Webco Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshfield, Missouri.
- Location
- 1687 West Washington, Marshfield, Missouri 65706
- CMS Provider Number
- 265520
- Inspections on file
- 23
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Webco Manor during CMS and state inspections, most recent first.
A resident with cardiac and pulmonary conditions, initially defaulted to full code status, later completed a physician-signed DNR order that was placed in an admission folder but not communicated to nursing or entered into the EMR. The Admissions Director did not forward the DNR paperwork to the SSD or DON, and the SSD created the resident’s profile as full code, leaving the hard chart, EMR, and door sticker system all reflecting full code. When the resident was found unresponsive, staff and EMS initiated and continued CPR based on the incorrect full code information, and only afterward did the SSD discover the signed DNR form in the admission packet.
A resident with multiple sclerosis and minimal cognitive impairment reported to a CNA that a CNA staff member was rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall above the resident’s head after being told to stop, causing the resident to feel fearful and request that the CNA not return. The CNA immediately informed an RN, wrote a statement, and attempted to contact the DON and Administrator by phone and text, but neither responded during the night. The RN reassigned the resident’s care and told the accused CNA not to re-enter the room but did not interview the resident and did not treat the report as an abuse allegation, so it was not escalated to leadership until later that morning, during which time the accused CNA continued working independently with other residents.
A resident with MS and minimal cognitive impairment reported that a CNA was rough during incontinence care, turned on a bright light while the resident was sleeping, and punched the wall above the resident’s head, causing the resident to feel fearful and request that the CNA not return. A CNA promptly informed the RN, documented the incident, and attempted to contact the DON and Administrator by phone and text, but the RN did not escalate the report, believing rough care was not abuse, and leadership did not respond during the night. The allegation was not documented in the resident’s progress notes, and the Administrator did not submit the required report to the State until more than seven hours after staff first became aware of the allegation, exceeding the facility’s two-hour reporting requirement for abuse allegations.
A resident with severe cognitive impairment was subjected to alleged abuse by a CNA, who placed a hand over the resident's mouth and used inappropriate language. The incident was witnessed by another CNA, who did not report it immediately but waited until the next day to inform another staff member, resulting in a delayed report to the DON, Administrator, and state agency. This delay exceeded the required two-hour reporting timeframe for abuse allegations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with neurogenic bladder continued to have an indwelling urinary catheter in place and performed their own catheter care, but there was no current physician order specifying the catheter's use, size, or change frequency, despite staff awareness of this omission.
The facility failed to notify the families of two residents after a significant change in condition and an allegation of abuse. A resident with dementia was involved in inappropriate touching, but their family was not informed. The facility's investigation revealed a lack of communication and documentation, and staff interviews confirmed that families should have been notified.
A facility failed to report allegations of sexual abuse involving inappropriate touching between residents to management and DHSS within the required timeframe. Despite staff awareness of the reporting protocol, incidents were not documented or reported promptly, leading to a deficiency in the facility's abuse prevention and reporting procedures.
A facility failed to investigate an alleged abuse incident when a resident was seen touching another resident inappropriately. Despite facility policies requiring immediate investigation and reporting, no documentation or investigation was conducted. Staff, including the DON and Administrator, were unaware of the incident, highlighting a deficiency in handling the situation.
A resident with dementia and psychotic disturbances exhibited inappropriate touching behavior towards other residents, but the facility failed to update the care plan to reflect these incidents. Despite staff awareness and documentation of the behavior, the MDS Coordinator did not amend the care plan, indicating a deficiency in the care planning process.
A resident with chronic pain syndrome and arthritis experienced inadequate pain management due to the facility's failure to document pain levels, follow up on medication effectiveness, and communicate with the physician about increased pain and unavailable medications. The resident's condition worsened, leading to a hospital transfer where a patella fracture was diagnosed.
A resident with rheumatoid arthritis experienced a decline in mobility and increased knee pain, which was not promptly communicated to the provider. Despite staff observations of the resident's swollen, red, and warm knee, and the resident's requests for medical attention, there was a delay in notifying the physician. The resident was eventually transferred to the hospital, where a patellar fracture was diagnosed.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to inadequate supervision and failure to implement necessary interventions. Despite triggering alarms and exhibiting exit-seeking behavior, the resident was not placed on 15-minute checks or given increased supervision. The resident was later found in a nearby cornfield after a search involving law enforcement.
Failure to Communicate and Update Resident DNR Status Resulting in CPR Contrary to Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status preference was clearly and accurately reflected in the medical record and available to staff, resulting in CPR being initiated contrary to the resident’s documented wishes. The resident was admitted with diagnoses including atrial fibrillation, cardiac disease, stroke, and lung disease, and was initially listed as a full code in the facility’s electronic medical record and on the face sheet. The facility’s practice was to default all new admissions to full code status until staff could confirm the resident’s preferences. The resident had normal cognition on the admission MDS and later completed an Outside Hospital Do-Not-Resuscitate (OHDNR) order, which was signed and dated by both the resident and the physician. The sequence of events leading to the deficiency began when the Admissions Director completed the admission paperwork with the resident, including code status and DNR documentation, and then placed all forms in a folder on their desk before leaving for the weekend. The Admissions Director did not notify nursing staff that the resident’s code status had changed from full code to DNR, did not make copies for the nursing charts, and did not provide the DNR paperwork to the Social Services Director (SSD) or the Director of Nursing (DON). As a result, the SSD created the resident’s electronic profile as a full code and did not receive or review the signed DNR form until after the resident’s death. The DON reported not receiving any DNR paperwork prior to the resident’s cardiopulmonary arrest, and the resident’s orders were not updated in the hard chart, EMR, or on the red/green door sticker system used to indicate code status. When the resident was later found unresponsive, staff followed the information available to them, which indicated the resident was a full code. Staff immediately called the nurse, initiated CPR, and called 911. EMS arrived and continued CPR for over an hour. During this time, the DON was called to the facility and contacted the family while the code was in progress. The resident’s progress notes documented the discovery of the resident unresponsive, the initiation of CPR, EMS involvement, and subsequent notifications to the family and physician. Only after these events did the SSD, while scanning the admission packet into the EMR, discover the signed DNR order that had not been communicated or entered into the resident’s record, confirming that staff had provided CPR despite the resident’s documented DNR preference.
Failure to Immediately Investigate and Protect Resident After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately and thoroughly investigate an allegation of staff-to-resident abuse and to ensure resident protection during the investigation. The facility’s Abuse and Neglect Policy requires the Administrator, DON, or designee to begin an internal investigation immediately and report to DHSS when an allegation arises. A resident with multiple sclerosis and minimal cognitive impairment, admitted in early February, reported to a CNA that a CNA staff member had been rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall three times above the resident’s head after being told to stop. The resident stated fear of this CNA and requested that the CNA not return to the room. CNA A documented the allegation in a written statement and immediately reported it to RN C during the night shift. CNA A then attempted to contact the DON and the Administrator by phone and text, sending a picture of the written statement to both, but received no response at that time because both leaders were asleep and did not hear their phones. RN C reassigned the resident’s care to CNA A and instructed CNA B not to return to the resident’s room, but did not enter the resident’s room or interview the resident about the allegation. RN C stated that being rough with cares was not considered an allegation of abuse and therefore did not report the incident to the DON or Administrator during the night. The Administrator and DON later acknowledged that rough care and punching a wall constituted abuse and that an investigation should have been started immediately. Other nursing staff interviewed indicated that any report of rough care where a resident does not feel safe should be treated as an abuse allegation, with immediate steps to ensure safety and report to leadership. Despite this, there was a delay from the time of the initial report during the night until the Administrator became aware and began an investigation later that morning, during which time the staff member implicated in the allegation continued to work independently with residents.
Failure to Timely Report Allegation of Rough Care and Threatening Behavior
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two hours after staff became aware of the allegation. The facility’s abuse policy required that any suspicion or knowledge of abuse, neglect, or misappropriation be reported immediately to the Administrator and charge nurse, and that the Administrator, DON, or designee begin an internal investigation immediately and report to DHSS within two hours if the allegation involved serious injury, or within 24 hours if it did not. A resident with multiple sclerosis and minimal cognitive impairment, admitted on 02/02/24, reported that a CNA had been rough during incontinence care and had punched the wall above the resident’s head, causing the resident to feel fearful and not want that CNA to return. In the early morning hours, between approximately 2:00 A.M. and 2:25 A.M., a CNA entered the resident’s room to provide care and was informed by the resident that another CNA had turned on a bright light while the resident was sleeping, was rough while attempting to change the resident, and, after being told to stop, punched the wall three times above the resident’s head before leaving. The CNA immediately reported the incident to the charge RN, wrote a statement, and attempted to notify the DON and Administrator by phone and text, including sending photos of the written statement. The charge RN acknowledged being informed between 2:00 A.M. and 3:00 A.M. that the resident complained of rough care and that the CNA had punched a wall, reassigned staff so the alleged CNA would not return to the room, but did not report the allegation to the DON or Administrator, believing that “rough with cares” was not an allegation of abuse. Despite the CNA’s attempts to contact leadership during the night, the DON and Administrator did not respond at that time, later stating they had been sleeping and did not hear their phones. The Administrator did not confirm the incident with staff until later that morning and did not submit the online report to DHSS until 9:58 A.M., more than seven hours after staff first became aware of the allegation. Facility records showed no progress note documentation of the allegation in the resident’s chart. Interviews with other nursing and CNA staff indicated they understood that rough care and a resident not feeling safe should be treated as an abuse allegation and reported immediately, and both the DON and Administrator acknowledged that rough care and punching a wall constituted abuse that should be reported to the State within two hours. The delay in reporting and lack of timely notification to DHSS constituted the deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to facility management and within two hours to the State Survey Agency, as required by both facility policy and regulation. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and Alzheimer's disease, who required total assistance with activities of daily living. On the evening of the incident, a Certified Nurse Aide (CNA) was observed by another CNA placing a hand over the resident's mouth and telling the resident to "shut the fuck up" while the resident was crying. The witnessing CNA did not report the incident immediately but instead informed another CNA the following day, who then reported it to the Director of Nursing (DON) and the Administrator. Documentation and interviews confirmed that the facility did not report the allegation to the Department of Health and Senior Services (DHSS) until the day after the incident, exceeding the required two-hour reporting window for abuse allegations. Staff interviews revealed that employees were aware of the policy to report abuse immediately and to notify the state within two hours, but the initial witness failed to follow this protocol. There was no documentation of immediate reporting to DHSS in the resident's records, and the delay in reporting constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Lack of Current Physician Order for Indwelling Catheter
Penalty
Summary
A resident with a diagnosis of neurogenic bladder had an indwelling urinary catheter in place. The physician initially ordered the discontinuation of the Foley catheter, but the resident refused, stating that the physician had not discussed the change and requested to speak with the physician first. The physician later agreed to allow the resident to keep the catheter and instructed that it be changed monthly. However, a review of the resident's medical record revealed there was no current physician's order for the catheter, including details such as catheter size or the frequency of changes, despite the resident continuing to have the catheter in place and performing their own catheter care. Observations confirmed the presence of the indwelling catheter and drainage bag, and staff interviews indicated awareness of the lack of a current physician's order for the catheter or its care. The absence of an updated physician's order for the ongoing use and maintenance of the urinary catheter constituted a deficiency in providing appropriate catheter care and ensuring proper documentation as required for residents with indwelling catheters.
Failure to Notify Families of Significant Changes and Allegations of Abuse
Penalty
Summary
The facility failed to notify the families or representatives of two residents following a significant change in condition and an allegation of abuse. Resident #1, who has a diagnosis of dementia and other mental health conditions, was involved in an incident where inappropriate touching of another resident occurred. The incident was documented by RN G, but there was no record of the resident's family or representative being informed about this change in condition or the abuse allegation. The facility's investigation revealed that the incident was discussed during a manager's meeting, but neither the interim administrator nor the Director of Nursing (DON) were initially informed. Additionally, the investigation showed that the families of both Resident #1 and Resident #2 were not notified of the incident. Resident #2, who has a durable power of attorney invoked, was also involved in the incident, but their representative was not informed of the potential abuse. Interviews with various staff members, including LPNs, the Social Services Director, and the interim administrator, confirmed that the families should have been notified of the incident. However, there was a lack of communication and documentation regarding the notification process. The facility did not have a policy in place for notifying resident representatives, which contributed to the oversight in communication.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of possible sexual abuse involving three residents to management and the state licensing agency, DHSS, within the required timeframe. The incidents involved inappropriate touching by one resident towards two other residents. The first incident occurred when a resident was observed putting their hands in the crotch of another resident, but the staff did not notify facility administration or DHSS immediately. The second incident involved the same resident touching another resident's groin area, which was also not reported to management or DHSS. The facility's policy requires that any allegations of abuse be reported immediately to management and within two hours to the state. However, the staff, including RN G, failed to notify the Director of Nursing (DON), Administrator, or DHSS about the incidents. The incidents were only brought to the attention of management during a meeting three days later, and the state was notified after this delay. Interviews with various staff members revealed that they were aware of the requirement to report such incidents within two hours, yet the protocol was not followed. The residents involved had various diagnoses, including dementia, depression, and cognitive communication deficits, which may have affected their ability to consent or understand the situation. Despite this, the facility did not document the incidents in the residents' medical records or take immediate action to report the allegations. The failure to report these incidents in a timely manner constitutes a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility staff failed to immediately investigate a possible abuse incident when a staff member witnessed one resident touching another resident inappropriately in the groin area. The incident was observed by an Activities Assistant who heard a resident yell that the person being touched was not the spouse of the resident doing the touching. The Activities Assistant then moved the resident who was touching to the nurses' station and informed the MDS Coordinator about the incident. However, there was no documentation of an investigation being initiated or completed regarding this allegation of possible abuse. The facility's policies on abuse and neglect, as well as the abuse prevention program, require that all allegations of abuse be investigated and reported within the required timeframes. Despite these policies, the staff did not document any investigation into the incident involving the two residents. Interviews with various staff members, including nurse aides, LPNs, the DON, and the Administrator, revealed that they were not aware of the incident and that no investigation had been conducted. The residents involved in the incident had diagnoses that included dementia, depression, and cognitive impairments, which could affect their understanding and behavior. The failure to investigate the incident was a violation of the facility's policies and federal requirements, as it did not ensure the protection of residents during the investigation of alleged abuse. The lack of awareness and action by the facility's staff and administration contributed to the deficiency in handling the situation appropriately.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to maintain a comprehensive person-centered care plan for a resident who exhibited inappropriate touching behavior towards other residents. The resident, diagnosed with unspecified dementia, psychotic disturbances, and depression, had incidents of inappropriate touching documented on two occasions. Despite these incidents, the resident's care plan was not updated to reflect the changes in behavior, which is a requirement for comprehensive care planning. The first incident involved the resident touching another resident inappropriately, which was observed by staff and documented by a Registered Nurse. However, the care plan was not updated following this incident. The second incident was witnessed by an Activities Assistant, who reported it to the MDS Coordinator and RN Consultant, yet the care plan still remained unchanged. Interviews with various staff members, including CNAs, LPNs, and the Social Services Director, revealed that inappropriate behaviors should be documented in the care plan, but this was not done. The MDS Coordinator, responsible for updating care plans, acknowledged awareness of the incidents but did not update the care plan to include the resident's inappropriate behavior. The Director of Nursing and Interim Administrator were also unaware of the incidents until days later, indicating a breakdown in communication and documentation processes. The failure to update the care plan after these incidents highlights a deficiency in the facility's care planning process.
Inadequate Pain Management and Communication in LTC Facility
Penalty
Summary
The facility failed to provide comprehensive pain management for a resident with chronic pain syndrome, rheumatoid arthritis, and osteoarthritis. The resident experienced increased pain in the right knee, which was swollen, red, and warm to the touch. Despite the resident's complaints and visible symptoms, staff did not consistently document the resident's pain levels or follow up on the effectiveness of administered pain medications. The resident's pain was not adequately addressed, and there was a lack of communication with the physician regarding the resident's increased pain and the ineffectiveness of the current pain management regimen. The facility's staff did not document the administration of prescribed medications, such as Lyrica, due to the medication being unavailable. The staff failed to notify the physician or nurse practitioner about the unavailability of Lyrica, which was intended to manage the resident's chronic pain. The resident's pain levels fluctuated, reaching as high as 10 on a scale of 0 to 10, yet there was no documented follow-up or additional interventions to address the continued pain. The resident's condition worsened, leading to increased dependency on staff for activities of daily living and a request for a second medical opinion. Interviews with staff revealed that there was a lack of communication and coordination in managing the resident's pain. Staff members were aware of the resident's pain and the unavailability of Lyrica but did not take appropriate steps to resolve the issue or communicate effectively with the physician. The resident was eventually transferred to the hospital, where a fracture of the right patella was diagnosed, indicating that the pain and symptoms were not adequately addressed in the facility.
Failure to Notify Provider of Change in Resident's Condition
Penalty
Summary
The facility failed to provide care per standards of practice by not addressing and notifying the provider of a change in condition for a resident whose knees became swollen, red, warm, and painful. The resident, who had a history of rheumatoid arthritis and chronic pain syndrome, experienced a significant decline in mobility and an increase in pain, which was not promptly communicated to the physician or nurse practitioner. Despite multiple staff observations and the resident's requests for medical attention, the necessary notifications and interventions were delayed. The resident's condition deteriorated over several days, with staff documenting the resident's inability to bear weight, increased pain, and changes in activities of daily living (ADLs). Various staff members, including CNAs and RNs, noted the resident's knee was swollen, red, and warm to touch, yet there was a lack of timely communication with the resident's healthcare provider. The resident expressed a desire for a second opinion and was eventually transferred to the hospital, where a fracture of the right patella was diagnosed. Interviews with facility staff revealed a breakdown in communication and documentation regarding the resident's condition. Several staff members assumed the resident was on the physician's list for evaluation, but there was no clear documentation of when or if the physician was notified of the resident's worsening condition. The facility's failure to have a policy related to change of condition contributed to the delay in appropriate medical intervention, resulting in the resident's transfer to the hospital for surgical repair.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident with a history of wandering and elopement attempts. The resident, who had severe cognitive impairment and was assessed as a high risk for elopement, was not adequately monitored despite having an electronic monitoring device. On the day of the incident, the resident attempted to leave the facility multiple times, triggering alarms, but was not placed on 15-minute checks or given increased supervision as per the facility's policy. The resident was last seen in the common area by staff at 8:00 P.M. and was later found missing during rounds. Despite the resident's known history of exit-seeking behavior and verbalizing intent to leave, staff did not implement new interventions or ensure all working staff were aware of the resident's elopement risk. The facility's investigation revealed that the resident was able to leave the premises and was found in a nearby cornfield, approximately 100 yards from the facility, after a search involving law enforcement. Interviews with staff indicated a lack of consistent communication and adherence to the facility's elopement policy. Staff were aware of the resident's behaviors but did not consistently apply the necessary checks or communicate effectively about the resident's risk. The facility's systems for monitoring and responding to elopement risks were not effectively utilized, leading to the resident's unsupervised departure from the facility.
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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