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F0656
D

Failure to Develop Care Plan for Behavior Monitoring

Richmond, Virginia Survey Completed on 10-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to develop and implement a comprehensive care plan addressing sexual or inappropriate behavior monitoring for one resident who was admitted with multiple medical diagnoses, including ischemic cardiomyopathy, CHF, atrial fibrillation, and an LVAD. The resident was found to be on the Virginia State Police Sex Offender Registry, but the care plan only addressed issues related to refusal of cardiac clinic appointments and daily weights, with no mention of monitoring for sexual or inappropriate behaviors. During the survey, interviews with administrative and nursing staff confirmed that monitoring for sexual or inappropriate behaviors should have been included in the care plan for a resident listed on the sex offender registry. Review of facility policies indicated that behaviors are to be assessed, monitored, and care planned, but this was not done for the resident in question. No additional information was provided prior to the survey exit.

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