Valley View Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Moberly, Missouri.
- Location
- 1600 East Rollins St, Moberly, Missouri 65270
- CMS Provider Number
- 265536
- Inspections on file
- 30
- Latest survey
- February 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Valley View Health & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure residents were treated with dignity and respect, as evidenced by the behavior of a CMT who was reported to be rude, rough, and condescending during care. Residents expressed feelings of anger and worthlessness, and staff corroborated these complaints. Despite previous write-ups and expectations for respectful treatment, the facility did not adequately address the ongoing issues with the CMT's behavior.
The facility failed to provide adequate assistance with ADLs for two residents, resulting in poor personal hygiene and grooming. One resident, with impaired mobility and cognitive issues, was found with long, dirty fingernails and soiled clothing, while another resident with Parkinson's disease had similar nail issues. Staff interviews revealed frequent refusals of care by the residents, and a lack of documented attempts to provide necessary hygiene care.
A resident in a LTC facility repeatedly obtained and used smoking materials inside the facility, despite being educated on the smoking policy. The resident was observed smoking in his room while wearing oxygen, posing a safety hazard. The facility failed to update the resident's care plan or smoking assessment in a timely manner, and did not implement new interventions for increased supervision, contributing to the ongoing issue.
A resident with a history of transverse myelitis, diabetes, and peripheral vascular disease experienced worsening pressure ulcers due to inadequate documentation and monitoring by the facility. The care plan was not updated to reflect the presence of pressure ulcers, and the facility failed to communicate changes to the resident's physician or NP. The decision to not use a low-air loss mattress, as recommended, was made without consulting the physician, contributing to the deficiency.
The facility failed to use proper transfer techniques for residents requiring assistance, leading to accidents and injuries. A resident sustained a fracture due to a fall during a transfer without a gait belt or proper footwear. Another resident, with a history of stroke, was transferred without a gait belt, feeling unsteady and fearful of falling. A third resident, with severe cognitive impairment, was also transferred without a gait belt, contrary to facility policy.
The facility failed to maintain safe and sanitary food handling practices, with staff observed not following proper hand hygiene, gloving, and hair restraint protocols. Food storage was inadequate, with items not properly sealed, labeled, or dated. Clean dishes were improperly stored, and surface sanitation was insufficient, leading to potential cross-contamination.
A long-term care facility failed to adhere to infection prevention protocols, with staff neglecting proper hand hygiene and Enhanced Barrier Precautions (EBP) during resident care. Observations revealed improper handling of soiled items, inadequate use of personal protective equipment, and incorrect storage of medical devices, increasing infection risks.
The facility failed to provide necessary oral hygiene care for two residents who required assistance. One resident, with multiple mental health diagnoses, did not receive regular teeth brushing or denture cleaning, leading to feelings of neglect. Another resident, with functional quadriplegia, had significant dental issues and reported a lack of staff assistance with oral care. Interviews with facility leadership revealed an expectation for oral care assistance that was not being met.
The facility failed to ensure the Medical Director or a designee attended the QAPI meetings quarterly, as required by their QAPI Plan. The QAA committee, responsible for addressing quality deficiencies, lacked the Medical Director's participation in meetings held in July, August, and September 2024. The Administrator confirmed the absence and noted that the Medical Director was not reminded monthly, nor was a designee sent.
Two residents in a long-term care facility were neglected in their ADL care. One resident, with a history of stroke, was left in bed with a swollen arm, unable to reach the call light or drinks, and was found with dried feces on the skin. Another resident, admitted with morbid obesity, experienced prolonged incontinence due to slow staff response, with soiled linens left unchanged for over seven hours. Staff interviews revealed a failure to adhere to care policies, resulting in these deficiencies.
A resident with an indwelling urinary catheter and a history of UTIs did not receive proper catheter care, leading to a deficiency. Observations showed feces around the catheter insertion site and improper cleaning by staff, despite facility policies requiring clean techniques to prevent infections. Interviews revealed staff did not follow care plans, contributing to the resident's risk of infection.
A facility failed to ensure proper hand hygiene and glove use by staff during care for a resident with a history of stroke and other conditions. Staff were observed using feces-soiled gloves to touch various items and apply skin barrier cream without washing hands or changing gloves, contrary to the facility's infection control policy. Interviews confirmed the staff's failure to follow proper procedures, leading to a deficiency in infection prevention and control.
A CMT at the facility removed and ingested hydrocodone-acetaminophen pills from the narcotic medication cards of three residents. The discrepancies were discovered during a random spot check by the consulting pharmacist, who confronted the CMT. The CMT admitted to consuming the medications and was subsequently terminated. The local police department was notified, and a complete count of all narcotics revealed no further discrepancies.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as evidenced by the behavior of Certified Medication Technician (CMT) F. Resident #10 reported that CMT F was rude and rough during care, which hurt the resident's feelings and made them feel angry. The resident expressed fear of retaliation if they reported CMT F's behavior. Resident #9 also experienced rough and forceful care from CMT F, who dismissed the resident's complaints with inappropriate language, making the resident feel worthless. Resident #13 described CMT F as condescending and authoritative, which provoked feelings of anger. The facility's policies on Resident Rights and Conduct and Behavior, which emphasize treating residents with kindness, respect, and dignity, were not adhered to by CMT F. Interviews with other staff members, including a Certified Nurse Assistant (CNA) and the Director of Nursing (DON), corroborated the residents' complaints. The CNA reported that many residents found CMT F's tone harsh and upsetting, and that complaints had been made to charge nurses without any action being taken. The DON acknowledged receiving complaints about CMT F's lack of a gentle approach. The Administrator confirmed that CMT F had been previously written up for not providing good customer service and reiterated the expectation that all residents should be treated with dignity and respect. Despite these expectations, the facility's failure to address the ongoing complaints about CMT F's behavior resulted in a deficiency in maintaining the residents' rights to a dignified existence and respectful treatment.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #1, who had an ADL self-care performance deficit related to impaired mobility and cognitive impairment, was observed with long, uneven fingernails and brown debris under them. The resident's room and clothing were also soiled with fecal matter, and there was a strong odor of urine and feces. Despite being cognitively intact according to the Minimum Data Set (MDS), the resident often refused showers and nail care, and staff did not document any attempts to provide nail care during showers. Resident #7, who had a self-care deficit related to Parkinson's disease and moderate cognitive impairment, was also found with long, uneven nails and brown debris under them. The resident required substantial assistance with bathing and personal hygiene but often refused care, allowing only certain staff to trim their nails. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were unaware of the resident's nail condition, indicating a lack of consistent care and monitoring. Interviews with staff revealed that both residents frequently refused showers and nail care, and staff felt limited in their ability to provide care due to these refusals. The facility's policy required staff to attempt different approaches if a resident resisted care, but there was no documentation of such attempts. The Administrator acknowledged the issue, noting that Resident #1's odor was a common complaint among other residents and that showers should be provided at least twice a week or per resident preference.
Inadequate Supervision of Resident Smoking in Facility
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident who repeatedly obtained and used smoking materials within the facility, despite being educated on the smoking policy. The resident, who was cognitively intact and had no visual or dexterity deficits, was observed smoking in his room while wearing oxygen, which posed a significant safety hazard. Despite multiple incidents of the resident being found with cigarettes and lighters, the facility did not update the resident's care plan or smoking assessment in a timely manner to reflect these occurrences or implement new interventions for increased supervision. The resident's care plan initially included education on smoking risks and the requirement to smoke only in designated areas without oxygen. However, the resident was found smoking in various locations within the facility, including his room and the dining room, and admitted to propping doors open to smoke unsupervised. Staff repeatedly educated the resident on the smoking policy, but there was no documentation of any other interventions being put in place until much later. The facility's smoking policy required assessments and individualized approaches for residents who smoke, but these were not consistently updated or enforced. Interviews with staff revealed that the resident had a history of being homeless and possibly picking up cigarette butts, which may have contributed to the difficulty in managing his smoking behavior. Despite the implementation of a new smoking policy requiring supervision, the resident continued to smoke inside the facility, and staff did not conduct room searches or provide increased supervision as needed. The facility's failure to adequately supervise the resident and update his care plan and smoking assessment contributed to the ongoing safety hazard.
Failure to Document and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to adequately document and monitor the pressure ulcers of a resident, leading to a worsening of the condition. The resident, who had a history of transverse myelitis, diabetes mellitus, and peripheral vascular disease, was readmitted to the facility with pressure ulcers on the buttocks. The facility's staff did not update the care plan to reflect the presence of these pressure ulcers, nor did they document any goals or interventions to address them. Despite the resident's condition worsening, there was no evidence that the staff communicated these changes to the resident's physician or primary care nurse practitioner (NP). The facility's wound care nurse, who was not wound care certified, was responsible for the resident's wound care. The nurse documented the condition of the pressure ulcers in weekly assessments but failed to notify the primary care NP of the changes in the resident's condition. The resident's care plan was not updated to include the use of a low-air loss mattress, as recommended in the hospital discharge orders, because the interdisciplinary team decided to focus on the resident's goal of returning home and working on slide board transfers. This decision was made without consulting the resident's physician or primary care NP. The primary care NP did not evaluate the pressure ulcers during visits and relied on the wound care nurse for updates. The NP assumed that other specialists were managing the resident's pressure ulcers, but there was no documentation to support this. The facility's Director of Nursing and Administrator were unaware of the worsening condition of the pressure ulcers until the resident was discharged to the hospital, where the ulcers were assessed as stage IV. The facility's failure to follow its wound care policy and communicate effectively with the primary care team contributed to the deficiency.
Failure to Use Proper Transfer Techniques
Penalty
Summary
The facility failed to ensure safe transfer techniques for residents requiring assistance, leading to accidents and injuries. Resident #133, who had intact cognition and required partial to moderate assistance with transfers, was not provided with proper footwear or a gait belt during a transfer to a bedside commode. This resulted in the resident slipping on a wet floor and sustaining a displaced fracture of the tibia/fibula. The CNA involved did not use a gait belt, as the resident had previously indicated they could transfer independently, and did not notice the wet floor prior to the transfer. Resident #30, who had a history of stroke and required assistance due to weakness, was also not provided with a gait belt during transfers. The resident expressed feeling unsteady and fearful of falling when assisted by CNA C, who lifted the resident under the arm instead of using a gait belt. The care plan indicated the need for a mechanical lift, but this was not followed, and the resident was barefoot during the transfer. Resident #21, with severe cognitive impairment and hemiplegia following a stroke, was assisted by CNA C without the use of a gait belt, despite the resident's care plan indicating the need for maximum assistance with transfers. The resident was able to stand briefly, but the lack of a gait belt was contrary to facility policy and staff training. Interviews with staff and administration confirmed the expectation that gait belts should be used for all standby transfers, but this was not consistently practiced.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner, as evidenced by multiple observations of improper hand hygiene, gloving techniques, and hair restraint usage by the dietary staff. The Dietary Manager and other staff members were observed handling food and kitchen equipment without changing gloves or washing hands between tasks, leading to potential cross-contamination. Additionally, staff were seen touching food contact surfaces with bare hands and using soiled gloves to handle ready-to-eat food items. Further observations revealed that hair restraints were not properly used, with staff members having exposed hair while preparing food. This lack of adherence to hygiene protocols was compounded by inadequate surface sanitation practices. Cleaning cloths were not properly sanitized or stored in sanitizing solutions, and spills were wiped with dry cloths that were not subsequently sanitized, increasing the risk of contamination. The facility also failed to adhere to proper food storage protocols. Opened food items were not securely sealed, labeled, or dated, and some items were stored contrary to manufacturer's instructions. Additionally, clean dishes were not stored inverted or covered, and some were found with visible debris or damage. These deficiencies in food handling and storage practices highlight significant lapses in maintaining a sanitary environment for food preparation and service.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, affecting several residents. Staff did not perform appropriate hand hygiene during personal care for two residents, and failed to utilize Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube. Additionally, a resident's urinary catheter drainage bag was improperly stored on the floor, and another resident's wound vac was also placed on the floor, increasing the risk of infection. These actions were observed during routine care and were not in compliance with the facility's policies. In one instance, a Certified Nurse Assistant (CNA) was observed cleaning a resident's perineal area, then handling soiled items and touching clean surfaces without washing hands or using hand sanitizer. The CNA admitted to not following proper hand hygiene protocols. Another CNA failed to wear a gown while providing care to a resident on EBP, despite signage indicating the requirement. The CNA also did not change gloves between dirty and clean tasks, and did not wash hands after removing gloves. Furthermore, a Certified Medication Technician (CMT) was observed administering medications without performing hand hygiene before and after the process. The CMT handled medications with bare hands and did not sanitize hands between residents. Interviews with staff, including the Infection Preventionist and Director of Nursing, confirmed that these practices were not in line with expected standards, highlighting a systemic issue in adherence to infection control protocols.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate oral hygiene care for two residents, Resident #41 and Resident #48, who required assistance with oral care. Resident #41, diagnosed with schizophrenia, depression, bipolar disorder, and PTSD, had a care plan indicating a need for extensive assistance with personal/oral hygiene. However, observations revealed that the resident's teeth were not brushed regularly, and the resident's upper dentures were not cleaned. Interviews with the resident and a CNA indicated a lack of awareness and action regarding the resident's oral care needs, with the resident expressing feelings of neglect and uncleanliness. Resident #48, with functional quadriplegia and poor dentition, was also dependent on staff for oral hygiene. Observations showed significant dental issues, including cavities and black stubs for teeth, with a white film and black spots on the lower teeth. The resident reported that staff did not assist with brushing teeth, leading to discomfort and a feeling of an unclean mouth. The care plan and Kardex did not specifically address the resident's oral hygiene needs, contributing to the oversight. Interviews with the Director of Nursing and the Administrator revealed an expectation for staff to assist with oral care every morning and after meals, which was not being met. The facility's policy on mouth care lacked specific instructions on the frequency of oral care, contributing to the deficiency in providing necessary oral hygiene assistance to the residents.
Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or a designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis, as required. The facility's QAPI Plan, dated March 2020, outlined that the Quality Assessment and Assurance (QAA) committee was responsible for addressing quality deficiencies, analyzing problems, establishing corrective actions, and reporting findings. The QAA committee was supposed to include the Administrator, all department heads, the Medical Director, and a Pharmacist. However, a review of the QAA meeting attendance logs for July, August, and September 2024 showed no documentation of attendance by the Medical Director or a designee. During an interview, the Administrator confirmed that the Medical Director did not attend any of the QAA meetings and had not been reminded monthly about the meetings, nor had a designee been sent in their place.
Neglect in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents who were dependent on staff for Activities of Daily Living (ADLs). Resident #2, who had a history of stroke and was receiving hospice care, was observed in a state of neglect. The resident was left in bed with a swollen, shiny, and taut right arm dangling off the side, unable to reach the call light or drinking cups. The resident's personal hygiene was neglected, as evidenced by matted hair, soiled gown, and dried feces on the skin. Staff failed to reposition the resident, provide range of motion exercises, or offer fluids, despite the resident's inability to perform these tasks independently. Resident #7, who was admitted with morbid obesity and lymphedema, experienced a similar lack of care. The resident reported that staff were slow to respond to call lights, resulting in prolonged periods of incontinence. The resident's bed linens were not changed for over seven hours, and staff covered the soiled bed with a towel instead of providing proper incontinence care. Observations confirmed the presence of a large urine stain and a strong odor, indicating neglect in maintaining the resident's hygiene and comfort. Interviews with staff, including the Director of Nursing and the Administrator, revealed a failure to adhere to the facility's policies and care plans. Staff admitted to being busy and not checking on residents as frequently as required. The facility's policy mandated that residents should be checked at least every two hours, kept clean and dry, and have access to fluids and call lights. However, these standards were not met, leading to the deficiencies observed in the care of Residents #2 and #7.
Failure to Provide Proper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate urinary incontinence and catheter care for a resident with an indwelling urinary catheter and a history of urinary tract infections (UTIs). The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, was observed with brown-colored urine in the catheter tubing and feces around the catheter insertion site. The facility's policy required staff to maintain clean technique and cleanse the catheter and surrounding area to prevent infections, but this was not followed. During an observation, a CNA and a Nurse Assistant were seen removing the resident's gown and noting soft, loose feces between the resident's legs, perineal skin folds, and around the catheter insertion site. Dried feces were also noted between the resident's upper thighs. The CNA wiped the resident's thighs and perineal skin folds with wet wipes but did not clean around the catheter insertion site or tubing. The resident's buttocks, hips, and perineal skin folds were soiled with feces, and the CNA repeatedly wiped these areas with wet wipes, causing the resident to yell out in pain. The staff did not cleanse the urinary catheter insertion site, leaving feces near it. Interviews with the CNA and the Director of Nursing revealed that the CNA had not checked on the resident since earlier in the morning and admitted to not providing proper perineal care or cleansing the catheter tubing and insertion site. The Director of Nursing stated that staff should follow care plans and provide necessary care to keep residents clean and prevent infections. The resident had a history of UTIs and was treated with antibiotics, highlighting the importance of proper catheter care to prevent further infections.
Inadequate Hand Hygiene and Glove Use During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use by nursing staff during personal care for a resident, leading to a deficiency in infection prevention and control. The facility's policy on hand hygiene, dated August 2019, emphasized the importance of handwashing as the primary means to prevent the spread of infections. It required staff to wash hands with soap and water when visibly soiled and to use alcohol-based hand rubs before and after direct contact with residents, among other situations. The policy also stated that gloves should be changed when soiled and that hand hygiene should be performed after removing gloves. During an observation, a Certified Nurse Assistant (CNA) and a Nurse Assistant (NA) were seen applying gloves without washing their hands and proceeding to provide care to a resident with soiled gloves. The resident, who had a history of stroke with paralysis, aphasia, and other conditions, was dependent on staff for personal care. The CNA used the same feces-soiled gloves to touch various items in the resident's room, including the bed controller and linens, and applied skin barrier cream to the resident's skin without changing gloves or washing hands. This was contrary to the facility's hand hygiene policy and posed a risk of infection. Interviews with the CNA and the Director of Nursing (DON) confirmed that the staff did not follow proper hand hygiene and glove-changing procedures. The CNA admitted to not washing hands or changing gloves correctly and acknowledged the importance of handwashing in preventing infections. The DON reiterated that staff should follow care plans and hand hygiene policies to keep residents clean and prevent the spread of infections. The facility's failure to adhere to its own infection control policies resulted in a deficiency noted by surveyors.
Misappropriation of Narcotic Pain Medication by CMT
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medication for three residents. Certified Medication Technician (CMT) A removed and ingested hydrocodone-acetaminophen pills from the narcotic medication cards of three residents while on duty. This was discovered during a random spot check by the consulting pharmacist, who found discrepancies in the narcotic counts and confronted CMT A, who admitted to consuming the medications. Resident #1 had moderately impaired cognition and took scheduled pain medication for chronic conditions, including chronic kidney disease and chronic venous hypertension. The narcotic count sheet showed a discrepancy of one pill missing, which CMT A admitted to ingesting. Resident #2, with severely impaired cognition and frequent pain, had a discrepancy of two pills missing from their narcotic count sheet, which CMT A also admitted to ingesting. Resident #3, with severely impaired cognition and multiple chronic conditions, had a discrepancy of one pill missing, which CMT A admitted to ingesting as well. The pharmacist and the Director of Nursing (DON) were informed of the discrepancies, and CMT A admitted to taking the medications. The DON immediately took CMT A to the administrator's office, where CMT A was terminated for misappropriation of resident narcotic medications. The local police department was notified, and a complete count of all narcotics was conducted, revealing no further discrepancies.
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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