Oakwood Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakewood, Colorado.
- Location
- 5301 W 1st Ave, Lakewood, Colorado 80226
- CMS Provider Number
- 065248
- Inspections on file
- 29
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Oakwood Care And Rehabilitation during CMS and state inspections, most recent first.
The facility’s QAPI program did not effectively identify or address significant issues related to abuse, neglect, and dementia care. Despite a policy requiring a data-driven QAPI plan and PIPs, there was no active PIP for the secure memory unit, where residents were able to wander into other rooms and engage in resident-to-resident physical abuse. The NHA and DON reported that staff had not received needed education on abuse and dementia, and although they mentioned working on PIPs such as falls and dementia training, they could not provide specific details, indicating that the QAPI process was not functioning as required to manage these concerns.
The facility failed to protect multiple residents from physical and verbal abuse by other residents, particularly in a secure memory care unit where many had severe dementia, wandering, and known behavioral disturbances. A resident who wandered frequently was physically assaulted on several occasions by different residents after entering their rooms, including being grabbed in bed, pushed, and physically redirected, sometimes resulting in a fall. Other residents with severe cognitive impairment and psychiatric conditions were knocked down, pushed in hallways, grabbed by the face, scratched, and involved in altercations over preferred seating, with at least one resident sustaining a forehead laceration. Two male roommates with cognitive and impulse‑control issues engaged in escalating verbal taunting and pushing over TV noise, leading to a fall and abrasion. Staff reported that residents commonly wandered into others’ rooms, that there were no proactive barriers to prevent unauthorized entry, and that they typically redirected residents only after conflicts began, while some incidents were not substantiated as abuse despite clear aggressive contact.
The facility failed to implement person-centered dementia care and supervision for multiple residents with dementia who frequently wandered and intruded into others’ rooms. Despite care plans and facility policy requiring assessment, monitoring, and redirection of wandering and territorial behaviors, residents were repeatedly observed pacing hallways without purpose, attempting to exit locked doors, and entering both occupied and unoccupied rooms without staff in line of sight or providing timely redirection. Some residents had documented triggers for aggression when others entered their rooms or personal space, yet planned interventions such as door barrier straps and close supervision were not consistently in place. Staff interviews confirmed that many residents wandered into others’ rooms, that staff did not consistently prevent this, and that some CNAs were unaware of where to find or how to follow care plans, resulting in residents not receiving the individualized dementia management needed to maintain their well-being.
The facility did not provide required, facility-specific training on abuse, neglect, exploitation, misappropriation, and reporting procedures to contracted and agency staff, despite a policy stating it applied to all caregivers. A hospice CNA observed a resident left wet for an extended period and believed this was neglect but did not report the concern to the facility for ten days. During the survey, an agency CNA reported receiving no supplemental training on the facility’s abuse and neglect policies, and leadership acknowledged that agency staff had not been trained by the facility and that communication with the hospice agency about concerns was lacking.
The facility failed to conduct a thorough investigation into an abuse allegation when a resident with moderately impaired cognition, depression, anxiety, and mobility limitations reported that a CNA pushed her onto a bath chair, threw a towel or wash cloth at her, and spoke to her in a rough manner during showering and at bedtime on more than one occasion. The investigation included interviews with the resident and the accused CNA, but did not document when the CNA last provided care to the resident, did not include interviews with other CNAs, nursing staff, or other residents about the CNA’s care, and did not assess the shower environment or observe the CNA’s shower and transfer technique. Despite the resident’s emotional distress and existing care plan to monitor behaviors and underlying causes, the facility concluded the allegation was unsubstantiated without completing the investigative steps required by its abuse policy.
A dependent resident with severe cognitive impairment, schizophrenia, mood disorder, and epilepsy, who required staff assistance for toileting hygiene, was not checked or changed for incontinence for over six hours despite the facility’s stated expectation that dependent residents be checked at least every two hours. Continuous observation showed no direct care staff entering the room to offer incontinence care until a CNA eventually found and changed a urine-soaked brief and bed linens. Staff interviews and prior nursing notes confirmed the resident’s ongoing incontinence issues, frequent refusal of care, and history of urinating in bed and on the floor, while multiple staff, including CNAs, an RN, an LPN, the DON, and the NHA, all acknowledged the two-hour incontinence check standard.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment, with persistent odors of urine and feces, unclean floors, stained linens, and unrepaired damage in resident rooms and common areas. Residents and their representatives reported frequent unpleasant odors and visible cleanliness issues, while staff interviews revealed confusion about cleaning responsibilities and inconsistent maintenance practices.
Two residents with significant cognitive impairment and complex medical needs did not have their representatives consistently involved in care plan development, as required. Representatives reported not being invited to or having difficulty scheduling care conferences, and facility records confirmed a lack of documented conferences and incomplete contact attempts over several months.
A resident's designated representative was not notified of multiple significant changes in the resident's condition, including facial swelling, urgent dental care, leg edema, loose stools, and bruising, despite facility policy requiring such notifications. The resident was cognitively impaired and unable to communicate, and staff interviews confirmed these events should have triggered notification and documentation.
Two residents did not receive their scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames as documented in the MARs. In several instances, medications were administered late or missed entirely, despite physician orders and professional standards requiring timely administration. Both residents reported ongoing pain and noted that delays in medication administration affected their comfort.
Multiple residents reported not having access to incontinence briefs for several days, being told by staff to use towels as substitutes, and receiving incorrectly sized briefs. Staff confirmed that the facility ran out of briefs, with limited alternatives available, and described being instructed to use towels due to budget restrictions. Facility leadership denied these claims, but grievances and observations supported the reports of inadequate supply and compromised resident dignity.
A resident was discharged home without proper documentation and communication of essential medical equipment needs, specifically two transfer poles required for safe transfers. The discharge summary and care plan did not include these needs, and only one transfer pole was installed at the time of discharge. Verbal confirmations with referral sources and home health were not documented, and the physician's discharge order was inaccurate and delayed.
A resident with multiple chronic conditions did not receive prescribed doses of Farxiga for three days due to delays in pharmacy delivery and lack of follow-up by staff. Documentation failed to show that the pharmacy or physician was notified about the missed doses, and the medication was not administered even after it became available, with no explanation provided.
A resident with a history of aggressive behavior due to dementia physically assaulted two other residents, causing injuries. The facility's care planning and supervision were inadequate, failing to address the resident's behavior history and implement effective interventions. Additionally, another resident verbally abused others, highlighting the facility's failure to protect residents from abuse.
The facility failed to provide residents with food at palatable temperatures, as evidenced by resident complaints and observations of meal service. Food items were served at inadequate temperatures, and there were issues with food coverage and shortages. Staff interviews revealed that plates were not pre-warmed, contributing to the problem.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with expired and unlabeled food items found in the main kitchen and nourishment rooms. Medications were improperly stored in a refrigerator, and staff interviews revealed lapses in adherence to food safety protocols.
The facility failed to report potential abuse incidents involving two residents to the State Agency. One resident, with a history of aggressive behavior, was involved in multiple unreported incidents of aggression. Another resident was found with injuries after an altercation, but the facility documented it as a fall and did not report it. Documentation errors and reliance on agency staff contributed to the reporting failures.
A facility failed to implement a timely and person-centered care plan for a resident with dementia and a history of aggression. Despite the resident's known history of physical and verbal aggression, the care plan lacked specific interventions upon admission, leading to delayed management of aggressive behaviors. Staff interviews indicated difficulties in predicting the resident's sporadic behaviors, contributing to the deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter and stage 4 pressure wounds. Staff, including therapists and CNAs, did not use required PPE during high-contact activities, and there was no EBP signage or PPE bin outside the resident's room. Interviews revealed staff were unaware of EBP requirements, and the ADON mistakenly removed precautionary signs and bins, leading to a deficiency in infection control.
The facility failed to protect four residents from mental and verbal abuse, leading to significant emotional distress. One resident was belittled by the activities director, another was neglected by a CNA, and two residents were repeatedly verbally abused by another resident. Despite staff reporting these incidents, the facility did not take timely or effective corrective actions.
The facility failed to ensure timely access to vision services for three residents, leading to deficiencies in their care. One resident with quadriplegia and astigmatism was not seen by the eye doctor despite multiple requests. Another resident with moderate cognitive impairment had not been offered an eye doctor appointment after losing her glasses. A third resident with worsening vision had not received his prescribed glasses months after his eye exam.
The facility failed to maintain a safe and sanitary laundry room, with issues including a wet and slippery floor, an uncovered drain, water leaks, and non-functional washing machines and dryers. The maintenance director acknowledged these problems but had not yet resolved them.
The facility failed to provide a consistent and engaging activity program for residents in the secured dementia care unit, leading to a lack of meaningful activities and inadequate supervision. Residents were often left idle, and staff did not engage them in activities or conversation. Additionally, the facility did not monitor residents effectively, resulting in resident-to-resident altercations and inappropriate interactions between staff and residents.
The facility failed to assist residents in obtaining routine or emergency dental services. One resident waited five months for extractions and dentures, another had no follow-up for dentures, a third had not seen a dentist since admission despite requests, and a fourth was not referred to a specialist as recommended.
The facility failed to maintain an effective infection control program, with housekeeping staff not consistently changing gloves or performing hand hygiene, improper use of disinfectant chemicals, and lapses in COVID-19 vaccination tracking. Additionally, infection control practices were not followed during wound care and medication administration.
The facility failed to implement policies and procedures related to pneumococcal immunizations for five residents, resulting in incomplete and outdated vaccination records and a lack of determination regarding additional doses needed.
The facility failed to manage pain according to professional standards and resident preferences for two residents, leading to unmanaged pain and inappropriate administration of pain medications outside the specified parameters in physician orders.
The facility failed to ensure that a resident received treatment and care in accordance with professional standards by not consistently assessing and documenting the resident's blood pressure prior to administering blood pressure medications. Staff interviews confirmed that the medication administration record did not prompt nurses to document the blood pressure, and the resident's blood pressure had not been documented since 3/11/24.
The facility failed to provide proper catheter care and maintenance for two residents, leading to deficiencies in minimizing the risk of urinary tract infections. Both residents had no orders for routine catheter care, maintenance, or monitoring, despite having comprehensive care plans that included such interventions. Interviews with staff revealed a lack of awareness and adherence to proper catheter care protocols.
The facility failed to ensure a resident was free of unnecessary psychotropic medications by not attempting a gradual dose reduction (GDR) or providing substantial documentation on why a GDR was contraindicated. Despite quarterly reviews, no GDR attempts were documented for the resident, who was prescribed multiple psychotropic medications.
The facility failed to ensure controlled medications were securely stored and that medication carts were locked when not in use. Controlled medications were found in an unsecured refrigerator, and medication carts were left unattended and unlocked by LPNs, posing a risk to residents.
The facility failed to ensure that two residents received showers according to their preferences and that these preferences were included in their care plans. One resident preferred showers at a specific time and with female caregivers due to a history of sexual abuse, while another resident required increased oxygen during showers but was given bed baths instead. Staff cited reasons such as being busy and unaware of specific needs for not accommodating these preferences.
A resident with quadriplegia reported feeling very hot and sweaty in his room, which lacked a window and had locked double doors leading to an atrium. The maintenance director confirmed the atrium was not in use and suggested a fan as a solution, but acknowledged safety concerns. The facility failed to assess the resident's preference for fresh air and did not provide an alternative solution, leading to the deficiency.
The facility failed to promptly investigate an alleged verbal abuse incident involving a resident and the Activities Director (AD). Despite the incident being reported by three staff members, the AD continued to work with unrestricted access to residents for over five hours. The investigation lacked specific details and did not document the emotional impact on the resident.
The facility failed to provide necessary hygiene services for a resident fully dependent on staff for ADLs, resulting in long, discolored, and soiled fingernails, greasy hair, and only two showers in the past 30 days. The resident expressed frustration and distress over the lack of proper care, while staff cited time constraints and the need for additional assistance as reasons for not providing showers.
Ineffective QAPI Program Fails to Address Abuse and Dementia Care Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program capable of identifying and addressing compliance concerns related to abuse, neglect, and dementia care. The facility’s written QAPI policy required establishment and implementation of a Quality Assessment and Assurance Committee, development of a written QAPI plan reviewed and updated annually, and implementation of data-driven Performance Improvement Projects (PIPs). However, surveyors found that the QAPI committee did not identify or address issues associated with abuse, neglect, and dementia care, despite existing concerns in these areas. Cross-referenced deficiencies included failures to ensure residents were free from abuse and failures to provide appropriate dementia care to help residents attain or maintain their highest level of functioning. Record review and staff interviews further showed that the facility did not have a QAPI PIP plan in place for the secure memory care unit, even though residents in that unit were able to wander from room to room, resulting in resident-to-resident physical abuse. The NHA and DON acknowledged that, at the time of the survey, there was no active PIP specific to the secure memory unit and that staff had not received needed education related to abuse and dementia. Although the DON stated the facility was working on several PIPs, including falls and dementia training, they were unable to provide specific details about these projects, demonstrating that the QAPI process was not effectively organized or implemented to address the identified concerns.
Failure to Prevent Resident-to-Resident Abuse in Dementia and Behavioral Care Units
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by other residents, despite known behavioral risks and repeated resident‑to‑resident altercations. The facility’s abuse policy states that residents have the right to be free from abuse, neglect, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. Surveyors found that six residents experienced abusive interactions that met the regulatory definition of abuse, even when the facility sometimes concluded that incidents were not intentional or did not substantiate them. Many of the involved residents had severe dementia, behavioral disturbances, wandering, and histories of aggression, yet the facility did not consistently implement preventive measures to keep them and others safe. One resident with severe dementia and wandering and aggressive behaviors was physically abused on three separate occasions by three different residents. In one incident, a roommate with Alzheimer’s disease and a history of several resident‑to‑resident altercations grabbed at this resident’s feet and tried to pull him out of bed while yelling that it was his room. In another incident, a resident with severe dementia and aggressive behaviors physically redirected the same wandering resident out of her room, causing him to lose balance and fall. In a third incident, a resident with severe cognitive impairment and a history of physical behaviors pushed this same wandering resident and yelled at him to get out of his room after the resident entered without invitation. Staff interviews confirmed that residents frequently wandered into others’ rooms and that staff generally redirected them only after they had already entered, with no proactive measures in place to prevent unauthorized room entry. Other residents were also subjected to physical abuse. One resident with severe dementia and delusional beliefs was knocked to the floor and struck with a wheelchair by a resident with Alzheimer’s disease who became highly agitated; in a separate event, the same victim was pushed in the hallway by another resident with severe dementia and a known potential for physical aggression, who told her to walk faster. Another severely cognitively impaired resident was physically abused twice: once when her roommate, who had severe dementia and a known tendency to become aggressive when her personal space was invaded, took her face in her hands and pushed it away, and again when a different resident, with impaired coping skills and poor impulse control, became verbally distressed over a preferred chair in the common area, reached toward her, and during the altercation she fell and sustained a forehead laceration requiring first aid. In another incident, a resident with dementia wandered into the room of a resident with severe dementia and behavioral problems and grabbed and scratched her hand. The facility also failed to protect two cognitively impaired or partially impaired male roommates from escalating verbal and physical abuse toward each other. One resident with memory deficits, poor impulse control, and a behavior care plan noting potential for physical aggression reported that tension over television noise had been building between him and his cognitively intact roommate. On the day of the incident, he described flipping off his roommate, exchanging verbally hostile remarks, asking if the roommate wanted to fight, and then engaging in a shoving match after the roommate hit his leg, which resulted in him falling and sustaining a small abrasion to his knee. Staff interviews indicated that abuse was understood to include bullying and hitting, and that the altercation was preceded by days of increasing tension between the two residents. Overall, staff acknowledged frequent wandering, frequent entry into others’ rooms, and reliance on redirection after the fact, rather than preventive strategies, in a unit where many residents had dementia, mental health issues, and known behavioral risks. In several investigations, the facility did not substantiate abuse despite clear physical contact and aggression, citing lack of malicious intent or dementia‑related agitation, and sometimes made no changes to care plans or room assignments. For example, the facility concluded that a wheelchair collision and repeated contact with a resident on the floor was due to impulsive propulsion rather than an attempt to harm, and it unsubstantiated incidents where one resident pushed another in the hall and where a roommate pushed another resident’s face away. In another case, the facility’s investigation of a fall with injury following a confrontation over a preferred chair did not clearly describe the sequence of events and focused on the absence of intentional harm rather than the regulatory definition of abuse. Staff interviews further revealed that many resident‑to‑resident altercations occurred at night or on weekends when agency staff were present, and that there were no measures in place to prevent residents from entering others’ rooms, despite widespread wandering and known behavioral triggers.
Failure to Implement Person-Centered Dementia Care and Supervision for Wandering Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, person-centered dementia care and supervision for multiple residents with dementia who exhibited wandering and territorial behaviors. Facility policy required individualized care plans, least restrictive approaches, thorough clinical assessment, monitoring of mood and behavior, and staff training in dementia care and behavior management. Despite this, surveyors observed residents with known dementia and wandering tendencies roaming hallways without purpose, entering other residents’ rooms, and intruding into others’ personal space and rooms without consistent staff monitoring or redirection. During group activities, several residents wandered the halls unobserved, and one resident repeatedly attempted to exit locked doors and became frustrated without timely staff intervention. Specific residents with documented dementia, severe cognitive impairment, and care plans addressing wandering and behavioral risks were not managed according to their care plan interventions. One resident with severe cognitive impairment and documented wandering and aggressive behaviors was observed going into other residents’ rooms without staff supervision or redirection, despite care plan directives for early staff-led redirection and immediate intervention when entering others’ rooms. Another resident with dementia and daily documented wandering was seen attempting to exit locked doors and then wandering the unit and trying to exit the front door without staff maintaining line-of-sight supervision, even though the resident had an elopement/wandering care plan. Additional residents with severe cognitive impairment and documented frequent wandering were observed pacing hallways, standing idly, and entering other residents’ rooms without staff monitoring or redirection, contrary to care plan interventions that called for structured activities, reorientation strategies, and redirection. Residents identified as territorial or prone to aggression when others entered their rooms or personal space were also not consistently protected through care-planned interventions. One resident with dementia and a care plan noting potential physical aggression and territoriality, including triggers such as others entering his room or personal space, was not supervised or protected when another resident rested her head on him and touched his head and hand, and when other residents were in close proximity, without staff monitoring or redirection. Another resident with a history of becoming physically aggressive when others wandered into his room had a care-planned intervention for retractable barrier straps across his doorway, but surveyors observed that these straps were not consistently in place, allowing wandering residents to enter his room unimpeded. Staff interviews confirmed that many or all residents on the secure memory unit wandered and entered other residents’ rooms, that staff relied on red barrier straps to deter entry, and that staff did not consistently prevent residents from going into others’ rooms, with some CNAs unaware of where to find care plans or unable to clearly describe non-restrictive behavior management approaches. The record reviews further showed a pattern of frequent wandering documented in daily activity tracking for many of these residents, including those whose MDS assessments did not always reflect wandering behaviors, while care plans for elopement and wandering called for identifying patterns, determining purpose of wandering, and providing structured activities and redirection. Despite these documented needs and interventions, surveyor observations over multiple days showed residents repeatedly wandering aimlessly, entering occupied and unoccupied rooms, and intruding on others’ privacy without consistent staff intervention. This mismatch between assessed needs, written care plans, and actual staff practices led to residents with dementia not receiving the individualized, person-centered dementia management and supervision necessary to maintain their highest practicable physical, mental, and psychosocial well-being, particularly in relation to wandering, room entry, and resident-to-resident interactions. Staff interviews corroborated that wandering and room entry by residents were common and difficult to manage, and that staff did not always know or follow care-planned interventions. One CNA acknowledged that residents frequently wandered into others’ rooms and that barrier straps were used only after complaints, while another CNA admitted not knowing where care plans were located. An LPN stated that all residents wandered, especially one younger resident, and that staff only redirected residents when they saw them enter rooms that were not theirs, which conflicted with observations showing a lack of consistent redirection. Another LPN stated that residents could not be stopped from going into other residents’ rooms and that redirection was difficult, underscoring the facility’s failure to implement effective, person-centered dementia management strategies as outlined in its own policy and residents’ care plans.
Failure to Train Contracted and Agency Staff on Abuse, Neglect, and Reporting Requirements
Penalty
Summary
The facility failed to provide required training to all staff, including contracted and agency personnel, on dementia care and on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and resident abuse prevention. The facility’s Abuse policy, revised April 2025, states that it applies to all staff, including employees, consultants, contractors, volunteers, students, and other caregivers, and requires that care and services be delivered in a way that promotes residents’ rights to be free from abuse, neglect, misappropriation, exploitation, or privacy violations. Despite this policy, the regional nurse consultant was unable to produce documentation of facility-specific abuse training for contracted or agency staff and stated that these staff were educated on abuse only by their agencies prior to working at the facility. Record review showed an allegation of neglect initiated by a hospice CNA, who believed a resident receiving care from him and his contracted hospice provider was being neglected by the facility when the resident was left wet for an extended period. The incident report documented that the hospice CNA observed suspected neglect on 11/9/25 but did not report it to the facility until 11/19/25, a delay of ten days. The facility’s investigation concluded that the contracted hospice CNA failed to report suspected neglect in a timely manner. In interviews, an agency CNA confirmed she had not received any supplementary training from the facility on facility policies or expectations related to abuse and neglect, and the regional nurse consultant and DON acknowledged that the facility had not provided abuse-reporting training to agency staff and needed better coordination with the hospice agency regarding communication of concerns.
Failure to Thoroughly Investigate Resident’s Abuse Allegation Against CNA
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of physical abuse by a CNA toward a resident. Facility policy on abuse prevention and prohibition required that investigations include interviews with staff on all shifts who might have information about the alleged incident, interviews with staff on all shifts who had contact with the accused employee, and actions based on the information gathered. In this case, the facility’s investigation documented that the resident reported being pushed onto a bath chair, having a towel thrown at her, and being told to wash herself during shower assistance, and that she felt she had been physically abused. The social services director interviewed the resident and noted she initially appeared emotionally distressed and tearful, with a flat affect and guarded posture, and later concluded the resident was a poor historian with difficulty recalling long-term details. The investigation included an interview with the accused CNA, who denied the allegation and stated she had not provided care to the resident in a long time, but the report did not document the last date the CNA had been assigned to or assisted with the resident’s care. The facility concluded the allegation was unsubstantiated due to lack of corroborating evidence, inability to identify a specific timeframe, and findings they considered consistent with routine care. However, the investigation lacked documentation of interviews with other CNAs or nursing staff who worked with the resident to determine whether she had reported rough care or problems with showering assistance to others during the relevant period. It also lacked documentation of interviews with other residents to determine whether they had concerns about the CNA’s care. The investigation further failed to document any assessment of the shower area to identify environmental factors that might have contributed to the resident feeling abused, and did not include any attempts to observe or assess the CNA’s performance while assisting residents with showering and transfers. The resident, who had moderately impaired cognition, a history of knee injury, generalized weakness, falls, depression, anxiety, and insomnia, required assistance from one to two staff for transfers and bathing and had a behavior care plan that included monitoring behavior episodes and attempting to determine underlying causes. During a later interview, the resident reiterated that the CNA had been rough with her on more than one occasion, including pushing her onto the bath chair, throwing a wash cloth at her, telling her to wash herself, and telling her to put herself to bed, and she became visibly upset when recalling these events. The DON acknowledged that no additional investigation was done beyond what was documented in the facility’s investigation report.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for a resident who was dependent on staff for toileting hygiene. The resident, an older adult with schizophrenia, an unspecified mood and behavior disorder, epilepsy, and severe cognitive impairment (BIMS score 0/15), was care planned for ADL self-care deficits requiring substantial supervision and encouragement due to frequent refusal of care. During continuous observation on 2/24/26 from 9:20 a.m. to 11:45 a.m. and again from 11:46 a.m. to 12:18 p.m., the resident remained in bed and no direct care staff were observed entering the room to offer incontinence care. An activities staff member briefly checked the room at 9:50 a.m. but left when the resident was sleeping, and a hospice social worker entered at 10:49 a.m. only to talk with the resident. At 12:07 p.m., a CNA entered the room and provided incontinence care, changing a urine-soaked brief and soiled bed linens. The CNA reported she believed the resident was last changed before her shift began at about 6:00 a.m., when hospice staff would have showered him, and acknowledged she had not checked him for incontinence since her shift started. This meant the resident had not received incontinence care for over six hours. The CNA further stated the resident often refused care, removed his own briefs, urinated in bed and on the floor, and lay in urine-soaked sheets, which she was responsible for changing. Nursing progress notes from prior dates documented episodes of the resident urinating on the floor and being found in bed with stool on the floor and urine-soaked linens and clothing. Multiple CNAs, an RN, the LPN, the DON, and the NHA all stated that dependent residents, including this resident, were expected to be checked and changed for incontinence at least every two hours, which did not occur during the observed period.
Failure to Maintain a Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in three of five units. Multiple observations and interviews revealed persistent odors of urine and feces in common hallways, resident rooms, and dining areas. Residents and their representatives reported frequent and strong smells of urine and feces, with some stating that the odors were so strong they had to cover their mouths and noses. Additionally, representatives noted issues such as broken blinds, missing lights, and sticky or stained floors in resident rooms and common areas. Direct observations by surveyors documented stained footprints, sticky and stained floors, dried feces in resident rooms, spills left uncleaned for hours, and cracks in floors and walls. Used linens and water pitchers were left in common areas for extended periods, and cleaning was observed to be incomplete, with crumbs and stains remaining under tables and on surfaces. Handrails and baseboards throughout the facility were scratched, chipped, and marked, and some repairs appeared to be temporary or incomplete. The facility's cleaning and maintenance practices were inconsistent, with unclear responsibilities between housekeeping and nursing staff regarding the cleaning of bodily fluids and spills. Staff interviews confirmed confusion about cleaning responsibilities and the frequency of deep cleaning. Housekeeping staff did not always clean under tables or mop common areas, and nursing staff were sometimes responsible for cleaning spills, but there was uncertainty about the cleaning solutions used and the condition of cleaning equipment. Maintenance issues, such as cracked floors and missing lights, were sometimes delayed due to communication problems and staff turnover. The facility's own policy required a sanitary, orderly, and comfortable environment, but observations and interviews indicated that these standards were not consistently met.
Failure to Involve Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans for two residents out of a sample of twelve. Both residents were cognitively impaired, with BIMS scores of zero, and required significant assistance with daily activities. For one resident, the representative reported only being invited to the initial care conference upon admission and had not been invited to any subsequent conferences for several months, despite attempts to contact social services. Documentation confirmed that no care conferences had occurred for this resident between July and December, except for a voicemail left during the survey period. For the second resident, the representative stated difficulty in scheduling care conferences and could not recall the last time one was held. The facility's records indicated that the representative did not attend the last documented care conference due to unsuccessful contact attempts, and there was no evidence of any further care conferences in the following months. Staff interviews confirmed that the facility was behind in scheduling both initial and quarterly care conferences for all residents, including the two in question, and that documentation of contact attempts was expected but not consistently completed.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of significant changes in the resident's condition, as required by facility policy. The policy states that the responsible party must be informed of any change in the resident's condition and the steps being taken, with all attempts at notification documented in the nursing progress notes. However, record review and interviews revealed that the representative was not notified of several notable changes, including facial swelling, an urgent dental visit, leg edema, loose stools, and bruising on the knee and face. The resident involved was cognitively impaired, with a BIMS score of zero, and required maximal assistance with daily activities. The medical record showed multiple incidents: a limp and mild bruising on the left knee, facial swelling and dental issues requiring urgent referral, right periorbital ecchymosis, and episodes of loose stools and leg edema. In each case, there was no documentation that the resident's representative was informed of these changes or the interventions ordered by physicians, despite the facility's policy and the resident's inability to communicate his needs. Interviews with staff, including RNs and regional clinical resources, confirmed that bruising, black eye, edema, and loose stools are considered changes of condition that require notification of the physician, DON, and the resident's representative. Staff acknowledged a gap in documentation regarding who was notified when a change of condition occurred. The resident's representative also reported not being informed about these significant health events, emphasizing the importance of communication due to the resident's inability to advocate for himself.
Failure to Administer Pain Medications Timely per Physician Orders
Penalty
Summary
The facility failed to ensure that two of five sampled residents received medication administration in accordance with professional standards and physician orders. Specifically, the facility did not administer scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames for both residents. The medication administration records (MARs) showed multiple instances where medications were given outside the allowed one-hour window before or after the scheduled time, and in one case, a dose was missed entirely. One resident, who had diagnoses including fibromyalgia, neuropathy, and chronic pain, was cognitively intact and relied on scheduled opioid medications to manage severe pain. The MARs indicated that her Oxycontin doses were administered late on several occasions, sometimes by more than an hour past the scheduled time. The resident reported experiencing high levels of pain and noted that her pain medications were not always given on time, although she could not recall specific dates. Another resident, with diagnoses including dementia, chronic kidney disease, and chronic pain, also received scheduled pain medications. The MARs for this resident documented several late administrations of oxycodone, with one dose not administered at all. This resident expressed a desire not to experience any pain and stated that delayed administration of her pain medication resulted in increased discomfort. Staff interviews confirmed that the medications were not administered within the required time frames and acknowledged the importance of timely medication administration as per physician orders.
Failure to Provide Adequate Incontinence Supplies and Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity and provide equal access to incontinence care supplies, as evidenced by multiple resident and staff interviews, observations, and grievance documentation. Several residents reported that they did not have access to incontinence briefs for several days due to the facility running out of supplies. Residents described being told by staff to use towels as a substitute for briefs, and some residents delayed having their briefs changed or were given incorrectly sized briefs. One resident reported that a pull-up garment provided as an alternative leaked, resulting in wet bedding that required changing by staff. Staff interviews corroborated the residents' accounts, with several staff members stating that the facility ran out of briefs at the end of May and beginning of June. Staff described limited availability of pull-up garments, which were not suitable for all residents, and reported taking briefs from some residents' rooms to use for others. Staff also stated that they were instructed by management to use towels as a substitute for briefs and that supply orders were restricted due to budget concerns. Grievance forms further documented resident concerns about running out of supplies and being told by staff that briefs were unavailable. Facility leadership, including the DON and NHA, denied instructing staff to use towels or restricting supply orders, and stated that the facility did not run out of briefs. However, the consistent reports from residents and staff, as well as direct observations of supply shortages and the use of incorrect brief sizes, indicate that the facility did not ensure adequate and appropriate incontinence care supplies were available to all residents, compromising their dignity and individualized care.
Failure to Document and Communicate Resident Discharge Needs and Equipment
Penalty
Summary
The facility failed to accurately document and communicate essential information regarding a resident's transfer and discharge. Specifically, the discharge summary did not include the resident's need for two transfer poles, and the discharge care plan lacked documentation of the resident's specific durable medical equipment requirements for a safe transition home. Additionally, there was no record of communication or confirmation from referral sources to ensure the resident's discharge needs were met, and the discharge date in the physician's orders was incorrect and not obtained in a timely manner. The resident, who was cognitively intact and required partial assistance with mobility and transfers, was discharged to his home with ongoing needs for specialized equipment, including two transfer poles for safe transfers. Despite therapy notes indicating the necessity of these poles and a purchase order being placed, only one transfer pole was installed at the time of discharge, and the second was not set up until later. The discharge documentation failed to reflect these needs, and the care plan did not address the equipment required for the resident's safety at home. Interviews with staff revealed that verbal confirmations regarding the resident's equipment and services were made with the home health agency and transition services team, but these communications were not documented in the resident's record. The transition services agent and supervisor confirmed that only one transfer pole was initially installed, and the second was found and installed after the resident had already been discharged. The social services director also acknowledged that the discharge date was communicated verbally but not documented.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering Farxiga as ordered by the physician for three consecutive days. The resident, who had diagnoses including type 2 diabetes mellitus, congestive heart failure, ischemic cardiomyopathy, and chronic kidney disease, did not receive the prescribed medication on three occasions. Documentation in the medication administration record indicated that the facility was awaiting delivery of the medication from the pharmacy, but there was no evidence that the pharmacy or the physician was notified about the missed doses. Additionally, on one of the days, the medication was available but still not administered, and no explanation was documented for this omission. Interviews with staff revealed that the process for ordering and following up on medications was inconsistent. Nursing staff reported that they would typically contact the pharmacy and notify the physician if a medication was unavailable, but there was no documentation to support that these actions were taken in this case. The clinical nurse consultant confirmed that the medication order was present in the resident's profile but was not filled by the pharmacy initially, and the medication was reordered and delivered, yet still not administered as required. The lack of timely communication and documentation contributed to the resident missing multiple doses of a critical medication.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, resulting in multiple incidents of physical and verbal abuse. Resident #2, who had a history of aggressive behavior due to dementia, was involved in two separate incidents of physical abuse. On one occasion, Resident #2 hit his roommate, Resident #8, causing a bruise under the eye. Despite being placed on one-on-one supervision initially, this was later reduced to 15-minute checks, which proved insufficient as Resident #2 later assaulted Resident #1, causing significant injuries that required hospitalization. The facility's care planning for Resident #2 was inadequate, as it did not address his history of aggressive behavior upon admission. Despite multiple documented incidents of verbal and physical aggression, the facility failed to implement effective interventions or consistently notify the physician of these behaviors. The care plan lacked specificity in documenting triggers and de-escalation strategies, and there was a failure to report certain incidents to the nursing home administrator, who was the designated abuse coordinator. Additionally, the facility failed to protect Residents #7 and #27 from verbal abuse by Resident #4. Resident #4, who had a history of verbal aggression and personality disorder, was involved in an incident where he verbally abused Resident #27. The facility's response to Resident #4's behavior was insufficient, as the interventions in place did not prevent the verbal abuse from occurring. The facility's documentation and reporting of these incidents were also found to be lacking, contributing to the overall deficiency in protecting residents from abuse.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste and temperature. Interviews with residents revealed dissatisfaction with the food, noting that it was often served cold and that the facility sometimes ran out of common food items. Observations during meal preparation and service showed that food was not maintained at appropriate temperatures, with test tray items such as broccoli and penne pasta being served at 102 degrees Fahrenheit and chicken breast at 120 degrees Fahrenheit. Additionally, the facility ran out of zucchini and broccoli during meal service, and the test tray was not properly covered, leaving food exposed. Staff interviews indicated that the plates used for room trays were not pre-warmed, contributing to the issue of cold food. The dietitian resource acknowledged that plates were not placed in the plate warmer prior to meal assembly and that there was a shortage of plate covers and lids, which may have contributed to the problem. The facility's dietary improvement plan, initiated in October 2024, was updated to address food temperature issues, but additional plates were not purchased until the survey was conducted.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and three of five nourishment rooms. Observations revealed several issues with food storage, including expired and unlabeled food items. In the main kitchen refrigerator, there were sealed containers of potato salad past their use-by dates, unsealed hot dogs, and unlabeled sauces. Additionally, thawed pork roasts and orange liquid packages lacked pull or expiration dates. An open bottle of expired cooking wine was also found. In the drink station refrigerator, expired and bloated apple slices, unwrapped cake, and expired yogurt and cottage cheese were observed. Multiple spills and crumbs were noted in the refrigerator and freezer. The 400 hall nourishment refrigerator contained a frozen pasta dish without a resident name or date, corn tortillas, grapes, and green chile sauce without proper labeling. Despite a sign indicating food should be discarded after 72 hours if not labeled, these items remained the following day. Medications were improperly stored in the 500 hall nourishment refrigerator, with vaccines placed in a butter conditioner that did not seal completely. Interviews with staff revealed a lack of adherence to labeling and dating protocols, with dietary staff responsible for managing nourishment refrigerators and ensuring food safety. The director of nursing confirmed that medications were not typically stored in nourishment refrigerators and were subsequently removed.
Failure to Report Alleged Abuse and Document Incidents
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the State Survey and Certification agency for two residents. Resident #2, who had a history of cerebral palsy, dementia with behavioral disturbance, and violent behavior, was involved in multiple incidents of aggressive behavior towards other residents. These incidents, which included verbal and physical aggression, were not reported to the State Agency as required. The facility's documentation was inadequate, and the incidents were not properly investigated for potential abuse. Resident #24, who was cognitively impaired and resided in a secure unit due to wandering behavior, was involved in an incident with Resident #2. During this incident, Resident #24 was found with injuries, including a laceration over the left eyebrow and a skin tear on the left hand. Despite the visible injuries and Resident #24's statement that he was hurt by someone, the facility documented the incident as a fall and did not report it to the State Agency. The facility's investigation was based on interviews with both residents, who denied physical contact, leading to the conclusion that no abuse occurred. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the facility's reporting process was flawed. Some incidents were not visible in the 24-hour report due to documentation errors, and agency staff were identified as contributing to these errors. The facility acknowledged that certain incidents should have been reported to the abuse coordinator and the State Agency but were not. The DON and NHA admitted to not seeing some of the documented notes, which contributed to the failure to report potential abuse.
Failure to Implement Timely Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, who had a history of physical aggression. Upon admission, the resident's care plan did not include person-centered interventions to address his history of physical and verbal aggression, which was necessary to prevent altercations with other residents. The resident, who was over 65 years old, had multiple diagnoses including cerebral palsy, acute respiratory failure, dementia with behavioral disturbance, and violent behavior. Despite these conditions, the facility did not implement a care plan addressing his aggressive behaviors until two months after his admission. The resident's comprehensive care plan, initiated shortly after admission, focused on monitoring cognitive function but lacked specific interventions for managing his aggressive behaviors. It was not until several months later that a focused care plan for verbally aggressive behaviors was initiated, and even then, it did not specify the playful behaviors that could be misconstrued. The care plan for physical behaviors was only initiated after further incidents, indicating a delay in addressing the resident's known history of aggression. Interviews with facility staff revealed that the resident's behaviors were sporadic and difficult to predict, which contributed to the delay in implementing a comprehensive care plan. The Director of Nursing stated that the facility initially aimed to establish a baseline for the resident's behavior before adding specific interventions to the care plan. However, this approach resulted in a lack of timely and effective interventions to prevent resident-to-resident abuse, as the facility did not update the care plan with necessary measures based on the resident's documented history of aggression.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program on one of its units, specifically in the care of a resident with a suprapubic catheter and stage 4 pressure wounds. The deficiency was observed when staff did not follow Enhanced Barrier Precautions (EBP) during high-contact activities with the resident. The Centers for Disease Control and Prevention (CDC) guidelines require the use of gowns and gloves during such activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, staff members, including a physical therapist, a speech language pathologist, and certified nurse aides, were observed entering the resident's room and providing care without donning the necessary personal protective equipment (PPE). The facility's policy required the use of EBP for residents with wounds and indwelling medical devices, such as the resident in question. Despite this, there was no EBP sign or PPE bin outside the resident's room to alert staff of the need for enhanced precautions. Observations revealed that staff members, including CNAs, failed to wear gowns while providing care, such as repositioning and toileting the resident, who had visible serosanguineous drainage from a wound dressing. Interviews with staff indicated a lack of awareness and understanding of the EBP requirements for the resident. The director of nursing (DON) and assistant director of nursing (ADON) acknowledged the absence of appropriate signage and PPE bins, which were supposed to alert staff to the resident's high infection risk status. The ADON admitted to removing the droplet precautions sign and PPE bin due to a misunderstanding of the resident's infection status and EBP requirements. This lack of adherence to infection control protocols and inadequate staff training contributed to the deficiency in maintaining a safe and sanitary environment for the resident.
Failure to Protect Residents from Mental and Verbal Abuse
Penalty
Summary
The facility failed to protect four residents from mental and verbal abuse, leading to significant emotional distress. Resident #79 reported that the activities director (AD) spoke to her rudely, raised her voice, and belittled her, making her feel like a scolded child. Despite three staff members promptly reporting the incident to the nursing home administrator (NHA), the facility did not initiate an investigation or take corrective actions for several hours, allowing the AD to continue working and interacting with residents, including Resident #79, for five hours after the incident. Resident #60 experienced severe pain from being reclined in his wheelchair for an extended period. When he asked a certified nurse aide (CNA) to help him into bed, the CNA raised his voice and told him that other residents had more important needs, making Resident #60 feel unimportant and neglected. The facility's response was inadequate, as the NHA acknowledged that the CNA should have sought assistance but did not ensure timely care for Resident #60. Residents #13 and #60 were subjected to repeated verbal abuse by Resident #31, who used racial slurs and offensive language. Despite staff witnessing these incidents and the facility conducting investigations, no effective corrective actions were taken to prevent further abuse. The facility failed to update care plans for the affected residents or adequately address the emotional impact of the abuse, leaving Residents #13 and #60 feeling fearful and distressed.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to vision services for three residents, leading to deficiencies in their care. Resident #93, who has quadriplegia and is cognitively intact, reported needing glasses due to astigmatism and had requested to see an eye doctor multiple times since admission. Despite the eye doctor visiting the facility in March 2024, Resident #93 was not seen because he was not on the list, and his vision needs were not addressed in his care plan. Resident #40, who has moderate cognitive impairment and requires supervision for eating and oral hygiene, reported needing to see an eye doctor because she had lost her glasses and had not been offered an appointment by the facility. Her vision needs were also not addressed in her care plan, and she had not seen an eye doctor in the past year. Resident #57, who has moderate cognitive impairment and multiple chronic conditions, saw an eye doctor in February 2024 and was found to need corrective lenses due to worsening vision. However, he had not received his glasses, and the facility was unaware of the status of his new glasses. The social services director acknowledged the inconsistency in ancillary services and the delay in providing necessary vision care to these residents.
Unsafe and Unsanitary Conditions in Laundry Room
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room. Observations revealed multiple environmental concerns, including a wet and slippery floor, a large uncovered drain, water leaking from the ceiling onto the floor and washing machines, and a container of sharps placed next to a washing machine. Additionally, there was water build-up on top of the washing machines, pieces of equipment, and a glove sticking out of one of the machines. Only two out of three washing machines and one out of three dryers were operational. The housekeeping supervisor was unsure about the items on top of the machines and the cause of the leak, while the maintenance director acknowledged the issues but had not yet resolved them. The maintenance director, who started working at the facility in February 2024, admitted that the laundry room needed attention and had not been cleaned. He pointed out the uncovered drain as a significant hazard and mentioned an ongoing investigation into the source of the leak. The maintenance director also noted that the container of sharps should not be in the laundry room and that the broken washing machine had been out of order for several years. He was in the process of obtaining quotes to repair or replace the non-functional machines. The overall condition of the laundry room was unsafe and unsanitary, posing risks to residents, staff, and the public.
Failure to Provide Engaging Activities and Adequate Supervision in Dementia Care Unit
Penalty
Summary
The facility failed to provide a consistent and engaging activity program for residents in the secured dementia care unit, leading to a lack of meaningful activities for residents. Observations revealed that residents were often left idle, dozing, or wandering the halls without access to independent activity supplies such as books, puzzles, or coloring pages. Staff did not engage residents in conversation or activities, and there was no structured activity schedule consistently followed. For example, Resident #97 repeatedly asked about exercise class but received no acknowledgment from staff, and Resident #84 expressed boredom and anxiety without staff intervention. Additionally, the facility did not provide adequate supervision to prevent resident-to-resident altercations. Resident #78, who had a history of wandering into other residents' rooms, was not monitored effectively, leading to an incident where Resident #78 entered Resident #41's room, resulting in a physical altercation. Staff were unaware of Resident #78's location during these incidents, and there was no documentation of increased monitoring for Resident #78 following the altercation. The facility also failed to interact with residents in a safe and appropriate manner. For instance, Resident #71 was involved in two separate incidents where staff engaged in a tug-of-war over nonessential objects, such as a towel and a chair, instead of offering a diversion or a more appropriate object. These interactions were not only confrontational but also left the resident unsupported and at risk of falling. The facility's lack of person-centered care and failure to address the residents' needs contributed to the residents' inability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining routine or emergency dental services as needed. Resident #57, who had broken teeth and was in pain, had been waiting for five months for follow-up dental services to have his teeth extracted and dentures made. Despite multiple dental consultations and recommendations for extractions, the resident's dental issues were not addressed in his care plan, and he did not receive prescribed pain relief medication from 4/1/24 through 4/8/24. Resident #40, who was edentulous, had been waiting several months for dentures to be made. The resident had no follow-up dental visits after 1/3/24, and her dental issues were not included in her care plan. The resident expressed difficulty eating without teeth and had not received any updates on the progress of her dentures. Resident #93, who had quadriplegia and a broken tooth causing pain, had not seen a dentist since being admitted to the facility despite multiple requests. The resident's dental needs were not addressed in his care plan, and he did not receive prescribed pain relief medication from 4/1/24 through 4/8/24. Additionally, Resident #84, who had dementia and required dental services, had not been referred to a dental specialist as recommended. The resident's representative had been calling the facility for months without receiving a response, and the resident's dental issues were not documented in her medical record or progress notes.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, leading to multiple deficiencies. Housekeeping staff did not consistently change gloves or perform hand hygiene when appropriate. Observations revealed that housekeepers used disinfectant chemicals improperly, failing to allow the necessary contact time for effective disinfection. Additionally, housekeeping staff did not follow proper hand hygiene protocols, such as washing hands for the required duration or using hand sanitizer correctly. These lapses were observed during routine cleaning of resident rooms and bathrooms, where surfaces were not visibly wet after being wiped down, indicating insufficient disinfection. Interviews with housekeeping staff and supervisors confirmed these practices, highlighting a lack of adherence to the facility's infection control policies and procedures. The facility also failed to track, offer, and administer the COVID-19 vaccination to residents. Record reviews showed that several residents had not been offered or received the 2023/2024 COVID-19 booster. The Infection Preventionist (IP) admitted that no COVID-19 vaccination clinics had been held since she started working at the facility, and the previous pharmacy used by the facility did not have access to the COVID-19 booster. This lack of vaccination tracking and administration is a significant lapse in infection control, especially given the ongoing pandemic. Infection control practices were also not followed during wound care and medication administration. An RN was observed performing wound care without sanitizing the bedside table or laying down a barrier for supplies. The RN did not perform hand hygiene after touching dirty items and before providing wound care. Similarly, an LPN did not wash or sanitize her hands between residents during medication administration, and when she did wash her hands, it was only for six seconds, far short of the recommended 20 seconds. These observations indicate a broader issue with adherence to infection control protocols among clinical staff, further compromising the safety and well-being of residents.
Failure to Implement Pneumococcal Immunization Policies
Penalty
Summary
The facility failed to implement policies and procedures related to pneumococcal immunizations for five residents. Specifically, the facility did not ensure that the electronic medical records (EMR) of these residents were up to date with their vaccination history. Additionally, the facility did not determine which pneumococcal vaccine was given to these residents and whether additional doses were needed. This deficiency was identified through record reviews and interviews with staff and residents' representatives. Resident #63, aged 70, was admitted with diagnoses including dementia and abnormal weight loss. The resident's minimum data set (MDS) assessment revealed that she was not up to date on her pneumococcal vaccination and had not been offered the vaccination. A review of her EMR confirmed the absence of documentation indicating that she had received or been offered the pneumococcal vaccination. Similar issues were found with Resident #68, who had diagnoses including hypertension, Alzheimer's disease, and depression. The MDS assessment for Resident #68 did not indicate if the resident was up to date on his pneumococcal vaccination, and the EMR review revealed that the resident had not received the vaccination despite consent being provided. Resident #84, aged 78, with diagnoses including heart disease, COPD, and dementia, was also found to be not up to date on the pneumococcal vaccination and had not been offered the vaccination. The EMR review confirmed this. Resident #3, aged 72, with diagnoses including dementia and multiple sclerosis, had an MDS assessment indicating that he was not up to date on the pneumococcal vaccination, and his power of attorney confirmed that the facility had not contacted her recently to obtain consent. Resident #31, aged 65, with multiple sclerosis, had an MDS assessment that did not indicate if he was up to date on the pneumococcal vaccination, and the EMR review revealed that he had not received the vaccination despite consent being provided.
Failure to Manage Pain Consistently with Professional Standards
Penalty
Summary
The facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two residents. Specifically, the facility did not offer person-centered non-pharmacological pain interventions for one resident and did not follow physician orders for pain parameters when administering as-needed pain medications for both residents. This resulted in the residents experiencing unmanaged pain and receiving inappropriate pain medications outside the specified parameters in their physician orders. Resident #57, a 66-year-old with multiple diagnoses including chronic pain, reported frequent pain that interfered with his sleep and daily activities. Despite his preference for non-pharmacological interventions like heat packs, the facility did not offer these options. Additionally, the resident was administered Hydrocodone-Acetaminophen for pain levels that did not align with the physician's specified parameters, leading to inappropriate pain management. Resident #87, under the age of 65 with diagnoses including morbid obesity and chronic pain, also experienced frequent pain that affected her daily activities. The facility administered Oxycodone at incorrect dosages based on her reported pain levels, which did not match the physician's orders. This included instances where the resident received higher doses of Oxycodone for lower pain levels and vice versa, indicating a failure to adhere to the prescribed pain management plan.
Failure to Document Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to ensure that Resident #87 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not consistently assess and document the resident's blood pressure prior to administering blood pressure medications. According to the April 2024 computerized physician orders, Resident #87 was prescribed Prazosin HCI Oral Capsule for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. However, the April 2024 vital signs summary and medication administration record (MAR) revealed that the resident's blood pressure was not assessed from 4/1/24 to 4/8/24 when the medication was administered. Interviews with staff confirmed the deficiency. Registered Nurse (RN) #3 stated that the medication administration record typically required the blood pressure to be taken prior to administering the medication, but the physician order for Prazosin was not prompting the nurses to document the blood pressure. The Assistant Director of Nursing (ADON) also confirmed that the physician orders instructed the licensed nurses to take the resident's blood pressure and hold the medication if the blood pressure was less than 110. However, the ADON acknowledged that Resident #87's blood pressure had not been documented since 3/11/24, although he trusted the nurses to take the blood pressure prior to administering the medication.
Failure to Provide Proper Catheter Care and Maintenance
Penalty
Summary
The facility failed to consistently provide catheter care, treatment, and services to minimize the risk of urinary tract infections for two residents. Resident #13, who had a suprapubic catheter, reported experiencing pain from his catheter and stated that he had been asking nursing staff for over a week to replace it, but it had not been done. A review of Resident #13's medical records revealed no orders for routine catheter care, maintenance, or monitoring, despite a history of recurrent catheter-associated urinary tract infections (CAUTI). The comprehensive care plan for Resident #13 included interventions for catheter care, but there was no documentation of catheter care or replacement being performed since his readmission. Resident #83, who had an indwelling catheter, also had no orders for routine catheter care, maintenance, or monitoring in her medical records. The resident could not remember the last time her catheter was changed. The comprehensive care plan for Resident #83 included interventions for catheter care, but there was no documentation of a void trial after the physician's note. Both residents had intact cognition and did not reject care or assistance. Interviews with the assistant director of nursing (ADON) and a licensed practical nurse (LPN) revealed that residents with catheters should have orders for care and monitoring to prevent infection. The ADON was not aware of Resident #13's complaints of pain or requests to have his catheter changed. The LPN stated that routine orders for changing a catheter were usually every three months and that all residents with catheters should have physician orders for care. The facility's failure to ensure proper catheter care and maintenance for these residents led to the identified deficiencies.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free of unnecessary psychotropic medications, specifically for one resident who did not receive a gradual dose reduction (GDR) for her antidepressant, sedative, and antipsychotic medications. The facility's policy required that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated. However, the facility did not attempt a GDR for the resident's medications or provide substantial documentation from the prescribing physician on why a GDR was contraindicated. Resident #87, under the age of 65, had multiple diagnoses including morbid obesity, bipolar disorder, PTSD, mood disorder, and cognitive communication deficit. Despite being cognitively intact and having minimal signs of depression, the resident was prescribed several psychotropic medications, including Citalopram, Latuda, Zolpidem Tartrate, and Valproic Acid. The interdisciplinary team (IDT) psychotropic reviews conducted on multiple occasions did not indicate any attempts for a GDR, and the medical record lacked a risk versus benefit statement requested by the facility. Interviews with the Social Services Director (SSD) confirmed that the resident's psychotropic medications were reviewed quarterly, but no GDR attempts were documented. The SSD was unsure when the last dose reduction was attempted for the resident. The facility's failure to follow its own policy and procedure for GDRs and to document the clinical justification for not attempting a GDR led to the deficiency identified in the report.
Failure to Properly Store and Secure Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards. Specifically, controlled medications were not stored in a locked storage container that was permanently affixed to the refrigerator. Six vials of liquid Ativan and one bottle of oral Ativan were found in a ziploc bag on the bottom shelf of the medication refrigerator, which was not securely affixed. The nursing home administrator in training acknowledged the issue and mentioned a temporary solution using zip ties until a permanent fix could be implemented. Additionally, the facility failed to ensure that medications were not left unattended. An LPN left a medication cup containing cardiac medications on top of the medication cart while stepping away to administer medications to a resident, leaving the cart out of direct line of sight. Another instance involved an LPN leaving the medication cart unlocked while not in sight, with other facility staff passing meal trays to residents. Both incidents were immediately reported to the assistant director of nursing, who confirmed that medications should not be left unattended and that medication carts should always be locked when not in use.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to ensure that two residents received showers according to their preferences and that these preferences were included in their care plans. Resident #87, who has diagnoses including morbid obesity, bipolar disorder, and PTSD, preferred to shower at 7:00 p.m. on Thursdays but did not receive showers on her preferred days on multiple occasions. Additionally, her care plan did not include her preference for female caregivers due to her history of sexual abuse. The staff acknowledged the resident's preferences but cited staff availability as a reason for not accommodating her requests consistently. Resident #57, with diagnoses including COPD and chronic respiratory failure, preferred to shower on Sunday and Wednesday nights but was given bed baths instead due to his increased oxygen needs during showers. The resident expressed dissatisfaction with bed baths, stating they did not make him feel clean. The facility staff were unaware of his increased oxygen needs and did not include his shower preferences in his care plan. The resident's previous facility had been able to accommodate his oxygen needs during showers, but this facility failed to do so. Interviews with staff, including CNAs and the ADON, revealed that while the residents' preferences were documented, they were not consistently followed due to various reasons such as staff being busy or unaware of specific needs. The facility's policies on bathing and ADLs were not effectively implemented, leading to the residents' preferences being overlooked and not included in their comprehensive care plans.
Failure to Provide a Comfortable and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident #93, who was under the age of 65 and diagnosed with quadriplegia, among other conditions. The resident's room did not have a window, and the only access to fresh air was through double doors leading to an atrium, which were locked and inaccessible. The resident reported feeling very hot and sweaty, which made him feel unclean. He had a fan in the room, but it was loud and not sufficient to cool the room. The maintenance director confirmed that the atrium was not in use and that he did not have a key to open the doors. He also mentioned that installing a window was impossible due to the building's original structure. The maintenance director suggested providing a fan as a solution but acknowledged that it would be a safety hazard to allow access to the atrium. The facility's policy on maintaining a safe, homelike environment emphasizes the importance of comfortable temperature levels and the resident's opinion of their living environment. Despite this, the facility did not assess the safety of the resident's preference for fresh air and did not provide an alternative solution to ensure the resident's comfort. The resident expressed a desire to open the double doors to the atrium for fresh air and sunlight, but this request was not accommodated, leading to the deficiency noted in the report.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to initiate and complete a thorough investigation of an alleged violation of mental and verbal abuse involving a resident. The incident occurred when the Activities Director (AD) spoke to a resident in a mean and belittling manner, causing the resident emotional distress. Despite the incident being reported by three staff members, the facility did not start an investigation or take immediate corrective actions to protect the resident from further abuse. The AD continued to work in the facility with unrestricted access to the resident and other residents for over five hours after the incident. The investigation documentation and interviews revealed several deficiencies. The witness statements lacked specific details such as the location and time of the incident, the proximity of the staff assailant to the resident, the exact words used, and the demeanor, gestures, tone, and volume of the AD's voice. Additionally, the investigation report did not document the findings, conclusions, or recommendations to prevent further abuse. The facility also failed to document the emotional impact of the incident on the resident and did not explore potential biases between the alleged abuser and witnesses. Interviews with staff members indicated that the incident was reported to the Nursing Home Administrator (NHA) around 12:30 p.m., but the NHA did not start an investigation or suspend the AD until over five hours later. The NHA stated that the staff did not explicitly mention that the incident was verbal abuse, which led to the delay in taking action. The AD admitted to raising her voice and not handling the situation well, acknowledging the need for more training in de-escalation techniques.
Failure to Provide Necessary Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for Resident #60, who was fully dependent on staff for all activities of daily living (ADLs) due to functional limitations in both lower extremities and cognitive communication deficits. Despite being cognitively intact, the resident's care plan indicated a need for assistance with bathing and grooming, including two staff members for bathing and transfers. However, observations revealed that the resident's fingernails were long, discolored, and visibly soiled on multiple occasions, and his hair was greasy. The resident reported receiving only two showers and one bed bath in the past 30 days, contrary to the care plan that scheduled showers twice a week. The resident expressed frustration and distress over the lack of proper hygiene care, stating that staff refused to provide showers, citing time constraints and the need for additional assistance with the hoyer lift. The facility's documentation did not indicate any refusals of showers by the resident, and the care plan did not document any refusals either. Interviews with staff revealed inconsistencies in the provision of care, with one CNA stating that the resident sometimes refused care but was unsure whose responsibility it was to trim the resident's nails. The assistant director of nursing (ADON) acknowledged the resident's history of refusals but noted that the resident was compliant when approached correctly. The ADON also stated that the resident should not have had visibly dirty and ungroomed nails, especially if the resident wanted assistance. The nursing home administrator (NHA) emphasized that residents requiring assistance should have been cared for, particularly those in visible discomfort and distress. The NHA stated that staff members unable to assist residents in a timely manner should notify the charge nurse and seek help from other staff. Despite these policies, the facility failed to provide adequate hygiene care for Resident #60, leading to the resident's frustration and distress over his unclean condition.
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Two severely cognitively impaired residents in a memory care unit, both with dementia and significant behavioral risk factors, became agitated with each other and engaged in a physical altercation that resulted in a facial scratch to one resident. Facility policy required immediate intervention, separation, and monitoring to prevent abuse, and both residents’ care plans identified risks for aggression, anxiety, and resident-to-resident altercations. Staff reported that only one staff member was assigned to seven residents, that residents often invaded each other’s space, and that fights did occur, including a fist fight between these two residents during the incident in question. The facility’s investigation substantiated the event as physical abuse, demonstrating a failure to protect residents from abuse and to implement effective monitoring and behavioral interventions.
A resident with bipolar disorder, PTSD, traumatic brain injury, and moderate cognitive impairment alleged that an LPN and CNA were rough and sexually abusive during incontinence care, stating the LPN aggressively rolled him, caused his head to hit the wall, and repeatedly inserted a finger into his anus despite his protests. The facility’s investigation relied on staff statements and lack of observed rectal trauma, did not interview the roommate, and did not explore why staff continued care after the resident’s abuse allegation. The resident also reported ongoing rough transfers, inadequate repositioning in a wheelchair causing pain and bruising, and lack of assistance with proper positioning for meals, which was corroborated by observation of poor positioning, a bruise on his arm, and food spilled on his shirt. Although the care plan noted a history of false allegations and required care in pairs and investigation of voiced concerns, it lacked a specific focus on the resident’s PTSD and did not address his repeated reports that staff’s incontinence care and handling were rough and abusive.
A resident with a history of falls, fractures, and significant mobility impairment experienced an unwitnessed fall from bed, which had been left in a high position despite care-plan interventions requiring it to be kept low with a fall mat. An RN found the resident on the floor, initiated neuro checks, and documented elevated BP readings and pain but did not complete or document a thorough head-to-toe assessment before moving the resident back to bed, and did not promptly notify the MD, hospice, or the resident’s representative. Hospice was contacted several hours later due to rising BP and severe pain; a hospice RN then assessed the resident, notified the on-call MD, and obtained an order to transfer the resident to the hospital, where imaging revealed multiple fractures and a scalp contusion. Staff interviews and facility policy confirmed that standard practice required immediate RN assessment prior to moving a fallen resident, timely MD and family notification, and adherence to fall-prevention interventions, all of which were not followed in this case.
The deficiency centers on failures in transportation safety and fall management that led to serious resident injuries. A resident with dementia and bilateral lower extremity impairments was transported in a wheelchair without foot pedals, seated on a blanket and Hoyer sling, and improperly restrained when the driver misapplied the lap and shoulder belt to avoid disturbing an ostomy bag. During the trip the resident slid forward, struck both legs on a step in the vehicle, and was later found to have bilateral tibial fractures with significant bruising, swelling, and pain. The driver’s training had been informal, passed down from another staff member without documented competencies, van‑specific procedures, or clear emergency protocols, and leadership acknowledged they had not investigated the admitted misuse of the seat belt. Separately, two residents at high risk for falls experienced multiple falls, including one with a facial laceration and maxillary sinus fracture, while care‑planned fall interventions such as scheduled toileting, prompted voiding, monitoring, and assisted transfers were not consistently implemented, and IDT reviews and implementation of recommended interventions were not always timely.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with cognitive impairment and documented visual deficits requested very hot tea, which a PTA dispensed from a hot beverage machine and then further heated in a microwave, contrary to facility policy prohibiting reheating of facility-provided drinks. The PTA secured a lid on the cup and placed it at the bedside. Due to visual impairment, the resident could not locate the drinking opening, attempted to remove the lid independently, and spilled the hot liquid onto an arm and thigh, sustaining second-degree partial thickness burns over approximately 6% TBSA. Nursing and NP assessments documented bright red, blanchable burns with blistering and subsequent healing, and staff interviews confirmed that the beverage had been overheated and that the resident’s visual impairment and lack of appropriate supervision and adaptive equipment contributed to the accident.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
The facility failed to maintain a full-time RN DON when the existing DON was reassigned as a temporary emergency NHA, leaving no separate RN designated to the DON role. Records showed the acting NHA held a temporary administrator permit while the staffing list indicated no full-time DON in place, despite a job description assigning the DON responsibility for 24-hour nursing oversight, staffing, and key clinical systems. Staff interviews revealed that nurses were unaware of the DON’s reassignment and continued to view this person as their direct supervisor, while the acting NHA reported performing both administrative and DON functions, including abuse coordination and state occurrence reporting, without any formal announcement or signage to inform staff, residents, or families of these role changes.
The facility’s QAPI program failed to identify and address critical quality of care issues related to resident change in condition, despite a written policy requiring comprehensive, data‑driven performance monitoring and corrective action. The facility had repeat F684 citations for quality of care and, in the current survey, was found to have not adequately assessed, monitored, documented, or communicated a resident’s change in condition, which was associated with the resident’s death and resulted in an immediate jeopardy finding. The MD reported he reviewed only those cases and policies presented to him and was unaware that the DON was also serving as the temporary emergency NHA amid leadership changes. The DON/acting NHA stated that QAPI meetings focused on standard topics and that change of condition evaluations were limited mainly to skin alterations and falls, acknowledging that staff were new to other types of change of condition assessments requiring thorough evaluation and provider/family notification.
A resident with CVA-related left-sided hemiplegia, who used a wheelchair and was cognitively intact, was moved to a different room after reporting strong chemical odors and refusing to return to the original room. Facility policy stated that staff would assist with packing and unpacking belongings for room changes, and staff reported that environmental services, nursing, or maintenance typically helped move items. In this case, however, staff repeatedly told the resident they could not move her belongings and would only escort her while she attempted to move them herself, despite her physical limitations. The NHA communicated by email that, due to prior disputes about handling of personal property, the resident was responsible for arranging family or third-party movers at her own expense, while staff would only provide access and oversight. As a result, most of the resident’s personal items remained in the original room for an extended period after she agreed to the permanent room change.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse between two cognitively impaired residents in the memory care unit. Facility policy required that residents be free from all forms of abuse and that staff immediately intervene, ensure resident safety, and keep residents separated and monitored when an assailant is identified. Despite this policy, the facility’s own investigation of an incident on 11/26/25 documented that two residents in the memory care unit became frustrated and agitated with each other, with elevated voices and defensive body language, and moved their arms as if they were going to hit each other. One resident sustained a superficial scratch above his left eyebrow, and the investigation concluded that the other resident likely made contact, resulting in the injury, and the incident was substantiated as physical abuse. One resident involved had Alzheimer’s disease and schizophrenia, was severely cognitively impaired with a BIMS score of 1, and required maximum assistance with ADLs. His care plan identified him as being at risk for resident-to-resident altercations related to individuals invading his space and at risk for re‑traumatization, with anxiety triggered by male caregivers or those perceived to be male. Interventions in his care plan included providing opportunities for positive interaction and attention, such as stopping and talking with him while passing by. On the date of the incident, a skin assessment documented a scratch above his left eyebrow, consistent with the facility’s determination that he was the victim of physical abuse by another resident. The other resident involved had Lewy body dementia, hypertension, and depression, was also severely cognitively impaired with a BIMS score of 0, and required maximum assistance with ADLs. His behavior care plan identified a risk for verbally abusive behaviors and potential psychosocial issues due to a prior incident in which he had received unprovoked agitation with physical abuse from another resident, with interventions including monitoring for signs of aggression, fear, or psychosocial trauma and documenting behaviors and interventions. An antipsychotic medication care plan further identified him as being at risk for aggressive behaviors, including non‑redirectable agitation, with instructions to intervene immediately if agitation was observed. Staff interviews indicated that only one staff member was assigned to seven residents on the unit, that residents sometimes got into each other’s space and fights occurred, and that the two residents had been seen in a fist fight on the date of the incident, demonstrating that the facility did not effectively prevent or intervene to stop resident‑to‑resident physical abuse in accordance with its abuse prevention policy and the residents’ care plans.
Failure to Thoroughly Investigate and Address Allegations of Sexual and Rough, Abusive Care
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document allegations of sexual abuse and rough, abusive care toward a resident. The facility’s abuse policy required that all reports of resident abuse be thoroughly investigated and documented. An investigation dated 2/24/26 addressed an allegation that a resident was sexually abused during incontinence care, but the investigation did not include interviewing the resident’s roommate about what he might have seen or heard during the alleged incident. The investigation concluded the allegation was unsubstantiated based on lack of physical trauma and staff statements, and it attributed the resident’s report to cognitive decline and terminal agitation, despite the resident’s clear and consistent account during the survey interview. The resident involved was under age 65 with diagnoses including bipolar disorder, anxiety, depression, PTSD, and traumatic brain injury. A recent MDS showed moderate cognitive impairment (BIMS 12/15), aggressive behavior, and delusions, and the resident was dependent on staff for toileting, transfers, and bed mobility, using a manual wheelchair. During the facility’s investigation, the resident reported that while yelling for help after a bowel movement, a CNA entered and began care, and then an LPN took over. The resident stated he did not want the LPN to provide care, tried to swat him away, and that the LPN grabbed his hands, rolled him aggressively causing his head to hit the wall, and inserted a finger into his anus four times while wiping, despite the resident yelling for him to stop. Staff statements conflicted with the resident’s account regarding who provided care and what occurred, and the facility did not investigate why staff did not stop care and have another staff member take over when the resident alleged abuse during the episode. The resident continued to report that staff were rough and that their approach to care felt abusive, including prior rough transfers by the same LPN and improper positioning and repositioning by other staff that caused pain and bruising. On the survey date, the resident described ongoing rough care, lack of staff responsiveness to his requests, and feeling that no one listened to or believed him. He reported that staff did not assist him to sit up properly for breakfast, resulting in difficulty eating and spilled food on his shirt. Observation during the interview showed the resident slouched and slumped to the left in his wheelchair, with his left arm hanging over the side, a bruise on his upper arm where the armrest was pressing, and dried oatmeal on his shirt from the morning meal. The resident’s care plan documented a history of false allegations and required care in pairs, investigation of all concerns voiced, and a calm, slow approach, but there was no specific care plan focus addressing his PTSD or his allegations of rough or abusive incontinence care, and the facility did not pursue his ongoing reports of rough and abusive treatment during personal care.
Failure to Assess, Notify, and Respond Appropriately After Unwitnessed Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards following an unwitnessed fall. A cognitively intact resident with a history of falls, prior fractures (including a right humerus fracture), osteoarthritis, muscle weakness, and difficulty walking was admitted with orders and care plan interventions that included keeping the bed in the lowest position, use of a high-impact fall mat, and a lipped mattress. The resident required maximal assistance with transfers and used a wheelchair. On the night of the incident, the resident was found on the floor on her left side in a somewhat fetal position, partially on and partially off the fall mat, with the bed raised in a high position. RN #1, who heard a loud sound and discovered the resident on the floor, documented an initial assessment that included vital signs showing elevated blood pressure and initiation of neurological monitoring. However, there was no documentation that RN #1 completed a thorough head-to-toe assessment before the resident was moved back to bed, despite facility policy requiring a nurse evaluation to determine presence of injury prior to moving a resident who has fallen. The record lacked evidence of a full assessment of injuries at the time of the fall, even though the resident later was found to have multiple fractures and a scalp contusion. Staff interviews, including from the DON and other nurses, confirmed that standard practice and policy required a complete RN assessment before moving a resident after a fall. Following the fall, RN #1 did not notify the physician, the resident’s representative, or hospice at the time of the incident, despite facility policy and staff statements that the physician and responsible party should be notified immediately after the assessment. The resident’s blood pressure continued to rise over several hours, and she complained of pain, yet the first notification was to hospice at 6:00 a.m., approximately three hours after the fall. The hospice RN arrived around 6:30 a.m., found the resident arousable to verbal stimuli with tense features, facial grimacing, and reporting severe pain, and then notified the on-call physician, who ordered transfer to the hospital. Hospital imaging revealed a left parietotemporal scalp contusion, an acute nondisplaced C7 vertebral fracture, multiple displaced fractures of at least the first six left ribs, a left scapula fracture, and a left clavicle fracture. The facility also failed to ensure the resident’s bed was maintained at a safe, low height as care-planned, and the transfer to the hospital did not occur until after hospice assessment and physician notification several hours post-fall. The resident’s representative reported that the resident lay in bed for three hours in severe pain without medical attention and that the family and physician were not notified by facility staff, but rather by hospice. Documentation showed that the facility did not contact the resident’s representative until later that afternoon, after the hospital had already identified multiple fractures and the resident was being admitted to intensive or trauma care. Staff interviews, including from CNAs, an LPN, an RN, and the DON, consistently described that facility practice required immediate RN assessment before moving a resident, prompt vital signs and neurological checks, and immediate notification of the physician and responsible party after a fall, particularly if there was pain or potential major injury. In this case, the facility failed to accurately and timely assess the resident after the fall, failed to promptly notify the physician and responsible party, did not ensure the bed was at the lowest and safest height, and did not ensure timely transfer to the hospital after an unwitnessed fall that resulted in major injury and pain. The facility’s own fall care plan and incident policy emphasized prevention of avoidable accidents, completion of a nurse evaluation prior to moving a resident who has fallen, and documentation of injury status and notifications. Despite these requirements, the EMR lacked a full head-to-toe assessment at the time of the fall, and the DON acknowledged that RN #1, an agency nurse, failed to document the fall appropriately, complete an accurate assessment, and notify the physician and the resident’s representative. The hospice RN confirmed that RN #1 did not notify the physician or the resident’s representative and that hospice was contacted due to the resident’s increased pain and rising blood pressure. These actions and omissions collectively led to the cited deficiency for failure to provide treatment and care in accordance with professional standards and the resident’s care plan following the fall.
Transportation Safety and Fall Management Failures Leading to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, particularly in relation to transportation safety and fall prevention. One resident with vascular dementia, bilateral lower extremity impairments, and dependence on staff for transfers was transported to an outside appointment in a facility vehicle while seated in a wheelchair without foot pedals. During the trip, the resident began sliding forward in the wheelchair. The transportation driver reported he could not immediately pull over while exiting the highway, and by the time he stopped, the resident had slid further forward so that her knees and legs were resting on a step behind the driver’s seat. The resident subsequently exhibited multiple bruises, abrasions, swelling of both legs, and severe pain. Facility records and later hospital documentation identified bilateral tibial fractures associated with this transport incident. The report details that the wheelchair was secured with a four‑point tie‑down, but the resident’s body was not properly restrained. The driver later demonstrated that he had routed the shoulder portion of the seat belt around the back of the van seat instead of across the resident’s shoulders, and placed the lap portion across the resident’s chest instead of her lap. He acknowledged this was not the proper use of the seat belt and attributed his actions in part to concern about disturbing the resident’s ostomy bag. He also stated that the resident was sitting on a blanket and a Hoyer sling, which he believed contributed to sliding, and that the absence of foot pedals left nothing to stop the resident’s forward movement. The facility’s own transportation policy required that drivers and passengers wear seatbelts and shoulder harnesses any time the vehicle was in motion and that wheelchairs be made secure with straps, but there was no evidence that the seat belt system was applied as intended in this case. The report further identifies systemic issues in transportation training and oversight that contributed to the deficiency. The van driver had been in the role for a little over a month and was trained informally by the central supply coordinator, who herself had been trained years earlier by a prior driver without documented competencies, checklists, or reference to an operations manual. The central supply coordinator reported no additional training or competencies since that initial instruction and was unaware of any policy or procedure for driving emergencies or clear guidance on whom the driver should contact for clinical or mechanical emergencies during transport. The maintenance director, responsible for monthly checks of the van, used a generic medical transport checklist, had no van‑specific training or competencies, and was unsure whether an operations manual was available. The administrator acknowledged that she was not sure what competencies the trainer had when she trained the current driver, that the DON and ADON were not trained on transportation, and that no investigation was completed into the driver’s admitted misuse of the seat belt. Collectively, these actions and inactions led to the transportation‑related accident and constituted a failure to maintain an accident‑free environment and adequate supervision. In addition, the deficiency includes failures related to fall management for two other residents at high risk for falls. One resident with vascular dementia, muscle wasting, difficulty walking, and severe cognitive impairment experienced 16 falls over a defined period, including an unwitnessed fall that resulted in a facial laceration and a maxillary sinus fracture requiring emergency department evaluation. The facility had a fall management policy requiring IDT review of falls and individualized care plan interventions, and the resident’s care plan contained multiple fall interventions such as scheduled toileting, prompted voiding, use of a non‑recording video monitor, and assistance with transfers. However, the report notes that care‑planned fall interventions were not consistently implemented in a timely manner, and surveyor observations during the survey period showed that staff were not consistently following the resident’s fall interventions. The report also notes that the IDT did not consistently review falls in a timely manner or ensure that recommended interventions were implemented. For the high‑risk resident with multiple falls, IDT notes documented repeated unwitnessed and witnessed falls associated with poor safety awareness, failure to use the call light, weakness, and attempts to ambulate or transfer without assistance. New interventions such as occupational therapy evaluations, room relocation closer to staff, and pharmacy review were recommended, but one occupational therapy evaluation was recommended after a fall even though it had already been recommended after a prior fall, indicating delays or gaps in implementation. Another resident with multiple falls had no timely identification and documentation of fall interventions after several falls. These patterns demonstrate that the facility did not ensure timely IDT review of falls or consistent implementation of care‑planned fall interventions, contributing to repeated falls and at least one major injury. Overall, the cited deficiency encompasses the facility’s failure to safely transport a dependent, cognitively impaired resident in accordance with its own transportation safety policy, resulting in bilateral tibial fractures, and its failure to consistently implement and timely review fall prevention interventions for residents at high risk for falls, including residents who sustained multiple falls and a serious injury.
Removal Plan
- Temporarily suspend all facility resident transportation services and transfer transportation to an outside company pending completion of training and validation.
- Immediately remove all staff members assigned transportation responsibilities from transportation duties pending completion of retraining and competency validation.
- Transport residents requiring appointments using medical transportation services through external transportation companies.
- Implement a resident transportation risk assessment tool to identify residents who require special transportation precautions; assess all residents who utilize facility transportation using this tool.
- Implement a comprehensive transportation safety program including: updated Transportation Safety Policy; Transportation Driver Job Description with defined safety duties; Transportation Staff Competency Validation process; Pre-Transport Safety Checklist (reviewed by administrator or designee); Transportation Special Circumstances Protocol; Transportation Incident Investigation Template; Transportation Safety Training Program; and Transportation Safety QAPI Monitoring Process.
- Require wheelchairs to be secured using a four-point tie-down system.
- Require residents to be secured with lap and shoulder seatbelts.
- Verify wheelchair brakes and foot pedals prior to transport by the administrator or designee.
- Confirm resident stability before departure by the administrator or designee.
- Evaluate residents’ medical devices/special medical circumstances individually (e.g., ostomies, indwelling urinary catheters, suprapubic catheters, oxygen equipment, other devices) and implement appropriate precautions prior to transportation as necessary.
- Provide mandatory transportation safety training for all transportation staff (wheelchair securement, restraint placement, medical device accommodations, emergency response); document attendance and validate competency using a checklist, with validation by the maintenance director and clinical liaison/designee as approved by the administrator.
- Complete a Pre-Transport Safety Checklist prior to each transport verifying wheelchair brakes engaged, foot pedals attached, four-point tie-down secured, lap and shoulder restraints applied, medical devices protected, and resident stability confirmed (completed by Maintenance Director and Clinical Liaison/Designee).
- Use a transportation incident ad hoc QAPI tool to ensure structured review of any transportation-related incident (incident description, equipment review, root cause analysis, corrective action planning).
Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Burn Injury from Improperly Heated Hot Beverage and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision when provided a hot beverage. A resident with diagnoses including a displaced intertrochanteric fracture of the left femur with routine healing, unspecified cataract, unspecified macular degeneration, disorientation, and restlessness and agitation requested very hot tea. The resident had moderate cognitive impairment with a BIMS score of 11 and was care planned as needing set-up assistance with eating and drinking. Although an MDS assessment indicated adequate vision without corrective lenses, subsequent care planning documented vision impairment related to cataracts, macular degeneration, and diplopia, and that the resident wore an eye patch and glasses. On the day of the incident, the resident asked a physical therapy assistant (PTA) to make her tea “very hot.” The PTA dispensed hot water for tea from the kitchenette coffee machine and then heated the beverage in a microwave for an additional 30 seconds at the resident’s request. The PTA then secured a lid on the cup and placed it on the resident’s bedside table. The facility’s Hot Beverage policy, in effect at the time, stated that hot beverages were to be served at a safe, palatable temperature, that hot beverage machines were to be set and maintained at manufacturer-recommended temperatures, and that microwaves were not to be used to reheat hot beverages if the temperature was not considered palatable; instead, a fresh cup was to be poured. The policy also directed staff to report safety or decline in managing hot beverages to the IDT or therapy for review and possible care plan updates. After the PTA placed the lidded cup at the bedside, the visually impaired resident attempted to drink the tea but could not locate the opening in the lid due to her macular degeneration. The resident then attempted to remove the lid independently, during which the hot tea spilled onto her right forearm and right posterior thigh. Nursing assessment documented bright red, blanchable burns with a broken blister on the arm, and measurements of 8 cm by 5 cm on the arm and 12 cm by 22 cm on the thigh. The NP assessed the injuries as second-degree partial thickness burns involving approximately 6% total body surface area, with the resident reporting pain of 3 out of 10 and denying numbness, tingling, fevers, or chills. Subsequent documentation showed the wounds progressing with scabbing and epithelial tissue formation prior to the resident’s discharge home. Staff interviews confirmed that, following the incident, it was recognized that the tea had been heated beyond the temperature at which it was dispensed from the coffee machine and that the resident’s impaired vision contributed to her difficulty using the standard lidded cup. The DON and RN stated that the PTA had reheated the tea in the microwave without checking the temperature and then served it to the resident, contrary to the facility’s policy prohibiting reheating of facility-provided drinks in microwaves. The dietary manager and nursing staff also indicated that the facility’s practice was to avoid reheating hot beverages and to rely on the coffee machine settings, which were kept at or below 160°F, rather than using microwaves for additional heating. These actions and inactions led to the resident being provided an excessively hot beverage in a manner that did not account for her visual impairment, resulting in the burn injury. The facility’s failure centered on not adhering to its own Hot Beverage policy and not adequately supervising or accommodating the resident’s known visual impairment when providing a very hot beverage. The PTA’s use of the microwave to further heat the tea, the absence of a temperature check before serving, and the placement of a standard lid that the visually impaired resident could not safely manage independently all contributed to the incident. The care plan at the time identified the resident as needing set-up assistance and, after the incident, was updated to include interventions such as encouraging the resident to leave lids on hot beverages and to use the call light for assistance with lids, indicating that these precautions were not in place or not implemented at the time of the burn event.
Failure to Follow PRN Diuretic Order Leads to Significant Weight Loss and Hypokalemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a diuretic, metolazone, was entered and administered as a scheduled daily medication instead of as a PRN medication with specific weight-based parameters. After an acute hospitalization for conditions including acute on chronic CHF, acute respiratory failure with hypoxia, COPD, atrial fibrillation, hypertension, morbid obesity, COVID-19, and MDRO history, the resident was readmitted to the facility. The hospital discharge order specified metolazone 2.5 mg to be taken once daily as needed for pulmonary edema due to chronic heart failure, only when the resident had a weight gain of 5 lbs over baseline, and to be given 30 minutes prior to Lasix. However, when the orders were transcribed into the facility’s EMR on readmission, metolazone was entered as a scheduled daily medication without PRN parameters, and this incorrect order did not match the hospital discharge instructions. The assistant DON, who entered the readmission orders from the hard-copy discharge packet because the phone lines were down and the usual electronic admission process was not used, input metolazone as a daily scheduled medication. The normal process of having two nurses verify and enter orders was not completed; the ADON entered the orders alone, and the second nurse verification did not occur. As a result, nursing staff administered metolazone 2.5 mg daily for eight days, in addition to the resident’s other diuretics (Lasix and spironolactone), without confirming that the resident had experienced the required 5 lb weight gain from baseline. The MAR documented daily administration of metolazone over this period, including on days when no weight was obtained, and on days when the resident’s weight was stable or decreasing rather than increasing. During this time, the resident experienced significant weight loss and symptoms consistent with a change in condition. Weight records showed a decline from approximately 190 lbs prior to hospitalization to 176.6 lbs when the error was identified, reflecting a loss of about 12–14 lbs over a short period. The resident and her representative reported that she became severely weak, excessively tired, and felt she could not regain her strength, with the representative describing the resident as very tired, exhausted, and feeling as though she could not “hang on any longer.” Clinical documentation noted significant weakness, excessive sleepiness during therapy, and that the resident was triggering for significant weight loss. Laboratory testing later showed hypokalemia, with a potassium level of 3.2 mEq/L. Interviews with nursing staff, the DON, the ADON, the PCP, the pharmacist, the resident, and the resident’s representative consistently attributed the resident’s weight loss, weakness, and low potassium at least in part to the erroneous daily administration of metolazone instead of PRN dosing based on weight gain. The facility’s own medication error policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards, and defined a significant medication error as one that causes resident discomfort or jeopardizes health and safety. In this case, the metolazone order in the EMR did not reflect the prescriber’s PRN order with weight-based parameters, and the medication was administered without verifying the required 5 lb weight gain. The resident’s care plan for diuretic therapy called for administering diuretics as ordered, monitoring for side effects such as fatigue and increased fall risk, and reporting pertinent lab results, including potassium. Staff interviews acknowledged that the error persisted for about eight days, that medication reconciliation was not completed upon readmission, and that the lack of a second nurse verification contributed to the error. The pharmacist and PCP described the effects of metolazone, especially in combination with Lasix, as including electrolyte abnormalities, weight loss, and weakness, and characterized the error as moderate, with the potential to increase electrolyte depletion and require close monitoring.
Failure to Maintain a Full-Time RN Director of Nursing During Temporary NHA Appointment
Penalty
Summary
The deficiency involves the facility’s failure to designate a registered nurse (RN) to serve as the full-time director of nursing (DON) while the existing DON was reassigned to act as the temporary emergency licensed nursing home administrator (NHA). Record review showed that the acting NHA held an active temporary permit for emergency situations beginning on 12/30/25 and expiring on 3/30/26. A staffing list review revealed there was no full-time DON in the building during this period. The DON job description, signed by the DON, specified that the DON’s primary purpose was to plan, organize, develop, and direct nursing operations, ensure quality resident care on a 24-hour basis, oversee recruitment and hiring of licensed personnel, manage nursing schedules, monitor staffing levels, and oversee implementation of nursing service objectives, policies, and procedures, including key clinical systems such as infection prevention and control, psychotropic and controlled substance management, skin and weight systems, risk management, and hospice liaison. Staff interviews confirmed that the individual serving as the full-time temporary NHA was also functioning as the full-time DON, with no other person appointed to the DON role. The chief nursing officer stated that the temporary NHA was also acting as the full-time DON and reported not knowing there was a regulation preventing this. Nursing staff, including an LPN and an RN, reported they were unaware that the DON had been appointed as the temporary NHA and continued to view the DON as their supervisor. The acting NHA described performing both administrative and clinical leadership duties, including occurrence reporting to the state, serving as abuse coordinator and investigator, and leading stand-up meetings, while relying on two unit managers, an LPN assistant DON, and an infection preventionist to assist with clinical duties and audits. There had been no announcement to staff, residents, or families about the acting NHA appointment or her role as abuse coordinator, and there was no signage indicating this responsibility.
Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys. Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence. Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.
Failure to Provide Timely Assistance With Resident Room-Change Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences during a room change, specifically by not providing timely assistance with moving the resident’s personal belongings. The facility’s Room Change policy, revised April 2025, states that environmental services staff or a designee will assist residents to pack their belongings prior to a room change, and nursing staff will assist residents to unpack belongings and get settled into the new room. The policy does not specify who will physically move the belongings between rooms, but staff interviews indicated an expectation that environmental services, nursing, or maintenance staff would typically assist with moving items or furniture. The resident involved was under age 65 and had multiple diagnoses, including CVA with left-sided hemiparesis and spastic hemiplegia, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. The resident was cognitively intact with a BIMS score of 15, used a wheelchair for mobility, and was independent with hygiene, toileting, bathing, and dressing, but required setup and cleanup assistance with eating. The resident had documented verbal behavioral symptoms such as yelling and cursing, and a behavior care plan that included communicating via email and following up on concerns in a timely manner. The resident reported irritation of the nose and eyes and refused to return to her original room after complaining of a strong smell of ammonia and bleach, and staff assisted her into another room that night so she could sleep. Following this move, the resident requested assistance from staff to bring toiletries, a plant, and other personal items from the original room to the new room. Progress notes documented that staff told the resident they were not allowed to move her belongings and could only accompany her while she moved them herself, despite her left-sided hemiplegia and inability to move the items independently. The resident stated she was told she needed to move the items herself or arrange for someone else to move them and that she felt she should not have to pay to move her own items because the facility had offered the room change. Email communications show that the NHA characterized the room change as an accommodation requested by the resident and informed her that, due to prior concerns about staff handling her property, her belongings should be moved by family, an authorized representative, or a third-party mover at her own expense, with staff only providing access and oversight. The resident agreed to permanently move to the new room, but most of her belongings remained in the previous room, and staff continued to only escort her to retrieve items herself. Staff interviews confirmed that, in typical room changes, families or staff would assist with moving belongings, and that in this case the facility did not expect the resident to move her own items but also did not provide direct assistance or documented resources for moving services. The permanent move of the resident’s belongings did not occur until 39 days after she agreed to the room transfer, during which time the majority of her personal items remained in the original room.
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