did not view family notification for medication changes as required when the resident was his/her own responsible party unless specifically requested.
The facility failed to implement a proper grievance procedure, lacking a designated grievance official, resident awareness of grievance rights, and documentation of investigations. Interviews revealed that residents were unaware of how to file grievances, and the facility did not maintain a grievance log. The newly hired QA staff member had not received any grievances for investigation, and concerns raised during care conferences were not documented.
The facility failed to label and date opened food items in the kitchen, violating their food storage policy. Observations revealed unlabeled containers of sweet and sour sauce, salad dressing, and strawberry halves in the cooler, as well as open cereal boxes in dry storage. Interviews with dietary staff confirmed the oversight, highlighting a lapse in adherence to food safety protocols.
The facility failed to provide required QAPI training to five staff members, including CNAs, an ES staff member, and a Nursing Supervisor, as revealed by personnel file reviews and confirmed by the DON. This deficiency could impact the staff's ability to address concerns through the QAPI program, potentially affecting the care of 72 residents.
The facility failed to conduct timely background checks for three CNAs before their hire, as required by policy. This oversight allowed the CNAs to work multiple shifts before their background checks were completed, potentially compromising resident safety. Interviews confirmed the checks were not completed prior to employment.
The facility failed to provide written transfer notifications to three residents and their representatives, as well as the Ombudsman, during hospitalizations. Despite the facility's policy requiring timely notification and information about transfers, no written notices were documented in the residents' EMRs. Interviews with the DON and Administrator confirmed the lack of communication and documentation, indicating a systemic issue in handling hospital transfers.
The facility failed to provide written bed hold notices to three residents within 24 hours of their emergency hospital transfers, as required by policy. Despite the facility's policy mandating such notices, none were documented for the residents involved. Interviews with the DON and Administrator confirmed the oversight, highlighting a systemic issue in policy adherence.
The facility failed to transmit MDS assessments for three residents within the required 14-day period, as confirmed by the DON. This lapse in timely submission, which is crucial for compliance and reimbursement, was due to a lack of oversight and adherence to facility policy.
The facility failed to ensure that three CNAs completed the required 12 hours of in-service training per year, as mandated by facility policy. Personnel files for these CNAs showed no evidence of the necessary training, which could negatively impact the care of 72 residents. The deficiency was confirmed by the DON.
The facility failed to ensure that two residents who self-administered medications had the necessary assessments, physician's orders, and care plans. One resident with allergic rhinitis was observed with a nasal spray at her bedside without proper documentation, while another resident with COPD self-administered an inhaler without supervision or a physician's order. The facility's policy requires assessments and care plans for self-administration, which were not completed for these residents.
A facility failed to provide timely follow-up information to a physician about a resident's skin condition, delaying treatment. The resident had memory issues and was dependent on staff, with blood blisters documented but not communicated effectively to the physician. Additionally, another resident, who was severely cognitively impaired, was given crushed Tylenol without a physician's order, causing discomfort. The facility did not assess the need for crushing medications, leading to inadequate care.
A resident was unable to call for help after falling in the bathroom due to the removal of the call light, which was not replaced or repaired in a timely manner. The resident, who was cognitively intact and independent in personal hygiene, reported the incident. Staff interviews confirmed the absence of the call light, and the Maintenance Director was aware but had not provided an alternative communication method.
Failure to Maintain Resident Dignity During Care, Noise, and Staff Interactions
Penalty
Summary
Facility staff failed to treat multiple residents with dignity and respect as required by the facility’s Dignity and Respect policy. One resident with dementia, anxiety disorder, chronic pain, moderate cognitive impairment, and total dependence on staff for mobility, transfers, toileting, and hygiene was observed being transferred from a wheelchair to bed with a mechanical lift and then repositioned roughly. After the transfer, CNAs used a reusable incontinence pad to pull the resident down in bed, causing the incontinence brief to remain in place and pinch the resident’s groin. When the resident yelled out, “Stop, you’re hurting me!”, one CNA told the resident to “hold on” and “you’re fine” and continued care without stopping to relieve the discomfort or acknowledge the pain. The same CNA later stated that the resident “always complained.” The same resident and the resident’s spouse reported additional incidents involving staff behavior that did not maintain dignity. The spouse stated that the CNA involved in the transfer was rough and always in a hurry, and described a prior episode during a transfer to a shower chair where the resident yelled out in pain while the CNA continued positioning, telling the resident to “hold on a minute.” The spouse also reported that the resident became upset and anxious when the Director of QAPI confronted a CNA in the dining room, placing hands on hips and repeatedly telling the CNA to get back to work while the CNA was on a lunch break eating with residents. This interaction occurred in front of residents, family members, and visitors and was described as unprofessional and upsetting to the resident. Another resident, cognitively intact with a documented hearing deficit and a care plan requiring staff to allow adequate time to respond and reduce environmental noise, reported that staff did not treat them with respect at night. The resident stated that night shift staff played music loudly enough to keep them awake and refused to turn it down, telling the resident it could not be lowered because other residents enjoyed it. Additionally, staff, including a CMT, were reported to have squirted each other with water in the dining room on a busy, stressful day. The resident with anxiety became upset and told staff to stop, but a CMT approached, handed the resident a squirter, and encouraged the resident to “shoot someone with it,” which the resident did not want to do and did not participate in. The DON later stated she was unaware of the loud music at night and the water-squirting incidents, but her stated expectation was that staff treat residents with dignity and respect and not be rough or rushed when providing care.
Failure to Maintain Palatable Meal Temperatures for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at an appetizing temperature to multiple residents, contrary to its own policy requiring hot foods on room trays to be at or above 120°F and complaints to be logged and investigated. The facility’s policy also called for periodic temperature checks at the point of service and completion of complaint investigations within 72 hours. A test tray taken after all residents were served showed the fried chicken thigh at 116°F and green beans at 112°F, below the facility’s preferred minimum temperature for palatability. Several residents reported that their food was frequently served cold. One cognitively intact resident who required setup assistance had a care plan directing that trays be served first and microwaved for 30 seconds to one minute before delivery, yet the resident stated the facility had a problem with cold food and that staff sometimes removed the tray cover and left while the resident was in the bathroom, resulting in cold food by the time the resident returned. Another cognitively intact resident who preferred to eat in the room and required tray setup assistance reported that soup ordered several times a week was always cold. A resident with moderate cognitive impairment and requiring setup assistance reported that food was frequently cold and that eggs served that morning were too cold to eat. Another resident with moderate cognitive impairment, who ate in the dining room and required setup assistance, stated that sometimes the food was cold. Staff interviews described operational practices that contributed to food cooling before service. A CNA reported that residents complained about cold food and that this CNA microwaved one resident’s food before delivery due to frequent complaints. CNAs explained that the kitchen now plates and covers food and places trays in a cart for staff to deliver, and if nursing staff are busy, trays sit until someone is available to pass them. One CNA stated that nursing staff clock in, receive report, and complete morning care while breakfast trays are already plated in the cart, and that by the time staff are available to pass trays, the food is at room temperature. An LPN confirmed that residents complained about cold food. The Dietary Manager stated his expectation that temperatures be checked before food leaves the kitchen and again before trays are served, and that food be maintained at or above 120°F by the time residents receive it, but he was not aware of any resident complaints. The Administrator stated his expectation that food reach and be maintained at the required temperature and that any deviation be investigated.
Failure to Notify Resident and Family of Medication Changes and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its own notification of changes policies by not informing a cognitively intact resident and/or the resident’s representatives of multiple medication changes and a hospital transfer. The facility’s policies required that changes in a resident’s condition or treatment be immediately shared with the resident and/or resident representative, that non-immediate changes be communicated on the shift they occurred, and that residents/representatives be educated about risks and benefits to allow informed choice. The resident’s face sheet showed the resident was his/her own responsible party, with two emergency contacts listed, and the admission MDS documented the resident as cognitively intact. Record review showed several physician order changes for colchicine and methotrexate that were not accompanied by documented notification to the resident or emergency contacts. Colchicine 0.6 mg twice daily was ordered on 10/15/25, held on 10/17/25, resumed on 10/20/25, changed to once daily on 10/24/25, and then discontinued on 10/25/25. Nurse notes contained no documentation that the resident or emergency contacts were notified when colchicine was restarted or when the directions changed. Methotrexate 2.5 mg was initially ordered as needed for rheumatoid arthritis flare-ups and later changed on 12/5/25 to a scheduled daily dose, again with no documentation in nurse notes that the resident or emergency contacts were notified of this change. The facility also failed to document notification of the resident’s emergency contacts when the resident was transferred to the hospital for abnormal vital signs on 1/14/26. The transfer form showed the resident was sent to the hospital by ambulance, but nurse notes contained no record of family notification. During interviews, both listed emergency contacts reported they were not informed of the medication changes or the hospital transfer, and one stated the family only learned of the hospital visit when a friend saw the resident entering the emergency department. An LPN stated nurses were supposed to call families for hospital transfers and significant changes, and the DON stated her expectation was that family would be notified when a resident was sent to the emergency department, but also indicated staff did not consider family notification required for medication changes when the resident was his/her own responsible party unless the family had requested it.
Deficiency in Grievance Procedure and Resident Awareness
Penalty
Summary
The facility failed to establish a comprehensive grievance procedure, which included designating a specific individual to lead investigations, informing residents of their right to file grievances, and documenting the results of grievance investigations. This deficiency was identified during interviews, record reviews, and policy reviews, affecting six residents who participated in a group interview. The facility's grievance policy outlined the need for a grievance official to oversee the process, track grievances, and provide written resolutions. However, the facility did not have grievance forms available in the neighborhoods or next to the grievance box, and there was no grievance log or documentation of investigations available for review. During interviews, the facility's administrator admitted to not having a grievance log or documentation of grievance investigations, stating that concerns were handled immediately during resident council meetings. The newly hired QA staff member, responsible for handling grievances, had not received any prior concerns for investigation. Additionally, the MDSC indicated that concerns expressed during care conferences were communicated to the DON or administrator but were not documented on the facility's grievance form. The resident group interview revealed that none of the residents were aware of the grievance process or the newly hired QA staff member, and a review of resident council meeting minutes showed no discussions about grievances or residents' rights to file them.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was properly labeled and dated with an open date, which is a violation of their own food storage policy. During an observation, it was found that several food items in the cooler, including a gallon container of sweet and sour sauce, a gallon container of salad dressing, and a five-pound container of strawberry halves, were opened but not labeled with an open date. Additionally, three boxes of cereal in the dry food storage area were also open and lacked an open date. This oversight in labeling and dating opened food items could potentially lead to the spread of foodborne illnesses among the 72 residents who receive meals from the kitchen. Interviews with the dietary staff revealed a lack of adherence to the facility's food storage procedures. A dietary aide acknowledged that items were supposed to be dated when opened to ensure timely disposal of food that had been stored for too long. The Dietary Manager confirmed that staff should have labeled the food items with an open date and mentioned efforts to ensure compliance with this practice. However, at the time of the survey, the deficiency in labeling and dating opened food items was evident, indicating a lapse in following established food safety protocols.
Lack of QAPI Training for Facility Staff
Penalty
Summary
The facility failed to ensure that five out of five employee files reviewed contained evidence of the required Quality Assurance and Performance Improvement (QAPI) training. This deficiency was identified through a review of personnel files and an interview with the Director of Nursing (DON). The personnel files of three Certified Nursing Assistants (CNAs), one Environmental Services (ES) staff member, and one Nursing Supervisor (NS) were examined. The CNAs had dates of hire ranging from March to August 2023, while the ES staff member and NS had been employed since 1987 and 2002, respectively. None of these files showed evidence of QAPI training. During an interview, the DON confirmed the absence of QAPI training for the facility staff. This lack of training had the potential to negatively impact the staff's ability to bring concerns to the QAPI program, which could, in turn, affect the 72 residents residing at the facility.
Failure to Conduct Timely Background Checks for CNAs
Penalty
Summary
The facility failed to ensure that background checks were conducted prior to hiring three Certified Nursing Assistants (CNAs), which is a violation of their policy aimed at safeguarding residents. The policy mandates that Human Resources (HR) initiate and review background checks before any prospective employee is hired. However, the records show that CNA6 was hired and began working before her background check was initiated and completed, with a delay of over a month. Similarly, CNA7's background check was submitted on her date of hire but was not completed until two weeks later, during which time she worked multiple shifts. CNA1 also started working before her background check was initiated and completed, with a delay of nearly a month. Interviews with the facility's Administrator and Infection Preventionist confirmed that the background checks for these employees were not completed before they started their employment, as required by the facility's policy. This oversight had the potential to result in the hiring of staff with unknown histories of abuse, neglect, exploitation, or theft, thereby compromising the safety and well-being of the residents. The facility's failure to adhere to its own policy on background checks represents a significant deficiency in its hiring practices.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notifications of hospital transfers to three residents and their representatives, as well as to the Ombudsman. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy requires that residents and their representatives receive timely notification, adequate preparation, and information about their transfer, including appeal rights. However, the facility did not adhere to this policy for three residents who were hospitalized. Resident 21 was transferred to the hospital on two occasions due to anxiety, confusion, and intensifying tremors. Despite these transfers, there was no evidence of a written transfer notification in the resident's electronic medical record (EMR). Similarly, Resident 41 was transferred to the emergency room after testing positive for COVID-19 and experiencing full-body tremors, but again, no written notification was found in the EMR. Interviews with the Director of Nursing (DON) and the Administrator confirmed that these residents did not receive the required written notices. Resident 2, who has chronic obstructive pulmonary disease, type II diabetes mellitus, and unspecified dementia, was transferred to the hospital after becoming unresponsive and confused during supper. The EMR lacked documentation of a written transfer notice for this resident as well. Additionally, the Ombudsman reported not receiving a monthly hospitalization list from the facility since January 2024, a fact confirmed by the DON and the Administrator. This lack of communication and documentation indicates a systemic issue in the facility's handling of hospital transfers.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to three residents, identified as R21, R41, and R2, within 24 hours of their emergency transfers to the hospital. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy requires that residents and their representatives receive written information about the state's bed hold duration and payment amount before a transfer. However, the facility did not adhere to this policy for the residents in question. Resident R21 was transferred to the hospital on two occasions due to anxiety, confusion, and intensifying tremors. Despite these transfers, there was no evidence in the electronic medical record (EMR) that a written bed hold notification was provided. Similarly, Resident R41 was transferred to the emergency room after testing positive for COVID-19 and experiencing full body tremors, but no written bed hold notice was documented in the EMR. Interviews with the Director of Nursing (DON) and the Administrator confirmed that these residents did not receive the required notices. Resident R2 was transferred to the hospital after becoming unresponsive and exhibiting unusual behavior during supper. The EMR showed no documentation of a written bed hold notice being provided at the time of transfer. Interviews with the DON and the Administrator further confirmed that the facility did not provide written bed hold notices to residents or their representatives, indicating a systemic issue in adhering to the facility's policy and state requirements.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of Minimum Data Set (MDS) assessments for three residents, which is a requirement for maintaining compliance and ensuring payment for necessary resident care. The facility's policy mandates that comprehensive assessments be transmitted electronically within 14 days of the care plan completion date, and all other MDS assessments within 14 days of the MDS completion date. However, the review of records for three residents revealed multiple instances where MDS assessments were completed but not transmitted within the required timeframe. For example, one resident had several assessments completed and submitted well beyond the 14-day requirement, with delays ranging from several weeks to over a month. The Director of Nursing (DON) confirmed during an interview that the assessments were indeed transmitted late and acknowledged that they should have been submitted within the stipulated 14 days. The DON also admitted to being unaware of the last time the missing assessment report was reviewed, indicating a lapse in oversight and adherence to the facility's policy. This deficiency in timely transmission of MDS assessments could potentially lead to non-payment for necessary resident care, as timely submission is crucial for compliance and reimbursement processes.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to ensure that three out of five Certified Nursing Assistants (CNAs) completed the required minimum of 12 hours of in-service training per year. This deficiency was identified through a review of personnel files and confirmed by the Director of Nursing (DON). The facility's policy mandates that all nursing employees receive at least 12 hours of in-service education annually, covering essential topics such as resident rights, abuse and neglect, infection control, and care for individuals with cognitive impairments or dementia. The personnel files of CNA1, CNA6, and CNA7 showed no evidence of the required in-service training for their respective employment periods. CNA1 and CNA6 were hired in August 2023, and CNA7 was hired in March 2023, yet none had documentation of completing the necessary training hours. The lack of in-service training could negatively impact the care provided to the 72 residents at the facility, as staff may not be adequately prepared to meet their needs.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the necessary assessments, physician's orders, and care plans in place. This deficiency was identified for two residents, R4 and R44, who were observed self-administering medications without the required documentation and assessments. The facility's policy requires an interdisciplinary team to assess a resident's ability to safely self-administer medications, document this in the medical record, and include it in the care plan. However, these steps were not followed for the residents in question. Resident R4, who was admitted with a diagnosis of allergic rhinitis, was observed with a nasal spray on her bedside table, which she self-administered. Although R4 had a physician's order allowing her to keep the nasal spray at her bedside, there was no documented assessment or care plan for self-administration of medication in her electronic medical record. The LPN confirmed the presence of the nasal spray but was unsure if R4 had been assessed or care planned for self-administration. Similarly, Resident R44, diagnosed with COPD, was observed self-administering an inhaler without supervision. The resident's physician orders did not include permission for self-administration, and there was no assessment or care plan documented for this practice. The Nursing Supervisor and DON confirmed the lack of assessment, physician's order, and care plan for R44's self-administration of medications.
Deficiencies in Physician Communication and Medication Administration
Penalty
Summary
The facility failed to provide timely follow-up information to a physician regarding a resident's skin condition, which delayed treatment. Resident 45 was admitted with memory problems and was dependent on staff for daily activities. On multiple occasions, the resident was observed with blood blisters on the right hand, which were documented by nursing staff. However, there was no evidence that the physician received timely updates on the condition, despite the physician's request for information following the resident's return from a hospital stay. The physician confirmed that she had not received the necessary updates to determine the next course of action. Additionally, the facility failed to assess the need to crush medications for another resident, Resident 5, who was severely cognitively impaired. The resident expressed discomfort with crushed Tylenol being administered in applesauce, as it would get under her dentures. Despite this, there was no physician's order to crush the medication, and staff continued to administer it in this manner. The Certified Medication Technician was unaware of any consideration for alternative administration routes, and the Director of Nursing acknowledged the absence of an order to crush medications. These deficiencies highlight the facility's failure to ensure timely and effective treatment for residents, as well as the lack of proper assessment and documentation regarding medication administration. The lack of communication and documentation regarding Resident 45's skin condition and the inappropriate medication administration for Resident 5 increased the risk of inadequate care.
Deficiency in Resident Call System
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathroom of one of the residents, identified as R4. This deficiency was observed during a survey where it was noted that the call light was removed from R4's bathroom to replace the one in her bedroom. As a result, R4 was unable to call for help after falling in the bathroom over the weekend. The resident, who was cognitively intact with a BIMS score of 14 out of 15 and independent in personal hygiene, reported the incident and stated that her family had already discussed the issue with the facility. Further observations on subsequent days confirmed the absence of a call light in R4's bathroom. Interviews with staff, including an LPN and the Maintenance Director, corroborated the missing call light. The Maintenance Director acknowledged awareness of the issue but was unable to repair it and had contacted an outside company for assistance. However, no alternative communication method was provided to R4 in the interim, leaving her without a means to call for assistance while using the restroom.
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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