Concordia Nursing & Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bella Vista, Arkansas.
- Location
- 7 Professional Drive, Bella Vista, Arkansas 72714
- CMS Provider Number
- 045143
- Inspections on file
- 21
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Concordia Nursing & Rehab, Llc during CMS and state inspections, most recent first.
The facility did not maintain a full-time DON or ensure RN coverage for at least 8 consecutive hours daily, leading to missed assessments, incomplete care plans, and inadequate oversight of resident care. As a result, residents experienced unaddressed falls, improper management of IV lines, and delays in care planning, with LPNs and CNAs left to manage without proper RN supervision.
The facility failed to maintain a full-time RN and lacked a DON, resulting in incomplete care plans, fall assessments, and MDS documentation. LPNs managing PICC lines were not properly certified or trained, and bed rails were installed without proper assessments, consent, or documentation. Residents who experienced falls did not receive appropriate assessments or interventions, and a newly admitted resident was not assessed for mobility or provided necessary equipment. These administrative failures led to multiple Immediate Jeopardy deficiencies.
A resident with severe cognitive impairment and high fall risk experienced multiple unwitnessed falls resulting in serious injuries, including fractures to both arms. Despite these incidents, staff did not update the care plan or implement new interventions after each fall, and there was a lack of consistent assessment and communication among nursing staff, especially in the absence of a DON. This failure to follow policy and ensure adequate supervision led to repeated accidents and non-compliance with quality of care standards.
The facility failed to complete required assessments, obtain informed consent, and ensure compatibility before installing bed rails for two residents with complex medical histories. Bed rails were observed in use without documentation, and staff interviews revealed confusion about procedures and responsibilities. Families were not informed or asked for consent, and maintenance staff did not follow manufacturer guidelines or keep records, resulting in unsafe conditions and noncompliance.
A facility failed to ensure that only properly certified LPNs managed and administered IV therapy via a PICC line for a resident, with multiple LPNs performing assessments and interventions outside their scope of practice and without RN oversight. The facility did not verify IV certification, lacked clear RN coverage, and did not provide required training, resulting in non-compliance with regulations and creating a situation likely to cause serious harm.
A resident with multiple medical conditions experienced a significant decline in mobility and psychosocial health after admission due to the facility's failure to assess mobility needs, develop an individualized care plan, and provide necessary adaptive equipment. The resident became totally dependent on staff for ADLs and was unable to participate in activities or maneuver their wheelchair independently, leading to distress and loss of independence. Staff did not inquire about or provide interventions to support the resident's independence until prompted by surveyors, and care planning responsibilities were neglected due to the absence of a DON.
Surveyors found that the facility did not post the most recent survey results in a location accessible to residents. During interviews, several residents were unaware of the survey results' availability, and surveyors located the outdated binder in an inconspicuous spot. The Administrator confirmed the binder had not been updated.
The facility did not ensure that two CNAs were certified in Arkansas or had completed required background checks and abuse registry checks for the state. Both CNAs were certified in Oklahoma, but their files lacked documentation of Arkansas certification and annual employment screening, and one CNA was unfamiliar with key infection control procedures.
The facility did not complete a thorough facility-wide assessment, omitting evaluation of staffing levels, staff competencies, and training, as well as failing to conduct a community-based risk analysis for natural disasters. There was no documented plan for staff recruitment or retention, and the assessment relied on outdated staffing ratios. A resident received IV therapy without evidence of LPN training or competency assessment for this service. Leadership gaps were evident, with key staff unable to fulfill their roles due to staffing shortages, and these issues were not addressed in the facility's assessment.
The facility failed to maintain an organized and accurate medical record system, resulting in incomplete and inaccessible documentation such as care plans, MDS, MAR, and TAR. Staff responsible for records were unable to keep up due to dual roles, and the absence of a DON left essential documentation and assessments unaddressed. Multiple residents' records lacked critical information, and the medical director and staff were unable to locate or explain missing orders and care plans. Policy requirements for timely and comprehensive documentation were not met, and there were reports of falsified records and signatures.
Surveyors made multiple requests for disclosure of ownership paperwork, but the facility did not provide the required documentation despite assurances from the Administrator that it would be supplied. The deficiency was cited due to the facility's failure to comply with disclosure requirements.
The facility did not provide required QAPI training to all staff upon hire or through in-service sessions. Review of training records and staff files showed no documentation of QAPI training, and interviews with leadership confirmed that QAPI in-services were not conducted, despite other mandatory trainings being provided.
The facility did not provide required Compliance and Ethics training to staff upon hire or as part of ongoing in-services. Documentation and staff interviews confirmed that in-service education covered other topics, but compliance and ethics were not included, and employee files lacked evidence of such training for both CNAs and LPNs.
The facility did not complete required MDS assessments within the mandated timeframe for several residents with complex medical needs. This deficiency was linked to a lack of clear responsibility and oversight during a period when the DON position was vacant, with staff interviews confirming that MDS duties were not assumed or completed as required.
The facility did not accurately complete MDS assessments for two residents, failing to document bedrail use and respiratory support devices such as oxygen and CPAP. One resident experienced multiple falls and fractures without proper assessment or family education regarding bedrails, while another received oxygen and CPAP therapy that was not reflected in their MDS. Staff interviews revealed confusion about documentation responsibilities and a lack of oversight during a period without a DON.
Surveyors found that the facility did not complete required MDS assessments or develop comprehensive, person-centered care plans for four residents, including those with complex medical needs and those receiving hospice care. In several cases, care plans were missing or delayed, and some residents only had limited plans addressing basic needs. The absence of a DON led to a lack of reassignment for these critical responsibilities, resulting in incomplete care planning and assessment.
Two residents experienced multiple falls, including one with a major injury, without timely updates or revisions to their comprehensive care plans. Most falls lacked documented interventions, and staff reported that care plans were incomplete and not updated due to the absence of a DON. The care plans in use did not reflect current risks or interventions, resulting in noncompliance with facility policy and regulatory requirements.
Surveyors found that food items in the kitchen and unit refrigerators were not consistently labeled, dated, or covered, and some were expired or missing required information. The fryer and ice machine were not cleaned as scheduled, with visible debris and residue present. Employee and resident foods were stored together in violation of facility policy, and staff interviews confirmed inconsistent adherence to food storage and sanitation protocols.
The facility did not include a statement in its arbitration agreement clarifying that signing was not a condition of admission. Although the Business Office Manager verbally informed residents and representatives of this, the written agreement only stated that signing was voluntary and could be rescinded, and there was no facility policy on arbitration agreements.
The facility's arbitration agreement, signed by residents or their representatives, did not specify that arbitration disputes would be held at a mutually convenient venue. Review of the agreement and checklist confirmed the omission, and staff interviews indicated there was no policy addressing arbitration venue details.
The facility did not identify or implement required infection control precautions for two residents—one with an infected wound and another with a urinary catheter—resulting in the absence of appropriate signage, PPE availability, and adherence to clean technique during care. Staff interviews revealed gaps in training and understanding of Enhanced Barrier Precautions and Transmission Based Precautions.
A resident with severe cognitive impairment and significant weight loss did not receive recommended high calorie snacks between meals, as staff were unaware of the dietary recommendation due to communication issues between the RD and CDM. The resident confirmed not receiving snacks, and staff interviews indicated that snacks were not routinely provided between meals.
A resident admitted with COPD and on hospice did not have a baseline care plan developed within 48 hours as required. Nursing staff reported confusion about care plan responsibilities and lacked access to the EHR, resulting in the absence of a baseline care plan in the resident's records until after the issue was identified.
Failure to Maintain Full-Time DON and RN Coverage Resulting in Lapses in Resident Care
Penalty
Summary
The facility failed to ensure the employment of a full-time Director of Nursing (DON) and did not provide registered nurse (RN) coverage for at least 8 consecutive hours per day, as required. Review of employee files and timecard reports revealed that the facility was without 8 consecutive hours of RN coverage on 53 out of 65 days, and there were periods when the DON position was vacant or filled by staff who did not fulfill the required duties. The lack of RN oversight and management led to significant lapses in care planning, assessment, and intervention for multiple residents. Several residents were directly affected by these deficiencies. One resident with severe cognitive impairment and a history of falls suffered two major falls with injuries, including fractures to both arms, without appropriate updates or escalation of interventions in their care plan. Another resident with a peripherally inserted central catheter (PICC) line did not receive RN assessment or care of the line for 18 days, and intravenous medications were administered by LPNs, some of whom were not verified as IV certified. Additional residents were admitted without timely completion of Minimum Data Set (MDS) assessments or comprehensive care plans, resulting in a lack of documented interventions for their care needs for extended periods. Interviews with staff confirmed that in the absence of an RN or DON, LPNs and CNAs were left to make assessments and update care plans, often without proper oversight or knowledge of the requirements. The Assistant Director of Nursing (ADON) did not assume DON responsibilities and was unaware that MDS assessments and care plans had not been completed. The facility's own documentation and staff statements indicated a lack of clear processes for ensuring RN coverage, verifying LPN IV certification, and maintaining compliance with federal and state regulations regarding nursing services.
Removal Plan
- Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
- In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
- Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
- In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
- In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
- In-service all staff by administrator and/or director of nursing in person or by phone on ESP and infection control.
Administrative Failures Result in Multiple Immediate Jeopardy Deficiencies
Penalty
Summary
The facility's administration failed to implement and enforce policies necessary for the effective management and operation of the facility, resulting in multiple deficiencies. There was no full-time RN working eight consecutive hours per day, and the facility lacked a Director of Nursing (DON) for an extended period. The responsibilities of the DON, including care planning, fall assessments, and MDS completion, were not being fulfilled, as confirmed by staff interviews. The Assistant Director of Nursing (ADON) was unable to assume these duties due to other responsibilities, and the Med Records Nurse had been working as a bedside nurse for six months, leaving medical records unattended. Employee files for former DONs showed no signed job descriptions, and there was no evidence of staff orientation or training programs as required by facility policy. The facility also failed to ensure that LPNs managing peripherally inserted central catheters (PICC) were properly certified or trained. The Administrator admitted to not tracking which LPNs were IV certified and confirmed there was no IV training provided in the facility. Bed rails were installed on most beds without proper assessments, consent, or documentation. The Housekeeping/Maintenance Supervisor, responsible for installing and maintaining bed rails, had not read manufacturer guidelines and did not keep logs or forms related to bed rail safety. Staff interviews revealed a lack of knowledge about bed rail assessments and documentation, and the process for determining bed rail use was informal and based on resident preference rather than clinical assessment. Residents who experienced falls did not receive fall assessments or updated care plans, and interventions to prevent further falls were not identified or implemented. A newly admitted resident was not assessed for mobility function, and necessary interventions and equipment to maintain independence were not provided. The facility was unable to provide a policy for Activities of Daily Living/Mobility when requested. These failures in administration and oversight led to Immediate Jeopardy findings for multiple federal regulations, with the potential to cause serious harm to all residents in the facility.
Removal Plan
- In-service/meeting given via phone by regional director to governing body members (Manager, medical director) and in person to administrator.
- Administrator in-serviced management staff (DON, COM, SS, HR, MOS) regarding the following: Responsibility of the Governing Body (facility oversight, operations and policy/procedure), Survey findings and Plan of Removal to correct: Fall Clinical Protocol, Registered Nurse requirement, Competent staff, Mobility, Bed rail usage and Supervision to prevent accidents, Plan moving forward to improve findings.
- In-service provided to Administrator by Regional Director.
- In-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required.
- Consent forms for residents with bed rails obtained.
- Bed rail assessments for residents with bed rails completed.
- Assessments and consents obtained for six residents identified as having bed rails with no assessments/consents.
- Monitoring sheets completed by Administrator and Director of Nursing (DON), by Housekeeping Supervisor and by Administrator and DON, for bed rail assessment and consents.
- File containing manufacturer guidelines for bed rails provided.
- Housekeeping Supervisor in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed.
- Staff in-serviced on bed rails and enhanced barrier precautions.
- Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.
Failure to Update Fall Interventions and Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received proper assessments and interventions to prevent further accidents. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced multiple falls within a short period. Despite documented incidents, including unwitnessed falls resulting in significant injuries such as fractures to both arms, the facility did not update the resident's care plan or implement new interventions after each event. The care plan remained unchanged even after the resident returned from the hospital with a cast, which the resident repeatedly removed, leading to additional falls and injuries. Staff interviews revealed that after each fall, assessments and incident reports were completed, but immediate interventions were not consistently documented or added to the care plan. The process for updating care plans and communicating new interventions to staff was not followed, particularly in the absence of a Director of Nursing (DON). The Assistant Director of Nursing (ADON) acknowledged that fall assessments and care plan updates were not being completed due to the lack of a DON, and that there was confusion among staff regarding their responsibilities in monitoring and preventing falls. The facility's policy required staff to identify and implement pertinent interventions after each fall, but this was not adhered to. The lack of timely and appropriate interventions, failure to update care plans, and insufficient staff training and oversight contributed to repeated falls and serious injuries for the resident. These actions and omissions resulted in non-compliance with federal requirements for quality of care and accident prevention.
Removal Plan
- Fall assessments and interventions reviewed and updated as needed for Residents #15 and #25 by facility nurse.
- In-service by administrator, regional director and nurse consultant for Nursing staff (RN, LPN, CNA) present and via phone for those not in facility regarding the following: Assessing, monitoring and intervening in falls to prevent injury and/or reduce falls; Proper interventions for falls; Care plans related to falls; Notification of PCP, DON, family and administrator.
- DON/Administrator in-serviced by regional director in regards to monitoring of incident and accident (I&A), fall records and daily nurse documentation to identify and address any concerns immediately.
Failure to Assess, Obtain Consent, and Ensure Safe Installation of Bed Rails
Penalty
Summary
The facility failed to ensure that proper assessments, informed consents, and compatibility checks were completed prior to the installation and use of bed rails for two residents. Observations revealed that bed rails were in use on both sides of the beds for these residents, but there was no documentation of bed rail assessments, informed consent from the residents or their representatives, or evidence that the bed rails were compatible with the beds according to manufacturer guidelines. Staff interviews confirmed a lack of understanding and inconsistent practices regarding bed rail assessments, installation, and documentation, with some staff unaware of the requirements or the process for determining bed rail use. For one resident with a history of falls, dementia, and chronic ischemic heart disease, bed rails were observed in the up position on multiple occasions. However, neither the care plan nor the closet care plan indicated the use of bed rails, and staff were unsure if the resident was supposed to have them. The spouse of this resident reported never being informed about the bed rails or asked for consent. Maintenance staff responsible for installing bed rails admitted to not measuring beds for compatibility, not reading manufacturer guidelines, and not keeping records of maintenance or safety checks, despite acknowledging that loose bed rails could be unsafe. For another resident with multiple diagnoses including dementia and insomnia, bed rails were also observed in use, but the care plan and MDS did not reflect this. Staff interviews indicated that bed rails were already installed upon admission and that housekeeping, not nursing, installed them. The resident's family confirmed they were not informed about the bed rails, the risks involved, or asked for consent. There was also evidence of gaps between the mattress and bed rails, raising concerns about entrapment, and no documentation was found to support the safe and appropriate use of bed rails for either resident.
Removal Plan
- Provide in-service to Administrator by Regional Director regarding bed rails and assessing, getting signed consent and order prior to use.
- Administrator to provide in-service to nursing staff in person and via phone regarding policy and procedure of bed rails, assessing, consent to use and physician order requirement.
- Review records to be completed by nurse manager to identify other residents with bed rails.
- Identified residents will be assessed by nurse and consent obtained.
- Administrator and DON will monitor care areas weekly to ensure bed rails are assessed and consent obtained and in the record.
- Care plan and MDS will be updated by LPN Nurse consultant.
- IDT team will work with environmental services supervisor to ensure bed frame and bed rails are compatible for the provided bed per manufacturers guidelines and recommendations.
- Provide in-service by administrator to environmental service supervisor regarding bed rails, bed maintenance and ensuring bedrails and bedframe are compatible to prevent entrapment zones.
Failure to Ensure Competent Nursing Staff for IV Therapy and PICC Line Management
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for every resident in a manner that maximized their well-being. Specifically, the facility did not ensure that LPNs with IV certification were the only staff accessing and managing a resident's PICC line, including administering IV antibiotics, performing IV flushes, and assessing the line's condition. Documentation revealed that multiple LPNs, some without documented IV certification, administered IV medications and performed assessments that were outside their scope of practice according to state regulations. The facility's own policies required consultation of state laws regarding scope of practice, but there was no evidence that the facility verified or tracked IV certification for LPNs, nor did it provide IV training to its staff. A review of the facility's staffing assessment and policies showed a lack of clear guidelines for RN coverage and no self-assessed staffing standards. The facility's job descriptions and interviews with staff indicated that LPNs were expected to perform assessments and interventions that should have been conducted by an RN, particularly for residents with complex needs such as those with a PICC line. The Arkansas Board of Nursing regulations specify that LPNs must work under the direction of an RN for tasks requiring substantial specialized judgment and skill, such as IV therapy and PICC line management. However, the facility did not ensure RN oversight or presence for these tasks, and staff interviews confirmed that LPNs were performing assessments and interventions independently. The deficiency was identified after a review of records for several residents, including one who was admitted with a PICC line for IV antibiotics and wound care. There were multiple days when no RN assessment or care of the line was documented, and IV antibiotics were administered by LPNs without verification of their IV certification. The facility's failure to ensure appropriate staffing, competency verification, and adherence to scope of practice requirements resulted in non-compliance with federal and state regulations, creating a situation that was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents.
Removal Plan
- Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
- In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
- Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
- In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
- In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
- Provide in-services by the Administrator and/or Director of nursing to licensed nursing staff regarding: Care plans-Baseline, comprehensive, and closet care plans completed timely; MDS Timeliness; RN Assessments and interventions; Fall Documentation; Enhanced Barrier Precautions (EBP)/INFECTION CONTROL.
- Regional Director to provide in-service via phone to Administrator regarding LPN Administration of IV medication. Administrator to in-service DON and Human Resource Coordinator on tracking IV certifications of LPNs in event of another PICC line admission.
Failure to Assess and Support Resident Mobility and Independence
Penalty
Summary
The facility failed to assess and address the mobility needs of a resident with multiple complex medical diagnoses, including respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and Raynaud's syndrome. Upon admission, the resident was documented as requiring assistance for most activities of daily living (ADLs) and was using a wheelchair for mobility. However, the initial evaluation was not a comprehensive assessment, and a required admission MDS was not completed by the deadline. The resident did not have a comprehensive, individualized care plan in place until well after admission, and the only care plan available was a generic, undated document with limited information. Observations and interviews revealed that the resident became totally dependent on staff for mobility and ADLs, resulting in a significant decline in functional status and psychosocial well-being. The resident reported feeling imprisoned, totally dependent, and expressed distress over the loss of independence. The resident was unable to maneuver the manual wheelchair due to multiple finger amputations and blackened fingertips, and staff did not provide or assess for appropriate adaptive equipment to promote independence. The resident's own mobility aids from home were not supplemented or replaced by the facility, and staff did not inquire about or provide interventions to support the resident's independence until prompted by surveyors. Staff interviews confirmed that care planning responsibilities were neglected due to the absence of a Director of Nursing, and no one had assumed those duties. The resident's psychosocial harm was compounded by missed opportunities to participate in activities due to lack of assistance and appropriate equipment. The facility also failed to communicate with the resident and their representative regarding available tools and interventions to improve mobility and independence, only reaching out after surveyor involvement. The lack of assessment, individualized care planning, and provision of necessary equipment led to a preventable decline in the resident's mobility and psychosocial health.
Removal Plan
- Provide in-service to Administrator by Nurse Consultant regarding preventing decline in residents' level of activities of daily living (ADL) functions, including providing necessary equipment appropriate for resident and facility.
- Administrator to provide in-service to DON regarding preventing decline in resident ADL functions, including providing necessary equipment and assessing for appropriate interventions to prevent declines.
- Administrator and Nurse Consultant to in-service nursing staff to identify and respond appropriately to a resident's decline in ADL functions, including assessing, monitoring and providing interventions. Nurses will be responsible for assessing and providing appropriate interventions.
- Contact Resident #184 family to bring specialized equipment (special belt for foot movement and trapeze bar) from home that is being requested by resident to facility so it can be used to assist with his independent transfer and repositioning.
- Administrator and DON to monitor care areas routinely to ensure equipment is in place.
- Notify Primary Care Physician of Resident #184 of mental health concerns and request further direction/orders. Contact family to bring personal items from home, notify Physician for any new orders and contact pharmacy for medication consult.
- Complete care plan and MDS for Resident #184.
Failure to Post Updated Survey Results in Accessible Location
Penalty
Summary
The facility failed to post the most recent survey results in an accessible location for residents to review. During interviews with four resident council members and the council president, all stated they were unaware of any posted survey results available for their viewing. Observations by surveyors confirmed that the survey results binder was not easily visible, as it was found in a metal and wicker rack on the floor beside a table near the entrance. Additionally, the binder contained outdated survey results from several months prior, rather than the most recent recertification survey. The Administrator acknowledged that the binder had not been updated and admitted to forgetting about it.
Failure to Verify State Certification and Background Checks for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were certified in the State of Arkansas and did not complete required background checks for two nurse aides. Review of employee files revealed that both CNAs were certified in Oklahoma, but there was no documentation of Arkansas certification, current abuse registry checks, or other background checks specific to Arkansas. Additionally, annual employment screening required by Oklahoma regulations was not documented for either CNA. Skills check-off documentation was only present for one CNA, and neither file contained evidence of Arkansas-specific qualifications or screenings. Interviews with the CNAs confirmed that they were unsure of their certification status in Arkansas and relied on their Oklahoma credentials. One CNA was unfamiliar with Enhanced Barrier Precautions and could not clearly articulate infection control procedures. Facility policies and job descriptions required state-approved training and certification, but the documentation and interviews indicated these requirements were not met for the two CNAs reviewed.
Failure to Conduct Comprehensive Facility Assessment and Staffing Evaluation
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment as required by its own policy and regulatory standards. The assessment did not include a thorough evaluation of available staffing, staff competencies, or training, nor did it incorporate a community-based risk analysis to identify potential natural disasters and their impact on residents and operations. The facility also did not formulate a plan for staff recruitment or retention to meet resident needs, and the assessment lacked up-to-date information on staffing needs by shift, relying instead on outdated ratios and an incomplete addendum that did not specify actual staffing requirements. A review of the facility's assessment profile revealed that while intravenous (IV) therapy was provided as a nursing service, there was no documented plan for education or training of LPNs in IV medication administration or care of specialized IV access devices. The facility did not assess or reassess nurse qualifications to ensure they could meet the identified nursing services. Additionally, the facility did not conduct a self-assessment to identify potential natural disasters or analyze their impact on residents, staff availability, utilities, or supplies, instead referring to a separate emergency preparedness binder that was not integrated into the facility assessment process. Interviews with staff indicated significant gaps in leadership and staffing. The facility was operating without a DON, and the ADON, who was also the Infection Preventionist, was unable to assume DON duties due to bedside responsibilities. The Medical Records Nurse reported being unable to perform her primary duties for an extended period due to working on the floor. These staffing challenges were not addressed in the facility assessment, and there was no outlined plan for recruitment or retention of staff to fill critical roles.
Failure to Maintain Organized and Accurate Medical Records
Penalty
Summary
The facility failed to maintain an organized and accurate medical record management system, resulting in incomplete and inaccessible resident records. Staff interviews revealed that the individual responsible for medical records was also working as a floor nurse and had not been able to keep up with documentation, prioritizing resident care over paperwork. There was no Director of Nursing (DON) in place, and as a result, essential documentation such as care plans, Minimum Data Sets (MDS), Medication Administration Records (MAR), and Treatment Administration Records (TAR) were not being completed or maintained. Staff reported that care plans had not been generated, and only basic admission evaluations were available, which were not comprehensive or updated. Record reviews for multiple residents showed missing or incomplete documentation, including the absence of MDS assessments, baseline and comprehensive care plans, physician progress notes, activity notes, provider orders, and diagnoses. In one instance, a resident's oxygen orders and CPAP documentation could not be found in the paper chart, and the medical director was unable to locate the necessary orders or explain how staff accessed the information needed for care. The medical director acknowledged a system failure and was unaware of the process for maintaining or reviewing care plans and assessments. Staff interviews further confirmed that no one had assumed responsibility for care plans, fall assessments, or MDSs in the absence of a DON, and the assistant director of nursing was overwhelmed with floor duties and infection control. Facility policy reviews indicated clear requirements for timely and comprehensive assessments and care plans, but these were not being followed. The job descriptions for the DON and medical director outlined responsibilities for oversight and quality assurance of medical records and care planning, but these duties were not being fulfilled. Additionally, the former human resources director reported witnessing falsification of records, including forged signatures on assessments and in-service documentation, and manipulation of time records to falsely indicate RN presence. These actions and inactions led to a breakdown in the facility's ability to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Failure to Provide Disclosure of Ownership Documentation
Penalty
Summary
The facility failed to provide disclosure of ownership paperwork upon repeated requests by surveyors. On three separate occasions, the Administrator was asked to supply the required documentation, but it was not provided. The Administrator indicated that the Director of Operations would be arriving to address the request, but even after this assurance, the paperwork was still not submitted by the time the survey concluded. No information regarding residents or their medical conditions was included in the report. This deficiency was identified based on the facility's inaction in responding to multiple direct requests for ownership disclosure documentation, as required by regulations.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff members upon hire and did not conduct in-service training on QAPI for direct care staff. Review of the QAPI Binder, which was last revised in April 2023, showed no documentation of QAPI training for staff, despite committee signatures indicating that staff are to be trained in QAPI systems and principles. Additionally, the facility assessment listed monthly in-services on various topics such as disaster drills, abuse/neglect, and resident rights, but did not include QAPI training. Employee file reviews for a CNA and an LPN revealed no evidence of QAPI training at the time of hire, although other required trainings were documented. Interviews with the Administrator and Director of Operations confirmed that QAPI in-services were not conducted and that QAPI meetings were held quarterly with participation from the executive team, but there was no evidence of QAPI training for all staff as required.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to all staff members upon hire and did not include compliance and ethics in its ongoing in-service education. Record reviews of the Required In-Service Book and Facility Assessment showed that in-services covered topics such as dementia/behavioral training, resident rights, infection control, emergency response, abuse and neglect, misappropriation of property, disaster drills, staff burnout, oral hygiene, lock out tag out, elopement, and coronavirus, but did not include compliance and ethics. Interviews with the Administrator confirmed that if a topic was not listed in the in-service book, it was not covered, and the Administrator did not respond when specifically asked about ethics training. Further review of employee files for a CNA and an LPN revealed no documentation of Compliance and Ethics training upon hire, with only other topics such as abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care, and suctioning acknowledged. Staff interviews confirmed that in-services were limited to the topics listed and did not include compliance and ethics. This lack of training was consistent across staff roles and was confirmed by both documentation and staff testimony.
Failure to Complete Timely MDS Assessments Due to Leadership Gaps
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the required 14-day timeframe for four residents reviewed. Facility policy requires a comprehensive assessment within fourteen days of admission, with the Assessment Coordinator responsible for ensuring timely completion. Record reviews showed that for multiple residents, including those with complex medical conditions such as congestive heart failure, dementia, diabetes, respiratory failure, and chronic kidney disease, the MDS assessments were either not completed or were significantly overdue. For example, one resident's quarterly MDS was still in progress well past the Assessment Reference Date, and another had both entry and admission MDSs overdue by 12 to 18 days. In some cases, the admission MDS was not completed until well after the deadline. Interviews with staff revealed a lack of clarity and accountability regarding MDS responsibilities. The LPN newly assigned to the MDS role reported that some residents did not have MDS assessments completed and that the previous DON, who was terminated, had not completed any MDSs during her tenure. The Assistant Director of Nursing stated she was unaware of the MDS and care plan status and had not assumed DON responsibilities. The Medical Director acknowledged the importance of timely MDS completion but stated he was not involved in the process. These findings indicate that the absence of a responsible party for MDS assessments during a period of leadership transition led to the deficiency.
Failure to Accurately Complete MDS Assessments for Bedrail and Respiratory Device Use
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, specifically regarding the use of bedrails and respiratory support devices. For one resident, the quarterly MDS did not indicate the use of bedrails, despite documentation and interviews revealing that bedrails were in use. The resident experienced multiple falls, resulting in fractures to both arms, and there was no documentation of family education or consent regarding bedrail use. Facility policy required assessment and documentation of bedrail use, including risks and appropriate interventions, but these steps were not followed. For another resident, the admission MDS did not reflect the use of continuous oxygen via nasal cannula or CPAP, even though these treatments were being provided. Interviews with nursing staff revealed confusion and lack of knowledge about where to find or document oxygen orders, and the absence of a DON led to incomplete assessments and missing documentation. The staff responsible for MDS completion either lacked access to necessary systems or were unaware of their responsibilities, resulting in incomplete and inaccurate resident assessments. Facility policies required comprehensive assessments to guide care planning and interventions, but these were not adhered to during the period when the DON position was vacant. Staff interviews confirmed that essential assessments, including fall and bedrail assessments, were not performed, and there was no clear delegation of responsibilities. The lack of accurate MDS documentation and failure to follow established protocols contributed directly to the deficiencies identified for both residents.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents as required by policy. For one resident, no Minimum Data Set (MDS) was completed after admission, resulting in the absence of a care plan with interventions to guide care for 26 days. Another resident receiving hospice services did not have a completed MDS or baseline care plan, with MDS assessments overdue by up to 18 days. A third resident's quarterly MDS was not completed, and although a care plan was eventually initiated, it was delayed and only addressed certain risks such as skin breakdown, falls, and pain. The fourth resident, with multiple medical diagnoses including malignant neoplasm, also did not have a completed MDS or comprehensive care plan at the time of review. Interviews revealed that the Director of Nursing (DON) was responsible for care plans, fall assessments, and MDSs, but these duties were not reassigned after the DON position became vacant. As a result, some residents only had limited care plans addressing basic needs such as transfers, incontinence, or eating, rather than comprehensive plans derived from thorough assessments. These findings were based on observations, interviews, record reviews, and facility document reviews.
Failure to Revise and Update Comprehensive Care Plans After Falls
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plans within the required timeframe for two residents who experienced multiple falls, including one with a major injury. For one resident with severe cognitive impairment and a history of 22 falls, the care plan was not updated to reflect each fall or to include new or escalated interventions. Documentation showed that only four of the 22 falls had any interventions recorded, and the majority of falls lacked both interventions and updates to the care plan. Staff interviews confirmed that fall interventions were not consistently included in the care plan used by direct care staff, and some interventions, such as the use of a floor mat, were not maintained or documented in the care plan. For the second resident, after an unwitnessed fall resulting in a major injury and subsequent readmission, the care plan was not revised to address the new risks or to include interventions following the incident. Review of records indicated that several falls occurred without corresponding updates to the care plan, and some incident reports lacked any documented interventions. Staff interviews revealed that care plans had not been generated or updated due to the absence of a Director of Nursing, and the care plans available to staff were incomplete, focusing mainly on basic care needs rather than comprehensive fall prevention or response. Facility policy requires that comprehensive, person-centered care plans be developed within seven days of the comprehensive assessment and updated with any significant change in condition, such as falls. The failure to update care plans after repeated falls and significant injuries, as well as the lack of documented interventions, demonstrates noncompliance with facility policy and regulatory requirements. Staff interviews further confirmed that the care plans in use did not reflect current risks or interventions, and there was a lack of leadership oversight to ensure care plans were maintained and revised as needed.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and sanitation practices. During an inspection of the kitchen and unit refrigerators, they observed expired food items, food without proper labeling or dating, and food that was not covered as required by facility policy. Specific findings included bags of lettuce, biscuit mix, crackers, and other items with expired or missing dates, as well as prepared foods such as cherry delight, apple pie, and ice cream that were not labeled or dated. Additionally, some food items were found uncovered in the walk-in refrigerator, and the facility's policy requiring all food to be labeled, covered, and dated was not consistently followed. The kitchen equipment was also found to be inadequately maintained. The fryer contained dried oil, grease, and food particles, and the oil was dark and contained visible debris, indicating it had not been cleaned as required. The ice machine was found to have black specks after being wiped, and cleaning logs showed it had not been cleaned according to the facility's weekly schedule. These observations were confirmed by dietary staff and the Certified Dietary Manager, who acknowledged that cleaning had not occurred as frequently as required. Further, the surveyors found that employee and resident food items were stored together in unit refrigerators, contrary to facility policy, which prohibits staff food from being stored with residents' food. Items belonging to both staff and residents were found without proper labeling, dating, or identification. Interviews with staff and the administrator revealed a lack of consistent adherence to these policies, with some staff believing it was acceptable to store items together if they were dated, despite the written policy stating otherwise.
Arbitration Agreement Lacked Required Admission Condition Statement
Penalty
Summary
The facility failed to ensure that its arbitration agreement, which was presented to residents or their representatives during the admission process, clearly stated that signing the agreement was not a condition of admission. Review of the facility's undated Arbitration Agreement and accompanying checklist revealed that there was no statement indicating that signing was not required for admission, although the agreement did mention that signing was voluntary and could be rescinded within ten days. During an interview, the Business Office Manager confirmed that while she verbally informed residents and representatives that signing was not a condition of admission, this information was not included in the written agreement. Additionally, the facility did not have a policy regarding arbitration agreements.
Arbitration Agreement Lacks Venue Provision
Penalty
Summary
The facility failed to ensure that its arbitration agreement, which was signed by residents or their representatives, included a provision specifying that the venue for arbitration disputes would be convenient for both parties. Review of the facility's undated Arbitration Agreement and Arbitration Checklist showed no mention of a mutually convenient location for arbitration proceedings. During interviews, the Business Office Manager confirmed that the agreement did not address venue details and that she informed residents and their representatives that signing the agreement was not a condition of admission. Additionally, the Administrator stated that the facility did not have a policy regarding arbitration.
Failure to Implement and Maintain Infection Control Precautions
Penalty
Summary
The facility failed to properly identify and implement necessary infection prevention and control measures for two residents requiring special precautions. One resident with wounds infected by Pseudomonas aeruginosa was not placed on Transmission Based Precautions (TBP), as there were no TBP orders, signage, or personal protective equipment (PPE) available outside the room or in the hallways. During wound care, a registered nurse performed hand hygiene and changed gloves but did not use a gown as required for TBP. Laboratory results confirming the infection were present in the resident's record, but appropriate precautions were not initiated. Another resident with an indwelling urinary catheter was not identified for Enhanced Barrier Precautions (EBP), and there were no EBP orders or signage posted. PPE was not available outside the resident's room or in common areas. During catheter care, a certified nursing assistant donned PPE but failed to maintain clean technique, touching contaminated surfaces and her own mask without changing gloves or performing hand hygiene before continuing care. This improper technique increased the risk of cross-contamination. Interviews with staff revealed inconsistent and insufficient training on infection control practices, including EBP and the correct use of PPE. Some staff were unclear about the requirements for EBP, and several had not received training on donning PPE. The former Director of Nursing was unfamiliar with the differences between EBP and TBP, and there was no clear leadership overseeing infection control responsibilities at the time of the survey.
Failure to Implement Dietary Recommendations for Resident with Weight Loss
Penalty
Summary
The facility failed to implement a dietary recommendation for a resident with significant medical conditions, including metabolic encephalopathy, atherosclerotic heart disease, multiple sclerosis, and type 2 diabetes mellitus. The resident, who had severe cognitive impairment and required assistance with eating, experienced documented weight loss of 5% or more in the last month or 10% or more in the last six months. A dietary recommendation was made by the Registered Dietician (RD) for high calorie snacks between meals due to the resident's oral intake being less than 25% and a 17% weight loss over three months. Despite this recommendation, staff interviews revealed that no morning or afternoon snacks were routinely provided, and the resident confirmed not receiving in-between meal snacks. The Certified Dietary Manager (CDM) stated that the kitchen did not send out snacks between meals and was unaware of the RD's recommendation, possibly due to email communication issues. The RD reported that dietary recommendations were typically communicated via email to the CDM, but could not specifically recall the recommendation for this resident without reviewing the chart. Other dietary recommendations from the same date were being followed, indicating a lapse in communication or implementation for this particular resident.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident who was admitted with chronic obstructive pulmonary disease and was also receiving hospice services. Review of the resident's records showed that no baseline care plan was completed as required by facility policy. Interviews with nursing staff revealed confusion regarding responsibilities for care plan development, with some staff lacking access to the electronic health record and relying on co-workers or paper notes. At the time of review, there was no baseline care plan available in the resident's room or chart, and staff confirmed the absence of such documentation. The baseline care plan was only placed in the resident's closet after the deficiency was identified.
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Two residents with moderate cognitive impairment and independent mobility were repeatedly seeking each other’s attention and were found by a CNA on the floor with their pants down, appearing to be engaged in consensual sexual activity. Staff separated them and returned them to secure units, and an LPN reported there was no plan for a consensual sexual relationship or private time, despite awareness of prior similar behavior. Both residents described themselves as being in a loving relationship, but the facility completed no assessments related to sexual activity, made no related care plan revisions, and obtained no orders for contraception, STD testing, or specialty consults. Conversations held by leadership with the residents about privacy and protection were not documented, and there was no facility policy addressing resident sexual relations, despite a general resident rights policy referencing self-determination and support in exercising rights.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
A resident with hemiplegia, hemiparesis, a below-knee amputation, moderate cognitive impairment, and wheelchair dependence was transported in a facility van by a CNA who had previously been in-serviced and skills-checked on van safety. During the trip, the CNA secured only three of the four required wheelchair floor locks, and a hold-down device had been removed from the van and not replaced. As the CNA drove over a road irregularity and braked, the incompletely secured wheelchair tilted backward, causing the resident to fall onto the van floor and report head pain with a nodule at the base of the skull. Facility policy required an environment free from accident hazards and staff competency in preventing avoidable accidents, but the missing tie-down and failure to fully secure the wheelchair led to this transport-related fall.
Surveyors found that the facility failed to follow physician orders for PICC line dressing changes, wound care, and catheter care for two residents. One resident with osteomyelitis, pressure ulcers, and an indwelling catheter had multiple missing entries on the TAR for ordered PICC line dressing changes, daily pressure ulcer treatments to the heel and coccyx, and catheter care every shift, with the DON confirming that blank TAR blocks indicated treatments were not completed. Another resident with a PICC line for antibiotic therapy had an order for weekly dressing changes, but the dressing was not changed as scheduled, the PICC site was left uncovered for several minutes during medication administration, and an LPN admitted initialing the TAR to indicate a dressing change that she had not performed, while the TN and APN confirmed the order required adherence to the weekly schedule.
A resident with MRSA colonization and a PICC line for IV antibiotics experienced multiple breaches in infection control by nursing staff. An LPN repeatedly double-gloved, handled room surfaces, trash can lids, and the medication cart, then donned new gloves without performing hand hygiene before preparing and administering oral and IV medications. During PICC access, the LPN wiped the access port for only a few seconds, allowed IV tubing to touch bedding, let the access port fall onto the resident’s arm, and then re-accessed the line without hand hygiene or glove changes. At another time, the PICC site was left uncovered while a treatment nurse prepared for a dressing change, and the LPN entered without prior hand hygiene, disconnected IV tubing, and flushed the line after only a brief alcohol wipe. Staff interviews showed uncertainty and inconsistency regarding required scrub times, glove use, and dressing change schedules, which conflicted with facility policies and stated expectations for aseptic PICC care and hand hygiene.
A resident with dementia, anxiety, depression, and on hospice had a Durable Power of Attorney, Living Will, and signed DNR order all specifying no CPR, and the face sheet reflected no CPR; however, physician orders, a MD progress note, and the MAR repeatedly listed the resident as full code from admission onward. Nursing staff and leadership (including a RN, LPN, ADON, DON, and the Administrator) acknowledged that while the advance directives and resuscitate/DNR form showed DNR status, the active orders and MAR still indicated full code, even though staff commonly rely on these documents to determine code status, contrary to facility policy requiring alignment of the care plan and physician orders with the resident’s documented treatment preferences.
A resident with depression, insomnia, and non-Alzheimer’s dementia experienced a documented decline from moderate to severe cognitive impairment on successive MDS assessments, but the care plan was not revised and continued to include an active "Sexual Expression" problem allowing engagement in sexual behavior with other consenting residents. This care plan had been initiated after an incident where two residents were found in bed together partially undressed and engaging in intimate behavior. The resident’s responsible party stated the resident was not capable of consenting to sexual activity, an LPN reported the resident could not express needs or make decisions about sexual relationships, and another LPN stated the care plan no longer reflected the resident’s needs due to steady decline. The Social Services Director had previously completed sexual consent questionnaires only at the time of the incident, and the Medical Director indicated that a sexual activity care plan was not appropriate for a resident with a very low BIMS score, while the Administrator acknowledged care plans were expected to be updated when MDS changes occurred.
A resident with traumatic brain injury, stroke history, and altered mental status was placed on a secured unit for elopement risk but had only general care plan interventions that were not updated when new wandering, exit‑seeking, and aggressive behaviors emerged. Over time, staff documented that the resident walked the halls at night, entered other residents’ rooms, voiced not living there, stated plans to leave through a window, followed staff through locked doors, and sought ways to get out after a home visit. Despite an elopement assessment and multiple behavior notes, no individualized elopement‑prevention interventions were added to the care plan. Eventually, during a night shift when a CNA reported dozing off and not re‑checking the room, the resident broke a bedroom window with furniture, left the building, and was later found off‑site by police after nearly being hit by a car, confirming that the care plan had not been effectively revised or implemented to address the resident’s exit‑seeking behaviors.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
Two residents with significant cognitive and neuromuscular/orthopedic conditions experienced falls when staff did not follow care-planned assistance and supervision requirements. One resident, care-planned for two-person assist with bed mobility, transfers, and personal hygiene, was found on the floor after a CNA attempted incontinent care alone. Another resident, care-planned for staff assistance with dressing and two-person assist for transfers with a slide board, was left seated at the edge of the bed and told to dress themself; the resident fell while unattended and was later found on the floor wearing a C-collar. CNAs reported relying on the electronic care plan/Kardex for instructions, but one CNA described unclear and brief initial training on accessing the system, while leadership stated CNAs were expected to verify care needs in the electronic care plan before each care episode.
Failure to Support and Assess Consensual Sexual Relationship Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to support residents’ rights to engage in a consensual sexual relationship between two cognitively impaired residents. Both residents had documented moderate cognitive impairment on their MDS assessments (BIMS scores of 11 and 12) and were independent with mobility. Their care plans identified "inappropriate seeking of other individual's attention" with interventions limited to separating and redirecting them. There was no documented assessment of their capacity for sexual decision-making or sexual activity either before or after an incident in which they were found with their pants down on the floor together. On the date of the incident, a CNA discovered the two residents in a room with their pants down, appearing to be having sex, and reported that it looked like they were consenting and that she had been told they had a history together. The CNA notified an LPN, and the residents were separated and returned to their secure units. The LPN confirmed there was no plan in place to allow a consensual sexual relationship or to provide private time for the residents, despite being aware that similar behavior had occurred previously. Interviews with the residents indicated that they viewed themselves as being in a relationship, that they loved each other, and that they did not intend harm. Record review showed no orders for birth control, sexually transmitted disease testing, or referrals to specialized clinics or physicians for either resident. There was no documentation in progress notes of education or conversations with staff regarding the incident, and no assessments related to sexual activity were completed before or after the event. The MDS nurse and Administrator acknowledged speaking with the residents about the incident and the possibility of providing privacy and protection, but the MDS nurse stated that none of these discussions or interventions were documented and nothing was added to the care plans. The Administrator also stated the facility did not have a policy on resident sexual relations, despite a resident rights policy referencing residents’ rights to self-determination and to be supported in exercising their rights.
Failure to Care Plan for Residents’ Sexual Health and Consensual Relationship
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable care plans addressing sexual health and consensual sexual relationships for two cognitively impaired residents. Resident #3, admitted with traumatic brain injury, bipolar disorder, mood disorder, and an unspecified mental disorder, had a BIMS score of 11 indicating moderate cognitive impairment and was independent with mobility. Resident #4, admitted with schizophrenia, schizoaffective disorder bipolar type, dementia, and psychosis, had a BIMS score of 12, also indicating moderate cognitive impairment, and was independent with mobility. Both residents’ care plans, updated on 03/11/2026, identified “inappropriate seeking of other individuals’ attention,” but the only interventions listed were to separate and redirect, with no individualized care plan addressing their sexual health, their ongoing relationship, or parameters for consensual sexual activity. On 03/11/2026, a CNA discovered Resident #3 and Resident #4 on the floor with their pants down, appearing to be engaged in consensual sexual activity. The CNA notified an LPN, and staff separated the residents and returned them to their secure units. Staff interviews revealed that there was no existing plan for a consensual sexual relationship, no plan for private time, and no documented assessment or care plan interventions related to sexual health, safe sex education, or contraception for these residents, despite knowledge of a prior relationship and the residents’ expressed desire and intent to engage in sexual activity. The MDS nurse and the Administrator acknowledged that no care plan revisions were made to address sexual health or the relationship, no documentation of related discussions or interventions was completed, and the facility had no policy on resident sexual relations and no established interventions for birth control.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wheelchair was fully and properly secured with all required safety straps before transport in the facility van, resulting in the resident falling backwards in the van. The resident had physician orders for LTC admission and diagnoses including hemiplegia and hemiparesis affecting the right dominant side, as well as an acquired absence of the left leg below the knee. The resident’s MDS showed moderate cognitive impairment, functional limitations in lower extremity range of motion bilaterally, and use of a wheelchair for mobility. The care plan documented a self-care performance deficit requiring limited assistance by one staff for transfers and noted an actual fall earlier in the month, with an intervention for staff education on proper van transport. On the date of the incident, the resident was being transported in the facility van by a CNA who served as the van driver. According to the facility’s reportable and the CNA’s written witness statement, the CNA applied two back floor locks and one front floor lock to secure the wheelchair but did not secure all four required locks. During the drive, as the CNA approached a dip or hump in the road and applied the brakes, the resident’s wheelchair tilted backwards. The resident stated they were falling, and when the CNA stopped the van, she found the resident lying flat on their back on the van floor with the wheelchair also on the floor. Nursing documentation indicated the resident reported pain at the base of the skull, had a nodule on the back of the head, and declined transfer to the emergency room. Interviews and document reviews showed that the CNA had previously received in-service training and skills checkoffs on how to properly secure residents in the van and had signed best-practice forms stating that wheelchairs would be securely attached to the van body and kept centered during transport. The Administrator reported that the CNA admitted she did not use the correct number of straps to secure the wheelchair and that a hold-down device (tie-down/safety strap) had been removed from the smaller van to be used in a larger van and was not replaced. The Maintenance staff confirmed that a hold-down device for the back of the wheelchair was missing from the van used for the transport and that tie-downs were interchangeable between vans. Subsequent observation with other CNAs demonstrated that when all four locks and the seat belt were properly engaged, the wheelchair did not move, but loosening the front locks allowed the wheelchair to move, illustrating how incomplete securement could permit wheelchair movement during transport. The facility’s Safety and Supervision of Residents policy stated that the environment should be made as free from accident hazards as possible and that employees should be trained and demonstrate competency in identifying and preventing accident hazards. Despite this policy and prior in-services, the resident’s wheelchair was not fully secured with all required straps at the time of transport, and a necessary hold-down device was missing from the van, directly contributing to the resident’s fall inside the vehicle.
Failure to Follow Physician Orders for PICC Line, Wound, and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for PICC line dressing changes, wound care, and indwelling catheter care for two residents. One resident was admitted with osteomyelitis of the vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus, and a pressure ulcer, and had a BIMS score indicating moderate cognitive impairment. Physician orders included a PICC line dressing change every three days, daily dressing changes to an unstageable right heel pressure ulcer, daily cleansing and dressing of an unstageable coccyx pressure ulcer, and catheter care every shift and PRN with soap and water or wipes for wound healing. Review of the Treatment Administration Record (TAR) for June showed multiple dates where there were no initials or check marks to indicate that the PICC line dressing changes, right heel dressing changes, coccyx pressure ulcer treatments, and catheter care had been completed as ordered. The TAR for this resident showed no documentation of PICC line dressing changes on several specified dates, despite an active order for changes every three days. Similarly, the TAR lacked initials or check marks for the ordered daily dressing changes to the right heel pressure ulcer on multiple dates. For the coccyx pressure ulcer, there were two separate orders—one to cleanse and apply wet-to-dry dressings with a specific brand dressing and island dressing every day shift, and a later order to cleanse and apply wet-to-dry dressings with a specific brand dressing and foam dressing every day shift. On several dates, the TAR contained open blocks with no initials or check marks, indicating that these treatments were not completed. Additionally, the TAR showed that catheter care ordered every shift and PRN was not documented as completed on multiple day shifts over a series of days. The DON confirmed that open blocks on the TAR indicated treatments were not completed. For the second resident, who was admitted with infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices, there was an order for a PICC line dressing change to the left upper arm every Wednesday on the day shift. The March TAR reflected this order and showed documented dressing changes on two Wednesdays, with check marks and initials indicating the treatment had been administered. During a medication pass observation, an LPN examined the PICC line dressing and was unsure of the last dressing change date, noting that the handwritten date on the dressing was unclear and that PICC line dressings could only be changed by an RN. Later observation showed the treatment nurse at the bedside with the PICC line site uncovered after the dressing had been removed, while the LPN administered oral medications and hung an antibiotic through the PICC line, leaving the site uncovered for several minutes. The treatment nurse stated the dressing change had been due the previous day but was not completed because the dressing was not available, and also stated she signed the TAR after completing the dressing change. Further interviews revealed documentation discrepancies for this second resident. The DON’s nursing incident/accident note documented that the PICC line dressing change was not completed on the scheduled day and was instead changed the following day. The LPN later acknowledged that the initials on the TAR for the scheduled dressing change date were hers, and admitted she had not changed the dressing but had only looked at it after being told by the treatment nurse that the dressing was within a seven-day time frame. She stated she placed her initials in the TAR block to indicate she had looked at the dressing, even though the TAR coding indicated that initials in the block meant the treatment was given. The treatment nurse reported changing the dressing on one earlier date and, when changing it later, observed a written date on the removed dressing that did not match any documented TAR entry and could not identify whose initials were on that dressing. The treatment nurse and APN both confirmed that the physician’s order required the dressing to be changed every Wednesday and that, even if changed on another day, it still needed to be changed on Wednesday per the order. The DON confirmed that staff initials in a TAR block indicated the treatment was given, an X indicated the treatment was not ordered for that day, and an open block indicated the treatment was not completed.
Improper Hand Hygiene and PICC Line Management During MRSA-Positive Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during the care of a resident with a PICC line and MRSA colonization. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, MRSA, and pain related to orthopedic prosthetic devices. The resident had a PICC line in the left arm for IV antibiotic therapy to treat the hip infection, and the care plan included contact isolation, use of gowns and gloves during physical contact, handwashing before leaving the room, and standard precautions for infection control. Orders and the TAR showed that PICC line dressings were to be changed weekly, and the MAR showed daily IV antibiotic administration. Surveyor observations on one morning showed that an LPN performed hand hygiene and donned two pairs of gloves along with other PPE before entering the resident’s room to obtain blood pressure and administer medications. The LPN entered the room multiple times, repeatedly double-gloving, and handled the blood pressure cuff, trash can lid, medication cart, and medication cards without performing hand hygiene between glove removal and donning new gloves. At one point, the LPN removed gloves, closed the trashcan lid with a gloved hand, then removed gloves and immediately donned a clean pair without hand hygiene before preparing and administering the resident’s oral medications. Later, when preparing to administer IV antibiotic through the PICC line, the LPN again donned PPE, placed supplies on paper towels on the overbed table, removed the cap from the PICC access port, and wiped the port with an alcohol pad for less than three seconds before flushing with normal saline. During this process, IV tubing touched the resident’s bedding, the access port fell back onto the resident’s arm, and the LPN discarded the contaminated tubing, obtained new tubing, and again wiped the access port for less than three seconds before attaching the tubing and starting the IV medication, without performing hand hygiene or changing gloves during the sequence. A subsequent observation the same day showed the treatment nurse at the bedside with the resident’s PICC line dressing removed, leaving the site uncovered while the resident looked at the open site and was not wearing a mask. The LPN entered without performing hand hygiene before donning PPE, administered oral medication, disconnected the IV tubing from the PICC line, wiped the access port for three seconds, and flushed with normal saline. The treatment nurse stated responsibility for PICC dressing changes and believed the last dressing change had occurred the prior week, but also reported that the dressing removed that day was marked with a date indicating it was due for change the previous day and that the dressing had not been changed because supplies had to be ordered. Facility records showed that the TAR had been signed for a PICC dressing change on a scheduled day, while later nursing documentation described that a dressing change ordered for a specific day had not been performed as ordered. Facility policies and CDC-based documents required hand hygiene before and after glove use, hand hygiene after glove removal, and disinfection of needleless access devices for at least 15 seconds, and the DON stated that the PICC port should be cleaned for 15 seconds and that the dressing should be in place before starting medication, which contrasted with the observed practices. Interviews with the LPN revealed that double gloving was used so gloves would not have to be changed as often, and the LPN acknowledged that hand hygiene should have been performed after removing gloves and before donning new ones. The LPN initially could not state the required length of time for scrubbing the PICC access port and later stated it should have been cleaned for at least 15 seconds, which differed from the observed practice of wiping for less than three seconds. The treatment nurse described limited availability of PICC dressing kits and that no specific person was responsible for ordering them, and reported having changed the resident’s PICC dressing two to three times since admission. The APN and DON both stated expectations that PICC sites and access ports be kept sterile or clean during medication administration and flushing, that staff use only one set of gloves at a time with handwashing between glove changes, and that the PICC port be cleaned for 15 seconds with alcohol swabs even when medicated caps are used. These expectations and policies contrasted with the observed failures in hand hygiene, glove use, PICC port disinfection, and maintaining an intact dressing prior to accessing the PICC line.
Inconsistent Documentation of DNR Status in Medical Record
Penalty
Summary
The facility failed to ensure that one resident’s medical record accurately and consistently reflected the resident’s advance directive specifying no Cardiopulmonary Resuscitation (CPR). The resident had non-Alzheimer’s dementia, anxiety, depression, moderate impairment in decision-making, and was receiving hospice services. Documentation in the record included a Durable Power of Attorney for Health Care, a Living Will Declaration, and a Resuscitate/Do Not Resuscitate order, all indicating that CPR and chest compressions were to be withheld and that the resident was a Do Not Resuscitate (DNR). The resident’s face sheet also indicated an advance directive for no CPR. Despite these documents, multiple parts of the electronic health record and physician documentation identified the resident as a full code. Physician’s orders from admission onward, including after the resident was admitted to hospice, contained orders indicating full code status. A MD progress note also documented the resident as a full code, and the Medication Administration Record (MAR) for the reviewed period listed the resident as full code. These entries conflicted with the existing DNR orders and advance directive documents in the record. Interviews with nursing staff and leadership confirmed awareness of the discrepancy between the resident’s documented advance directives and the active physician orders and MAR entries. A RN, an LPN, the ADON, the DON, and the Administrator each acknowledged that the resident’s advance directives and resuscitate/do not resuscitate order indicated DNR status, while the current physician orders and MAR showed full code. Staff stated that code status is typically verified using the medical record, MAR, and face sheet, and they recognized that the inconsistency meant staff could rely on incorrect information about whether to initiate CPR. Facility policy required that advanced directives be respected, that the plan of care be consistent with documented treatment preferences, and that the physician be notified so appropriate orders could be documented in the medical record and care plan, which did not occur in this case.
Failure to Revise Sexual Expression Care Plan After Cognitive Decline
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan after a significant decline in cognitive status and changes documented on the quarterly MDS. One resident with active diagnoses of depression, insomnia, and non-Alzheimer’s dementia had a BIMS score of 09 on the 07/30/2025 quarterly MDS, indicating moderate cognitive impairment, which later declined to a BIMS score of 03 on the 01/05/2026 quarterly MDS, indicating severe cognitive impairment. Despite this documented decline, the resident’s care plan continued to include an active problem of “Sexual Expression,” initiated on 08/15/2025 after an incident in which the resident was found in another resident’s bed with both residents partially undressed and engaging in intimate behavior. The care plan goal was to allow the resident to engage in sexual behavior with other consenting residents, with interventions focused on ensuring appropriate consent, providing privacy, and observing for changes in mood or cognition. Interviews and record reviews showed that the care plan was not updated to reflect the resident’s current cognitive status or capacity for consent. The resident’s responsible party stated that the resident was not capable of consenting to sexual relationships or activity and had not been capable for a long time, and identified themselves as the decision maker. An LPN familiar with the resident reported that the resident could not express needs or wants and did not believe the resident was ever capable of making decisions about a sexual relationship, despite what was documented on the care plan. Another LPN stated that the current care plan was not accurate due to the resident’s steady decline. The Social Services Director reported completing sexual consent questionnaires for both involved residents at the time of the original incident and determining they could consent, but acknowledged the form was not set to repeat on subsequent assessments. The Medical Director stated that a care plan for sexual activity for a resident with a BIMS score of 03 was not appropriate because sexual knowledge would be low, and the Administrator confirmed that care plans were expected to be updated quickly when the MDS reflected a change, underscoring that this did not occur for this resident’s sexual expression care plan.
Failure to Update Care Plan for New Exit-Seeking Behaviors Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts. On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors. In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.
Removal Plan
- Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
- Complete new elopement risk assessments for residents residing on the secured unit.
- For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
- Complete environment exit safety checks.
- Revise and update all secured unit residents' care plans based on the Plan of Removal.
- Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
- Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
- Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
- Order shatter-resistant film for front-facing secured unit windows and install it.
- Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
- Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.
Elopement from locked unit due to inadequate supervision and response to exit-seeking behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known wandering and elopement risk, resulting in an elopement through a broken bedroom window. The resident had a history of traumatic brain injury, cerebral infarction, altered mental status, and wandering, and had been admitted to a secured unit due to elopement risk. An MDS assessment earlier in the year showed the resident as cognitively intact and independently ambulatory, but a later BIMS assessment showed moderately impaired cognition. The resident’s care plan identified the need for placement on a secured unit related to traumatic brain injury and elopement risk, with interventions focused on therapeutic activities and monitoring of psychotropic medications, but did not include enhanced supervision measures in response to escalating exit-seeking behaviors. In the weeks prior to the elopement, multiple progress notes and staff interviews documented increased exit-seeking and behavioral changes after the resident returned from a home visit. On one day, progress notes recorded that the resident was up all night walking the halls, going in and out of other residents’ rooms, voicing that they did not live in the facility, and stating an intention to get out through a window. Staff documented that the resident had been seeking elopement since returning from a home visit, had been looking for ways to get out, followed staff out locked doors, and showed force when staff tried to return the resident to the unit. Another note from the same day described the resident talking loudly, being aggressive toward staff, and repeatedly expressing a desire to leave the facility. An elopement assessment documented that the resident ambulated independently, had a history of following staff and others, and had been wandering halls and standing by locked exit doors after returning from home. On the night of the elopement, camera footage showed the resident repeatedly moving between the resident’s room, the day room, and the bathroom until entering the room at approximately 3:12 a.m. and not re-emerging. Staff interviews revealed that the CNA assigned to the unit acknowledged that the resident had been trying to start a fight with another resident for two days, that the resident typically went in and out of the room throughout the night, and that staff did not normally go back to check on the resident once the resident returned to the room. The CNA reported that she did not check on the resident after the last interaction around 9:30–10:00 p.m., that she sometimes could not take breaks due to staffing, and that she dozed off for about 30 minutes during the shift. The DON later stated that the CNA reported falling asleep and not hearing the window break. Staff discovered the broken window only when an LPN returned from break around 4:25 a.m., at which point the resident was found to be missing. Law enforcement records and interviews confirmed that the facility reported the resident missing in the early morning hours and that the resident was located off-site by police after a citizen reported almost striking the resident with a vehicle. The police officer stated that the resident was found near a school approximately 1.9 miles from the facility, requiring travel across an intersection and along areas without sidewalks. The resident told police they were walking to find family. Interviews with multiple CNAs and nurses indicated that the resident had been going door to door asking how to get out, watching staff to see if they were paying attention, and walking back and forth to doors after returning from a family visit. The DON and Administrator both stated they were not aware of prior elopement attempts beyond wandering and walking back and forth, and the MDS Coordinator reported she had not been informed of the January incident in which the resident voiced a plan to escape through a window. Facility policies required staff to know the location of residents under their care and to implement care plan strategies for residents at risk of wandering or elopement, but staff interviews showed that routine checks were not performed on the resident during the night of the incident and that the resident’s escalating exit-seeking behaviors were not effectively communicated or translated into increased supervision. A police incident report and witness statements further detailed that the resident exited the building by throwing an end table through the bedroom window. The facility’s own missing resident and wandering/elopement policies stated that staff are responsible for knowing residents’ whereabouts and that care plans for at-risk residents must include safety strategies and interventions. Despite documented behaviors such as wandering, standing at locked doors, following staff out locked exits, verbalizing intent to leave, and specifically stating a plan to get out through a window, there was no evidence in the record that supervision was increased or that staff adjusted monitoring practices during periods of heightened exit-seeking. Staff interviews also revealed that for several weeks there had often been only one CNA on the locked unit at night, and that the CNA on duty the night of the elopement positioned herself in a doorway with hall lights off and later admitted to dozing off. These actions and inactions resulted in the resident being able to break the window, leave the secured unit and facility, and travel a significant distance off-site before being located and returned by police.
Failure to Follow Care-Planned Assistance and Supervision Leading to Resident Falls
Penalty
Summary
Facility staff failed to follow care-planned interventions for assistance and supervision for two residents, resulting in falls. Resident #2, admitted with Alzheimer's disease, spastic hemiplegic cerebral palsy, and neuromuscular bladder dysfunction, had a care plan requiring assistance of two staff for bathing/showering, bed mobility, personal hygiene, toilet use, and transferring. On 06/04/2025, the DON and an LPN responded to Resident #2's room and found the resident on their back on the floor after CNA #1 attempted to perform incontinent care alone, contrary to the care plan specifying a two-person assist for bed mobility, transfers, and personal hygiene. CNA #1 later stated that, upon hiring, it was not made clear how to access the electronic care plan system and that initial training on the system was brief and difficult to see. Resident #3 was admitted with spinal stenosis of the cervical region, cervical disc disorder with radiculopathy, generalized muscle weakness, and was receiving surgical aftercare following nervous system surgery. The care plan required assistance of one staff member for toileting, bathing/showering, dressing, and bed mobility, and assistance of two staff members for transferring, including use of a sliding board with two-person assist. A progress note documented that on 01/15/2026, an LPN was called to Resident #3's room and found the resident lying face down on the floor wearing a cervical collar, after the resident reported being told to dress themself. The resident later recounted that a CNA had helped them to a seated position at the edge of the bed, then left the room with another staff member while the resident attempted to dress themself, during which time the fall occurred. Interviews with multiple CNAs and facility leadership confirmed that CNAs were expected to obtain resident care instructions from the electronic care plan/Kardex system and that Resident #3 required staff assistance for all tasks except meals. CNA #2 acknowledged leaving Resident #3 unattended while assisting another staff member, despite the electronic care plan indicating the resident did not perform tasks alone. Another CNA reported sometimes being the only staff member in the room when transferring Resident #3 with a slide board, even though the care plan required two staff. The DON and Administrator stated that aides were trained one-on-one on the electronic care plans after morning huddles and that CNAs were expected to verify care requirements in the electronic care plan before providing care. The Medical Director stated it was his expectation that orders were followed as written in the care plan. Standard of practice cited requires that residents receive treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices.
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