Woodland Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Missouri.
- Location
- 1347 East Valley Watermill Road, Springfield, Missouri 65803
- CMS Provider Number
- 265749
- Inspections on file
- 40
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Woodland Manor during CMS and state inspections, most recent first.
A facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required two-hour timeframe. After a resident with dementia and PTSD reported being grabbed on the forearm by another resident, staff assessed for injury and notified the Administrator, but the incident was not reported to DHSS as required by policy. Staff interviews revealed awareness of the reporting requirement, but the Administrator did not report the incident due to the absence of visible injury at the time.
A resident with bilateral above-the-knee amputations and multiple comorbidities did not receive a drop arm bedside commode as ordered by a physician, despite repeated requests and clear need for increased independence. The order was not entered into the medical record or acted upon promptly, and staff interviews revealed delays, lack of follow-up, and confusion about the ordering process, resulting in the resident continuing to use briefs and requiring staff assistance.
A resident with multiple medical conditions and bilateral amputations suffered burns after independently heating and transporting hot soup, which spilled when their wheelchair struck a door. Staff failed to update the care plan with new interventions or conduct a hot food/liquid risk assessment, and there was no policy or consistent enforcement regarding resident use of microwaves, leaving accident hazards unaddressed.
A resident who was dependent on staff for mobility and toileting was repeatedly spoken to disrespectfully by a CNA, who made comments about back pain and discouraged the resident from wearing an incontinent brief to bed, despite the resident's preference. Other staff confirmed the CNA's behavior and noted the resident felt pressured and uncared for, with the facility's policy requiring respect for resident autonomy and dignity.
A resident with PTSD and a history of trauma did not receive individualized, trauma-informed care, as staff failed to include the resident's specific triggers in the care plan and did not consistently respond to their needs, resulting in repeated distress when the resident was left waiting in bed and staff communicated in ways that triggered their PTSD.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions necessary to address all care needs, as identified during a survey event.
The facility did not ensure that several nurse aides completed required CNA training, competency evaluation, and certification testing within four months of hire, resulting in uncertified staff providing direct care beyond the allowed timeframe. Staff interviews revealed confusion about requirements, delays in enrollment and testing, and a lack of policy or effective tracking system for NA certification status.
A resident with multiple complex medical conditions experienced a significant decline in cognition and required increased assistance with care, but staff failed to promptly notify the provider or family and did not document the change in condition or monitoring as required by facility policy. Despite staff observations of increased confusion, lethargy, and decreased responsiveness, timely assessment and communication were lacking, resulting in delayed medical intervention and eventual hospital transfer for sepsis, UTI, and pneumonia.
An LPN made disrespectful comments and used a harsh tone with three residents, including individuals with parkinsonism, dementia, and a recent amputation. Incidents included telling a resident they were seeking pity, responding rudely to a family member's request for pain medication, and instructing a resident to "pull yourself together" before providing assistance. Staff interviews confirmed these actions were considered disrespectful and not in line with facility policy.
The facility did not consistently complete or document full wound assessments for four residents with pressure ulcers, despite its policy requiring weekly measurements and detailed documentation. After the departure of the wound care nurse, staff interviews revealed confusion about wound tracking responsibilities, and there was no consistent wound log or weekly assessment, resulting in a failure to monitor wound progression.
A resident with neuromuscular bladder dysfunction and severely impaired cognition did not have a care plan addressing the use, care, and monitoring of an indwelling urinary catheter. Staff demonstrated inconsistent practices in catheter care, documentation, and monitoring, with observations showing improper catheter bag placement and lack of intake/output tracking. These deficiencies contributed to a significant change in the resident's condition, resulting in hospitalization.
A resident with multiple chronic conditions, including diabetes and a history of cellulitis, did not receive consistent and accurate skin assessments or timely documentation of wounds by staff. Nursing staff failed to obtain or document wound care orders, and incomplete or missing assessments led to gaps in care. Communication lapses among staff resulted in the resident's wounds not being properly tracked or treated according to facility policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms or indwelling medical devices. Observations showed a lack of signage and PPE, with staff only wearing gloves during care for three residents. Interviews revealed staff were unaware of EBP requirements, and the facility had not developed a policy or trained staff on EBP.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA). Specifically, an incident involving two residents, where one resident entered another's room and grabbed their forearm, was not reported to the Department of Health and Senior Services (DHSS) as required by facility policy and state law. The facility's policy defines abuse and mandates immediate reporting of all allegations to the Administrator, DON, and appropriate authorities, with 'immediately' defined as within two hours. The incident in question involved a resident with diagnoses including dementia, PTSD, and major depressive disorder. This resident reported that another resident entered their room, grabbed their forearm, and only released after being asked. Staff intervened and assessed the resident for injury, initially finding none, but a subsequent assessment revealed a small bruise. Despite the resident reporting the incident to both the Administrator and Social Services Director (SSD), and expressing a desire to file a grievance, there was no documentation or evidence that the incident was reported to DHSS as required. Interviews with staff, including LPNs, CNA, SSD, and the Administrator, confirmed knowledge of the reporting requirement and the two-hour window for notification. However, staff either assumed the Administrator would report the incident or did not believe the incident warranted reporting due to the absence of visible injury at the time. The Administrator acknowledged being notified of the incident but chose not to report it, citing the lack of injury and no prior issues with the resident involved. DHSS records confirmed that the facility did not self-report the altercation or abuse allegation.
Failure to Provide Ordered Commode for Resident with Bilateral Amputations
Penalty
Summary
A deficiency occurred when the facility failed to provide a drop arm bedside commode for a resident with bilateral above-the-knee amputations, despite a physician's order and the resident's expressed preference. The resident, who was cognitively intact and independent in many activities of daily living, had diagnoses including traumatic amputations of both legs, long-term kidney disease, severe obesity, major depressive disorder, anxiety, and PTSD. The resident was at risk for pressure ulcers and had bladder and bowel incontinence, requiring the use of briefs and staff assistance for changing. The resident repeatedly requested a commode to increase independence and dignity, as using briefs was embarrassing and limited autonomy. The process for obtaining the commode was not followed appropriately. Although a handwritten physician's order for a heavy-duty bedside commode with a drop arm was written, it was not entered into the resident's electronic medical record or acted upon in a timely manner. The Director of Rehab provided the order and product information to the Administrator and Social Services Director (SSD), but the SSD delayed ordering the commode, citing being too busy and concerns about cost and delivery time. The SSD also cancelled an initial order due to a long delivery estimate and did not have documentation of the cancelled order. Multiple staff interviews confirmed that the resident's request for a commode was known, but there was no documented follow-up or timely action to fulfill the order. The facility did not have a policy regarding the process for ordering durable medical equipment or handling handwritten physician orders. Staff interviews revealed confusion about the process and responsibilities for ordering equipment. The lack of clear documentation, communication, and timely action resulted in the resident not receiving the commode as ordered, impacting the resident's independence and dignity.
Failure to Prevent Burn Injury and Update Care Plan After Resident Spill of Hot Soup
Penalty
Summary
Facility staff failed to ensure that all residents were kept as free from accident hazards as possible when they did not implement steps to prevent future burns and did not update the care plan regarding a burn incident for a resident who suffered burns after spilling hot soup on themselves. The resident, who was cognitively intact and used both a motorized and manual wheelchair independently, had significant medical history including bilateral above-the-knee amputations, long-term kidney disease, major depressive disorder, anxiety, PTSD, and peripheral vascular disease. The resident was independent at meals and typically heated their own food using a microwave located in a room on the unit hall. On the day of the incident, the resident was carrying a bowl of hot tomato soup in their wheelchair when they ran into a door, causing the soup to spill onto their abdomen and chest. Initial nursing notes indicated that cool cloths were applied and the area was left open to air per physician instructions. However, within two days, the affected areas developed fluid-filled blisters, some of which had popped, requiring wound care treatment. The care plan was not updated to reflect the new risk or to include interventions to prevent future burns, and no hot food/hot liquid risk assessment was completed for the resident. Interviews with staff revealed that there was no policy regarding resident use of microwaves, and the rooms containing microwaves were not locked, allowing any resident access despite signs indicating they were for employees only. Staff reported that residents were not supposed to use the microwaves without assistance, but enforcement was inconsistent, and the resident in question frequently used the microwave independently. There was no documentation of risk assessments or care planning related to hot food or microwave use for any residents, and staff were generally unaware of any such policies or procedures.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident who was dependent on staff for transfers, bed mobility, and toileting. The resident, who had diagnoses including diabetes, heart failure, severe obesity, anxiety disorder, and depression, expressed a preference to wear an incontinent brief to bed and to have his or her sleeping patterns honored, as documented in the care plan. However, Certified Nurse Aide (CNA) A repeatedly spoke to the resident in a disrespectful manner, making comments about back pain caused by assisting the resident and expressing reluctance to help. CNA A also slammed the door when leaving the resident's room, which the resident found hurtful and disrespectful. Multiple interviews with other staff members confirmed that CNA A discouraged the resident from wearing an incontinent brief to bed, insisting it was healthier to sleep without one, despite the resident's stated preference. The resident reported feeling pressured by CNA A to comply with this suggestion, ultimately relenting to avoid conflict, even though it made the resident feel uncared for and diminished. Other CNAs and LPNs corroborated that CNA A's behavior was perceived as disrespectful and that the resident had shared concerns about not receiving timely incontinent care during the night shift. The facility's policy required staff to respect residents' autonomy, dignity, and preferences, including sleeping routines and personal care choices. Despite this, CNA A's actions and comments did not align with these expectations, as evidenced by the resident's repeated experiences of disrespect and disregard for personal preferences. The issue was further compounded by the resident's reluctance to report the behavior due to fear of retaliation and a desire to avoid causing trouble for staff.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and a diagnosis of PTSD received appropriate treatment and services to attain the highest practicable psychosocial well-being. The resident, who was cognitively intact and had diagnoses including PTSD, major depressive disorder, generalized anxiety disorder, and recent bilateral above-the-knee amputations, expressed specific triggers related to their trauma history. These included a strong need to be gotten out of bed immediately upon waking, a preference for the door to be left open, and a light to be left on at night. Despite these clearly communicated needs, the resident's care plan did not include individualized interventions addressing their PTSD triggers, nor did the facility have a policy regarding PTSD or trauma-based care. Staff interactions and documentation revealed repeated instances where the resident was told by nursing staff that it might not be possible to get them up multiple times during the night, or that they would have to wait for assistance due to staffing requirements for Hoyer lift transfers. The resident frequently refused to go to bed out of fear of being left in bed and feeling trapped, which was a direct trigger for their PTSD. Staff notes and interviews indicated that the resident was often left waiting for up to ten minutes or more to be assisted out of bed, and that staff did not always communicate effectively about the wait or the process, further exacerbating the resident's distress. Some staff members did not recognize the connection between the resident's behaviors and their PTSD triggers, and there was a lack of trauma-informed care planning and staff education on the subject. Multiple interviews with staff, including CNAs, RNs, the MDS Coordinator, Social Services Designee, ADON, DON, and the Administrator, confirmed that the resident's specific PTSD triggers were not included in the care plan and that staff were not consistently aware of or responsive to these triggers. Staff acknowledged that it was inappropriate to tell a resident they could not be gotten up as often as they wished, and several staff members were unaware of the need to include trauma-informed interventions in the care plan. The facility's failure to identify, care plan, and provide services responsive to the resident's trauma history and PTSD triggers resulted in the resident experiencing repeated distress and a lack of individualized, trauma-informed care.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that meets all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was cited during a survey event referenced by event ID DE1Z12, with an exit date of 03/22/25.
Failure to Ensure Timely CNA Training and Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed state-approved certified nursing assistant (CNA) training, competency evaluation, and certification testing within four months of hire, as required. Five NAs continued to provide direct care to residents beyond the 120-day limit without having completed the necessary training and certification. Interviews and record reviews revealed that some NAs had not started their CNA classes, while others were delayed in being enrolled or scheduled for testing. The facility did not provide a policy regarding NA training classes, and there was confusion among staff and administration regarding the requirements and tracking of NA certification status. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both indicated a lack of awareness about which NAs were working beyond the allowed timeframe without certification. The ADON described issues with the online training provider, including difficulties enrolling staff and scheduling tests, which contributed to the delays. The Administrator and DON both stated that NAs should be moved to non-care areas if not certified within 120 days, but evidence showed that uncertified NAs continued to provide direct care. The facility census at the time was 87 residents.
Failure to Timely Notify Provider and Address Change in Resident Condition
Penalty
Summary
The facility failed to provide care in accordance with professional standards of quality by not addressing and notifying the provider in a timely manner regarding a resident's significant change in condition. The resident, who had multiple complex diagnoses including acute and chronic respiratory failure, acute kidney failure, malignant neoplasm of the uterus, non-traumatic intracerebral hemorrhage, and pneumonia, experienced a noticeable decline in cognition and required increased assistance with activities of daily living. Staff observations and interviews revealed that the resident, previously able to communicate needs and perform some self-care with limited assistance, became increasingly confused, less verbal, and more dependent on staff for mobility and toileting over a two-day period. Certified Nurse Aides (CNAs) and other staff noted the resident's changes, such as increased confusion, sleepiness, and inability to pivot or stand as usual. These changes were reported to the LPN on duty, who assessed the resident and took vital signs, which were documented as normal. However, there was a lack of timely and thorough documentation regarding the resident's change in condition, monitoring, and physician notification on the first day of the observed decline. The LPN instructed staff to monitor the resident more closely but did not immediately notify the physician or family about the significant changes. The following day, the resident's condition further deteriorated, with continued lethargy, poor responsiveness, and refusal of meals, prompting a delayed call to the provider and eventual transfer to the hospital after family intervention. Facility policy required prompt notification of the provider and family in the event of a significant change in a resident's condition, as well as detailed assessment and documentation. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed expectations for timely assessment, documentation, and communication with the provider and family. Despite these policies, the staff did not follow through with timely notification or documentation, resulting in a delay in appropriate medical intervention for the resident, who was later diagnosed with sepsis, UTI, and pneumonia upon hospital admission.
Failure to Ensure Resident Dignity Due to Disrespectful Staff Interactions
Penalty
Summary
The facility failed to ensure that all residents were treated in a dignified manner, as evidenced by multiple incidents involving a Licensed Practical Nurse (LPN) who made disrespectful comments and used a harsh tone with three residents. The facility's own policy requires staff to promote dignity and respect for residents at all times, but this was not upheld in several documented interactions. For example, one resident with parkinsonism, depression, and neurocognitive disorder reported that the LPN made a comment implying the resident was seeking pity while the resident was sitting in the doorway, visibly upset and in pain. This was corroborated by interviews with staff and the Social Services Director, who confirmed the resident's account and acknowledged the comment as disrespectful. Another incident involved a resident with dementia, whose family member reported that the LPN responded rudely when asked about pain medication, stating that the LPN had many other residents to care for and would attend to the resident when able. When the LPN eventually brought the medication, the resident inquired about it and the LPN reportedly responded in a rude manner before leaving the room abruptly. This interaction was reported by the family to the Social Services Director, who confirmed the details and recognized the behavior as inappropriate. A third resident, who had a history of surgical amputation, chronic kidney disease, and mental health conditions, described being in pain and waiting for assistance to use the bathroom. The resident reported that the LPN told them, in a certain tone, to "pull yourself together" before staff would help, which the resident and other staff members identified as disrespectful. Interviews with other staff, including CNAs and RNs, confirmed that such comments would be considered disrespectful and not in line with facility expectations. These incidents collectively demonstrate a pattern of staff failing to maintain resident dignity and respect as required by facility policy.
Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to provide care in accordance with standard practice for residents with pressure ulcers, specifically by not completing and documenting full wound assessments in a consistent and timely manner. This deficiency was observed in four residents who had identified pressure ulcers. The facility's own policy required charge nurses to document wound characteristics and for the wound nurse to perform weekly measurements and assessments until wounds healed. However, documentation and assessment were lacking for all four residents. One resident with a history of amputation, diabetes, and venous insufficiency developed a new stage three pressure ulcer, but there was no documentation of wound measurements or descriptions for over a month after the ulcer was identified. Another resident with quadriplegia and stage four pressure ulcers had inconsistent wound documentation, with no completed assessments recorded for over a month. A third resident with a recent amputation and diabetic complications had a left heel ulcer, but after an initial assessment, no further complete wound assessments were documented, and wound care company notes were missing from the record. The fourth resident, who had a history of skin impairment and used a wheelchair, developed a stage two pressure injury, but staff did not document a complete assessment or indicate if the ulcer had healed. Interviews with staff revealed confusion and inconsistency in wound tracking and documentation responsibilities, especially after the departure of the facility's wound care nurse. The administrator and DON attempted to track wounds, but there was no consistent wound log or weekly assessment documentation. The lack of clear documentation and assessment practices led to the failure to monitor whether wounds were improving or declining, as required by facility policy.
Failure to Develop and Implement Comprehensive Catheter Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan addressing the use, care, and monitoring of an indwelling urinary catheter for a resident with neuromuscular bladder dysfunction and severely impaired cognition. The resident was dependent on staff for all activities of daily living, including toileting and hygiene, and had physician orders for catheter care every shift and PRN changes for leaking or blockage. Despite these orders and facility policy, the resident's care plan did not include interventions or monitoring related to the indwelling catheter. Observations and interviews revealed inconsistent practices and documentation regarding catheter care and monitoring. The resident's catheter bag was observed resting on a fall mat and under the bed, not consistently kept off the floor or below bladder level as required. Staff interviews indicated varying understandings of catheter care frequency, documentation of intake and output, and reporting of abnormal findings. Some staff reported not documenting urinary output for this resident, and there was no consistent tracking of fluid intake or output in the resident's records. The lack of a comprehensive care plan and inconsistent monitoring contributed to a significant change in the resident's condition, including lethargy, nonresponsiveness, and decreased urine output, which resulted in hospitalization. Upon return from the hospital, the resident continued to have an indwelling catheter, but the care plan still did not address catheter management. Facility policy and staff expectations for catheter care, monitoring, and documentation were not consistently followed or reflected in the resident's care plan.
Failure to Accurately Assess, Document, and Treat Resident Skin Conditions
Penalty
Summary
Facility staff failed to provide care according to standard practice by not accurately and consistently tracking a resident's skin conditions, failing to document timely and complete assessments, and not documenting or obtaining appropriate wound care orders. The resident involved had multiple complex medical diagnoses, including vascular dementia, chronic kidney disease, diabetes, hypertension, anemia, and a history of cellulitis and peripheral arterial disease. The care plan identified the resident as at risk for pressure ulcers and required weekly systematic skin inspections and prompt reporting of any skin breakdown. Despite these requirements, documentation showed incomplete descriptions of the resident's skin condition during weekly assessments, with several instances where the assessments lacked full details of the wounds or changes in skin integrity. There were also periods where no documentation was made regarding the resident's right lower leg and foot, even though the resident had ongoing issues with redness, blisters, and wounds. Staff failed to consistently notify the physician or obtain wound care orders as required by facility policy, and the resident was not listed on the facility's wound logs during periods when wounds were present. Interviews with nursing and aide staff revealed inconsistent practices in skin assessment and reporting, with some staff unaware of the resident's wounds and others noting that wound care orders were not obtained or documented. The wound nurse was not aware of the resident's multiple wounds until prompted by a new order, and there was a lack of communication and follow-through regarding wound care protocols. These failures resulted in the resident's skin conditions not being properly assessed, tracked, or treated according to physician orders and facility policy.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program by not developing a policy regarding Enhanced Barrier Precautions (EBP) for residents infected with multidrug-resistant organisms (MDRO) or those with chronic wounds and indwelling medical devices. The facility did not train staff on EBP, did not have personal protective equipment (PPE) and signage present for residents meeting EBP guidelines, and did not ensure staff wore PPE in accordance with CDC guidelines. This deficiency was observed in three residents who met the guidelines for EBP, out of a sample of nine residents in a facility with a census of 83. Resident #1, diagnosed with quadriplegia and a colostomy, had an indwelling catheter and multiple pressure injuries. Observations showed no signage on the resident's door indicating EBP, no PPE available, and staff only wearing gloves during catheter care. Resident #2, with multiple sclerosis and quadriplegia, also had an indwelling catheter. Similar observations were made, with no signage or PPE present, and staff not wearing appropriate PPE during care. Resident #3, with chronic kidney disease and urine retention, had an indwelling catheter, and again, no signage or PPE was observed, with staff only wearing gloves during care. Interviews with various staff members, including a Certified Medication Technician, Licensed Practical Nurse, Registered Nurse, and Certified Nurse Aides, revealed a lack of awareness and understanding of EBP. The Assistant Director of Nursing admitted that procedures for EBP had not been implemented, and the Infection Preventionist/Director of Nursing was working on it. The Administrator and DON/IP acknowledged that staff were not aware of residents on EBP and that appropriate PPE was not being used during catheter care.
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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