Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Williamsburg Village Healthcare Campus during CMS and state inspections, most recent first.
Failure to Provide Timely Incontinence Care: A resident with CVA, intact cognition, and total bowel and bladder incontinence was found heavily wet with urine and soiled with feces after staff did not provide the ordered two-hour rounds and incontinence care. The CNA assigned to the resident, another CNA, and an LVN all stated the resident required two-person assistance and that rounds were supposed to be completed every two hours and as needed, but the resident was not checked and changed timely during the night shift.
Failure to Perform Hand Hygiene During Incontinence Care: Two CNAs provided incontinence care to a resident with CVA history and bowel/bladder incontinence but did not perform hand hygiene at required points during the task. One CNA changed gloves and handled clean linen without washing hands, and both CNAs later acknowledged they forgot hand hygiene before, during, and after care, including after glove changes and before leaving the room.
A cognitively impaired resident with dementia and known exit‑seeking behavior twice eloped from a secured unit after staff failed to maintain functional door and window alarms and to implement effective monitoring. In the first incident, a floor technician saw someone leaving through a back door whose alarm had been turned off so staff could use it for breaks, but he did not follow or redirect the individual; the resident was later found off‑site by law enforcement. Despite this, the resident’s elopement assessment rated him low risk and there was no documented one‑to‑one or 15‑minute monitoring. Days later, the same resident eloped again through a window in his former room where the alarm had been removed and safety brackets broken, allowing the window to open wide enough for him to exit without staff noticing; he was later located at a hospital being treated for chest pain. These events show that nonfunctioning alarms, unsecured egress points, and insufficient supervision directly led to repeated elopements.
A resident admitted with cellulitis, HTN, wound infection, and risk of malnutrition, and assessed with moderate cognitive impairment and need for supervision with most ADLs, chose to leave AMA to a community shelter after refusing care, medications, and wound treatment. The SW documented informing the resident that leaving would be AMA and that medications could not be sent, and nursing documented that leadership was aware and the resident left with belongings. However, the physician discharge summary left the condition upon discharge, prognosis, and discharge diagnosis sections blank and did not include special instructions, precautions, or risks related to the AMA discharge. The EHR contained no completed AMA form signed by the resident or staff, and interviews confirmed that required AMA procedures and written discharge instructions outlined in facility policy, including execution of AMA forms, were not documented for this discharge.
A resident with severe cognitive impairment and multiple comorbidities fell in a hallway after becoming agitated during redirection, striking his head and torso against a handrail and sustaining a facial abrasion. The assigned LVN reported verbally that the resident was ambulatory and at baseline afterward but did not document vitals, neuro checks, or a post-fall assessment in the EHR, and did not notify the MD, DON, ADON, weekend supervisor, or the resident’s family at the time of the incident. Later that day, family observed a bloody bandage and mental status changes, learned of the fall only after questioning the LVN, and then signed the resident out and transported him to the hospital, where he was found to have rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. Subsequent interviews and record review showed that required immediate assessment, documentation, and notification protocols for incidents and changes in condition were not followed.
A resident with severe dementia and known fall and wandering risks fell after becoming agitated during redirection, striking his head and torso on a hallway rail and sustaining a visible facial abrasion. The assigned LVN helped the resident up and applied a bandage but did not complete or document required post‑fall assessments such as vitals, head‑to‑toe exam, neuro checks, or pain assessment, and did not notify the MD, DON, ADON, weekend supervisor, or the family. Later that day, the family noticed the bloody bandage and a change in the resident’s mental status, questioned the LVN, and then signed the resident out and transported him to the hospital, where he was diagnosed with rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. Facility records and staff interviews confirmed that the mandated assessments and notifications were not performed or documented at the time of the fall.
A resident with severe cognitive impairment, dementia, and fall/wandering risk, who required supervision and assistance with mobility and ADLs, was observed roaming in and out of rooms and was redirected by an LVN. During redirection, the resident became aggressive, attempted to hit the nurse, lost balance, and fell against a handrail, sustaining a noted abrasion to the temple. Later that day, at the family’s request, the resident was sent to the hospital for change of condition and was diagnosed with rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. Despite facility policy and federal requirements mandating prompt reporting of alleged abuse/neglect incidents and events resulting in serious bodily injury to the Administrator and appropriate agencies within specified timeframes, the DON and Administrator did not report the incident to the State agency or other required authorities, constituting a failure to timely report a serious, reportable event.
A resident with severe cognitive impairment, multiple comorbidities, and identified fall and wandering risks experienced a witnessed fall after becoming aggressive during redirection, striking a handrail and sustaining a visible abrasion. The primary LVN did not report the fall to the Administrator or notify the MD or family, and the subsequent transfer note to the hospital cited a change in condition (N/V) without linking it to the fall. Hospital evaluation revealed multiple traumatic injuries, including rib fractures, adrenal hematoma, and a grade 3 liver laceration. Despite being informed of the serious injuries and that the fall occurred in the facility, the Administrator and DON did not promptly initiate or document a thorough investigation in accordance with the facility’s abuse/neglect investigation policy.
Failure to Provide Privacy Covers for Urinary Collection Bags: Two residents with urinary catheters had collection bags left uncovered and visible, including one facing the room entrance and another visible from the hall. One resident had Alzheimer’s disease, severe cognitive impairment, and required a catheter for wound healing; the other had a stroke with paralysis of all four extremities, pressure ulcers, contractures, and severe cognitive impairment. Staff stated privacy covers were required for dignity and privacy, including while residents were in bed.
A facility left an elopement binder in the lobby that contained residents' admission records with names, SSNs, Medicare and Medicaid numbers, addresses, phone numbers, and responsible party information. The ADM, LVN, and DON all acknowledged the binder should have been kept on the memory care unit and that leaving it in the lobby exposed PHI to unauthorized individuals. The facility also failed to maintain room privacy when one resident was visible from the hallway while using a urinal and another room had no window blinds, leaving the resident easily seen at night.
Failure to Provide Routine Nail Care and Grooming: Two residents who needed staff help with ADLs were found with overgrown fingernails, and one also had facial hair that had not been shaved regularly. One resident had stroke-related contractures, dementia, and legal blindness, while the other had stroke-related weakness, diabetes, pain, and visual impairment. Staff and the DON acknowledged the residents needed regular bathing, grooming, and careful hand care, but the records and observations showed the nail and shaving care had not been provided routinely.
Surveyors found multiple food safety failures in the North and South kitchens. In the North Kitchen, thawed meats, pies, and bagels were observed in a freezer that was reading above freezing, with no completed temp log. In the South Kitchen, unlabeled and undated foods were found in the fridge, dry storage, and freezer, the freezer was also above freezing with missing temp log entries, and beef patty fritters were left out on the counter to thaw and were soft to touch.
Unsafe Freezer Temperatures and Equipment Maintenance Failures: Surveyors found thawed, unlabeled, and undated food in reach-in freezers in the North and South kitchens, with temperatures recorded between 40 and 50 degrees and incomplete temp logs. Staff interviews showed confusion about who was responsible for checking temps and reporting equipment problems, and the dietary manager and maintenance supervisor acknowledged the freezers were not functioning properly. The report also noted one resident’s bed was not in proper working condition.
Missing privacy curtains were found in three resident rooms, including rooms with ceiling-mounted tracks and hanger clips already in place but no curtain installed. Surveyors observed the missing curtains in rooms #115, #116, and #119, and staff interviews confirmed that resident privacy was important for dignity and that nursing, housekeeping, and maintenance each had roles related to curtain replacement and room upkeep. The DON was unaware of the issue, and the Administrator could not provide a policy on resident privacy or privacy curtains.
Failure to maintain an effective pest control program: gnats were observed in a resident’s room, the North Kitchen, and on the 700 Hall. Staff members, including kitchen staff, an LVN, a Dietary Manager, and Maintenance staff, acknowledged awareness of the gnats, and one resident reported the problem was ongoing and that he avoided eating food in his room because of the gnats. The facility’s pest control policy required an ongoing program to keep the building free of insects and rodents.
Unapproved Bedside Medication Storage and Self-Administration: Two residents had medications in their possession without documented IDT approval or self-administration assessments. One resident with asthma/COPD kept an Atrovent inhaler in the TV room after a staff member gave it to him, and another resident with severe cognitive impairment had eye drops and Voltaren gel at the bedside for personal use. Staff and the DON stated residents were not supposed to keep meds at bedside unless assessed and approved.
A resident’s room had peeling ceiling plaster hanging down with drywall visible. The resident said the issue started after rain and was getting bigger, but she was unsure if anyone would fix it and could not recall reporting it. A CNA was unaware of the problem, the assigned RN said she thought it was being fixed, and the Maintenance Supervisor said he had not been aware of it. The maintenance logbook contained no request for ceiling repair.
A facility failed to develop complete care plans for two residents with significant medical needs. One resident had a PEG tube, NPO orders, malnutrition, and was observed drinking and keeping snacks and drinks at bedside, but the care plan did not address the feeding tube or his oral intake preferences. Another resident had severe cognitive impairment, a CVC line, and IV antibiotics, but the care plan did not address antibiotic therapy or central line care; staff confirmed these needs were not included.
A facility failed to provide proper G-tube care for two residents. One resident’s tube feeding and water bags were observed without required labels, while another resident’s enteral feeding was not managed according to the current MD order, including failure to reconnect at the ordered time and use of a formula bag that was not changed as expected. Staff interviews showed confusion about the feeding regimen, bag dating, and whether the resident was on continuous or bolus feedings.
IV therapy was not managed per orders for two residents receiving IV antibiotics. One resident with a central line had a peeling dressing and unlabeled IV bag and tubing, while another resident with a PICC had a half-administered cefazolin bag that was not connected and also lacked date, time, and initials. Staff interviews confirmed the dressing changes and IV labeling expectations, and one LPN stated the resident did not receive the full dose and the physician was not notified.
Expired meds were found on a nurse med cart and in a med room/refrigerator, including ibuprofen, buspirone, multivitamins, and daptomycin past their expiration dates. In addition, a resident with BIMS 10 and diagnoses including anemia, cancer, malnutrition, MDR organism, and HIV missed multiple ordered enteral meds and doses of methadone; the resident said he did not receive his morning meds, and the LPN stated she was unaware she was assigned to provide his care and meds.
A resident with moderate cognitive impairment and diagnoses including HIV, cancer, malnutrition, anemia, and sepsis-related treatment orders missed multiple scheduled meds, including Dovato, hydromorphone, methadone, amoxicillin/clavulanate potassium, and apixaban. The resident stated he had not received his morning meds, while an LVN said she was unaware she was responsible for his care that shift and did not have his meds on her cart; the ADON confirmed the missed doses on the MAR.
Failure to Disinfect Blood Pressure Cuff Between Residents: During a morning med pass, an MA used the same BP cuff on two residents with severely impaired cognition and HTN without disinfecting it between uses. The MA stated reusable equipment should be disinfected between each resident and that she did not have wipes on her cart; the DON stated staff were expected to disinfect BP cuffs between residents.
A resident with dementia, kidney failure requiring dialysis, and impaired mobility was left unattended and unsupervised in a facility transport van for several hours in cold weather after returning from a dialysis appointment. The resident, who used a wheelchair and lived on a memory care unit, was later discovered buckled into a van seat with his wheelchair stored in the back, while temperatures were in the 30s°F. Staff interviews revealed that the resident was not promptly accounted for on the unit, that a CNA eventually noticed movement in the van and found the resident inside, and that nursing staff doubted the resident could have independently exited the secured unit, navigated outside, loaded his wheelchair, and buckled himself in. The resident reported that the driver had left him in the van, and the medical record lacked documentation of the incident or subsequent assessments, contributing to a finding of Immediate Jeopardy related to inadequate supervision and accident hazard prevention.
Multiple residents with pressure ulcers, end-stage skin failure, and a Kennedy terminal ulcer did not consistently receive ordered wound care, as wound treatment records showed numerous missed entries and progress notes lacked documentation of care. One resident with severe cognitive impairment and multiple stage 4 and unstageable foot and heel ulcers had many days where prescribed cleansing and dressings were not provided. Another resident with sacral end-stage skin failure had daily and PRN wound orders that were repeatedly marked as missed on the treatment record. A third terminal resident with a Kennedy ulcer on the ischium also had ordered Dakin’s-based dressings missed on several days. Observations confirmed the presence of wounds and that when the wound care nurse did perform treatments, they followed ordered procedures, but interviews revealed that floor nurses were responsible for wound care when the wound nurse was off and that the wound nurse had not monitored treatment administration records, contributing to unaddressed missed treatments.
A resident with dementia, severe cognitive impairment, and impaired mobility who used a wheelchair and received thrice-weekly dialysis was discovered in the facility’s transport van late in the evening after having returned from dialysis earlier that afternoon. Staff reported that the resident was found seated and belted in the van, and the resident stated that the driver had left him there, while the driver and Administrator asserted the resident had been returned to the unit and later made his way back to the van. An LVN stated she did not believe the resident was physically or cognitively capable of independently leaving the locked unit, navigating to the van, loading his wheelchair, and buckling himself in. The incident was not documented in the EHR, and the Administrator did not report the alleged neglect to the state agency as required by the facility’s abuse/neglect policy, which mandates timely reporting of reportable allegations to regulatory authorities.
A resident with stroke-related weakness and ESRD, care planned for Hoyer lift transfers with two-person assist, was manually transferred from bed to wheelchair by several CNAs instead of using the mechanical lift. During the transfer, the resident’s leg twisted, causing immediate severe pain, but she was still transported to dialysis, where she arrived crying, with a Hoyer sling under her and 10/10 left leg pain. Dialysis staff reported the resident consistently stated that aides at the facility had twisted her leg during the transfer, and she was sent to the ED, where imaging showed an acute comminuted distal femur fracture. One CNA admitted the lift was reportedly broken and that they used a sling and draw sheet with multiple staff, while other CNAs gave conflicting accounts and did not report the resident’s pain to an LVN, contrary to the care plan and facility policies on mechanical lifts and change of condition.
A resident with impaired mobility and a care plan requiring Hoyer lift transfers was manually transferred from bed to wheelchair by multiple CNAs, after which she immediately reported severe leg pain and stated that staff had twisted her leg. She was transported to dialysis still in pain, where dialysis staff observed her crying, unable to move her leg, and still in a Hoyer sling, and she repeatedly told them that nursing home staff had hurt her during the transfer. Hospital evaluation revealed an acute distal femur fracture. Despite the resident’s consistent allegations to family and dialysis staff that the injury occurred during a transfer at the facility and the facility’s policy requiring reporting of all alleged abuse/neglect to the State, the DON and Administrator concluded the incident was not reportable, believing it occurred at the dialysis center, and did not report the allegation to the State Survey Agency within the required timeframe.
A resident who was care planned for Hoyer lift transfers with two‑person assistance was manually transferred from bed to wheelchair by multiple CNAs, after which she immediately reported severe left leg pain. She was transported to dialysis, where staff found her crying in pain with a Hoyer sling still under her, and she consistently reported that nursing home aides had twisted her leg during the transfer. Dialysis staff did not move her to a dialysis chair due to pain and arranged EMS transport; hospital imaging showed an acute distal femur fracture. Despite multiple consistent accounts from the resident and dialysis staff that the injury occurred during a facility transfer and that the resident had reported pain before leaving, the DON did not verify events with the dialysis center, did not interview all involved staff at the time (including the assisting CNA), and could not produce documented staff statements, while the Administrator asserted the event was not reportable because it allegedly occurred at dialysis. The facility’s actions and omissions show it failed to conduct and document a thorough investigation of an allegation of neglect and injury as required by its abuse/neglect policy.
Two residents with severe cognitive and physical impairments did not receive timely incontinence care, resulting in them being found in heavily soiled briefs and linens. The CNA assigned did not follow proper perineal care procedures, including failing to cleanse the perineal area and not changing gloves after a bowel movement. Nursing staff acknowledged the expectation for incontinence rounds every two hours but could not confirm compliance, and training records lacked specific guidance on the required frequency of care.
Two residents with significant medical conditions did not receive proper incontinence care when a CNA failed to perform hand hygiene and change gloves between tasks, and did not cleanse the peri area as required. Despite prior training and facility policy, the CNA used the same gloves after handling soiled linens and before applying clean briefs, actions confirmed by interviews with nursing leadership and staff.
A resident with severe cognitive impairment and multiple diagnoses was discharged to another facility without a completed discharge summary, as required. Nursing staff did not complete the summary due to unfamiliarity with a new system, and facility leadership was unaware of the omission. Only a progress note and physician discharge summary were present, and the facility's policy for discharge documentation and notification was not fully followed.
Two residents with severe cognitive impairment and behavioral health needs were physically harmed in separate altercations with other residents. In one case, a resident was struck with a ruler and stabbed with a pen by a roommate, resulting in lacerations and emotional distress. In another, a resident was pushed by another resident, causing a hip and wrist fracture that required hospitalization and surgery. Staff and record reviews confirmed that the facility did not prevent these incidents, leading to significant harm.
A resident with severe dementia and a history of wandering eloped from the facility by breaking a window, despite being on 15-minute checks. The resident was found by police exhibiting psychotic behaviors and was transported to the hospital for evaluation. Staff interviews and records confirmed that required supervision was in place, but the resident was able to leave undetected between checks.
Two residents with severe cognitive impairment and incontinence did not receive timely incontinence care as required by their care plans, resulting in prolonged periods without changing, double briefing, and soiled bedding. Staff interviews confirmed knowledge of protocols for two-hour rounding and single brief use, but these were not consistently followed.
A resident with multiple pressure ulcers did not receive wound care as ordered by the physician due to a delay in entering treatment orders into the electronic system, resulting in missed or undocumented wound care treatments. Staff interviews and record reviews confirmed that the orders were not promptly entered or followed, leading to a lapse in the resident's prescribed wound care regimen.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed enteral feedings on several occasions, as documented in the MAR. Nursing staff and the DON confirmed the missed feedings and were unable to provide documentation or reasons for the omissions, despite facility policy requiring prompt implementation and documentation of physician orders.
Staff failed to follow infection control protocols by not performing required hand hygiene during incontinence and wound care for two residents with severe cognitive impairment and complex medical needs, including a stage 4 pressure ulcer. CNAs and an RN were observed skipping handwashing before, during, and after care, handling both soiled and clean items with the same gloves, and not disinfecting surfaces used for wound care supplies, despite facility policies and reported training.
The facility did not ensure that residents were seen by a physician at the required intervals, with all face-to-face visits being conducted solely by a nurse practitioner rather than alternating with the physician as required. Several residents with complex medical needs did not have documented physician visits in their clinical records, and the attending physician acknowledged falling behind on these responsibilities.
A resident with dementia and multiple chronic conditions was not administered her prescribed morning medications on two consecutive days. Staff failed to make additional attempts, document refusals, or notify the physician as required by facility policy, resulting in missed doses of essential medications and lack of appropriate follow-up.
Two residents were prescribed Austedo, a medication for involuntary movements, without documented evidence or formal diagnosis of tardive dyskinesia or other movement disorders. AIMS assessments and nursing notes did not support the need for the medication, and staff interviews revealed a lack of awareness regarding movement issues or the rationale for the prescription. The facility's actions did not align with its policy requiring formal diagnosis and interdisciplinary review before initiating such treatment.
A resident with Alzheimer's disease and significant mobility limitations was found with her call light on the floor and out of reach, despite her care plan requiring it to be accessible due to fall risk. Staff interviews confirmed the expectation that call lights should always be within reach, but this was not ensured during the incident.
A resident with Alzheimer's disease and esophagitis, identified as a fall risk and requiring substantial assistance, did not have prescribed fall prevention interventions implemented as outlined in her care plan. Observations showed the bed was not in the lowest position, the fall mat was not in place, and bed rails were not raised. Staff interviews revealed lapses in following and understanding the care plan interventions.
A resident with Alzheimer's disease and esophagitis, requiring total assistance with eating and on a puree diet, was not provided with feeding assistance, resulting in an untouched meal. The CNA attempted to feed the resident but did not report the missed meal to the LVN, who was unaware until later. Facility policy requiring notification to nursing staff when food intake is low was not followed.
A resident with severe cognitive impairment was injured in an altercation with another resident who pushed her, causing a hip fracture. The second resident, known for verbal aggression and paranoia, was not adequately monitored or managed, leading to the incident. Staff intervened, but the injury had already occurred.
A resident's morphine pills were misappropriated by the ADON, who altered the medication count sheet to show fewer pills than were initially present. The resident, with a history of cancer and moderate cognitive impairment, was due for a morphine dose, but the pills were missing from the cart. The ADON was suspended pending investigation.
A resident with breast cancer missed four doses of the prescribed cancer medication Ibrance due to the facility's failure to administer it as ordered. The DON cited delivery issues from a specialty pharmacy but confirmed there was no valid reason for the missed doses, highlighting the importance of maintaining therapeutic blood levels.
The facility failed to provide adequate personal hygiene care for three residents, leading to deficiencies in their grooming and bathing routines. A resident with severe cognitive impairment was not consistently shaved, despite expressing a desire for facial hair removal. Another resident, legally blind and requiring full assistance, was observed with unwanted facial hair, and there was no record of her being shaved. Additionally, a resident with cognitive impairments did not receive consistent showers, as documented in the facility's records. Staffing and scheduling issues contributed to these deficiencies.
The facility's North and South kitchens failed to meet food safety standards. In the North kitchen, several food items were not labeled or dated, risking foodborne illness. In the South kitchen, Nutrition Aides with facial hair did not wear beard guards while handling food and clean dishes, due to unavailability. These actions violated facility policies and the Federal Food Code, potentially endangering residents.
A resident's dignity was compromised when their catheter urine collection bag was observed without a privacy cover, lying on the floor. Despite the resident's discomfort, staff were unaware of the issue, which violated the facility's policy on catheter care. Interviews with staff highlighted a lack of communication and adherence to privacy protocols.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received needed incontinence care. Resident #1 was admitted with a diagnosis of cerebrovascular accident, was cognitively intact with a BIMS score of 14, and was always incontinent of bowel and bladder. Her care plan identified her as at risk for bowel and bladder incontinence and directed staff to check and change her, and keep her clean and dry. During an early morning observation, Resident #1 stated she had last been changed at 11:00 PM and that staff came to her room at 1:00 AM but did not change her brief. When staff later provided care, her brief and draw sheet were heavily soaked with urine and the draw sheet was stained with bowel movement. CNA A, CNA B, and the LVN each stated the resident required two-person assistance, that rounds and incontinence care were supposed to occur every two hours and as needed, and that the resident had not been checked and changed timely during the night shift. The DON and ADON stated their expectation was that CNAs perform two-hour rounds and nurses monitor them to ensure residents are checked for wetness.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for infection control. During incontinence care for a resident with a history of cerebrovascular accident, intact cognition, and bowel and bladder incontinence, CNA A and CNA B washed their hands, put on gloves, and began care, but then failed to perform hand hygiene at multiple points during the procedure. While providing care, CNA B cleansed the resident’s abdominal folds and perineal area, removed her gloves, and put on new gloves without washing her hands. CNA B then cleansed the resident’s buttocks and thighs while the resident’s brief and draw sheet were soaked with urine and the draw sheet was stained with feces. CNA B handled clean linen and a clean brief while wearing the same gloves used during care, and later removed her gloves and left the room without performing hand hygiene. CNA A also removed soiled linen and changed gloves without washing her hands. Both CNAs stated they forgot to perform hand hygiene during care, and the DON and ADON stated staff were expected to perform hand hygiene before contact, during care when moving from dirty to clean, after care, and when changing gloves.
Repeated Elopements Due to Disabled Alarms and Inadequate Supervision on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a hazard‑free, secure environment for a cognitively impaired resident on a secured unit, resulting in two elopements. The resident was an adult male with non‑Alzheimer’s dementia, neurocognitive disorder, severe cognitive impairment (BIMS score of 7), and a history of wandering per admission clinicals. His MDS showed he ambulated independently and required moderate assistance with most ADLs. His care plan, revised 04/22/26, identified cognitive loss and exit‑seeking behaviors, with interventions such as redirection and moving him closer to the nurses’ station for monitoring. Despite this, the resident told staff he had been trying to get out of the door every day for 20 days, indicating ongoing exit‑seeking that was not effectively addressed. On the first elopement, at approximately 2:00 a.m. on 04/20/26, the resident was discovered missing from his room and a Code Green was activated. A floor technician reported seeing a man in a gray hoodie exiting the back door around that time. The technician stated the exit door alarm, which should have sounded when opened, had been turned off by someone so staff could go out for breaks without disturbing the facility or getting locked out. Instead of intervening or following the individual he saw leaving, the technician went to inform an aide, and by the time staff searched outside, the resident could not be located. Law enforcement later found and returned the resident around 4:30 a.m. The resident subsequently stated he had been trying the door daily and finally found it unlocked, and that he had walked for 2–3 hours looking for public transportation before encountering officers. Following the first elopement, the resident’s elopement assessment on 04/20/26 scored him as low risk (score 10) with no mental or behavioral issues documented, despite his dementia, history of wandering, and expressed exit‑seeking. The DON later stated that residents with exit‑seeking behaviors were to be placed on 15‑minute checks for 72 hours and, if unresolved, on one‑to‑one supervision until reassessment and psych clearance; however, there was no evidence provided of 15‑minute checks for this resident, and he was not placed on one‑to‑one supervision. On the second elopement, during the overnight shift of 04/23–04/24, staff last observed the resident near the nurses’ station around 12:30 a.m., awake, eating snacks, writing, and later napping on a couch. Around 1:30 a.m., he was found missing, and staff discovered that a window in his previous room was open with part of the window alarm removed and the brackets that should have limited the window opening to 6 inches broken off. Staff reported that the alarm on that window had been removed, so no alert sounded when it was opened. The resident eloped through this unsecured window without staff noticing and was later found at a hospital under another name, being treated for chest pain. These events demonstrate that exit doors and windows were not consistently secured or alarmed as required, and that staff supervision and monitoring interventions were not effectively implemented for a known exit‑seeking, cognitively impaired resident on a secured unit. The facility’s own elopement policy required that alarms and security measures function properly, that residents at risk for elopement be appropriately assessed and care planned, and that staff respond immediately when a resident is missing. In this case, the exit door alarm had been turned off, the window alarm and safety brackets were broken or removed, and the resident’s elopement risk assessment did not reflect his documented history of wandering and exit‑seeking. Staff interviews confirmed that the floor technician did not follow the resident when he saw someone leaving through the back door, and that staff were unaware of the disabled window alarm until after the second elopement. The combination of disabled or nonfunctional alarms, unsecured egress points, and inadequate implementation of monitoring interventions for a resident with dementia and exit‑seeking behaviors led directly to the two elopement incidents that formed the basis of the deficiency.
Failure to Provide Complete Clinical Information and AMA Documentation at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge summary contained an accurate and current description of clinical status and sufficiently detailed, individualized care instructions at the time of discharge against medical advice (AMA). The resident was an adult female admitted with active diagnoses including hypertension, wound infection, and risk of malnutrition, and her baseline care plan documented antibiotic therapy for a wound infection, pneumonia, and UTI, along with monitoring of vital signs, behavioral concerns (talking to herself, moderate elopement risk), and skin issues including a surgical wound and mild risk for pressure ulcers. The MDS reflected moderate cognitive impairment (BIMS score of 8) and a need for supervision with most ADLs. The baseline care plan noted an expectation for discharge to the community but did not include documented interventions related to that discharge. On the day of discharge, progress notes documented that the resident told the social worker she wanted to discharge to a community shelter and was informed that leaving at that time would be an AMA discharge and that medications could not be sent with her; the resident stated she understood and still wished to leave. A subsequent nursing note documented that the resident continued to refuse care, medications, and wound treatment, made arrangements to leave, and left the facility AMA with her belongings, with administration, DON, ADON, and the social worker aware. The physician discharge summary form listed the admission diagnosis of cellulitis of the right lower limb and essential hypertension, identified the discharge type as AMA, and noted that medications were locked in the med room and personal property was taken with the resident, but left the sections for condition upon discharge, prognosis, and discharge diagnosis blank. Further record review showed there was no documentation of special instructions or precautions for ongoing care or of risks associated with discharging AMA in the discharge summary. The electronic health record contained no completed AMA document signed by staff or the resident, despite the facility’s policy requiring AMA forms to be executed when a resident leaves without a physician’s order after being informed of risks and consequences. Interviews with the interim administrator, social worker, NP, and DON confirmed that the resident had been at the facility only a few days, was treated with antibiotics for a leg wound infection, refused care and medications, and chose to leave AMA, and that the social worker was not aware at the time that an AMA discharge form was required. The facility’s written Discharge/Transfer Policy required obtaining a discharge order, notifying the resident and family or representative, providing written discharge instructions/education, and, for AMA discharges, holding a care conference with the treating physician to explain risks and having the resident complete all required AMA forms, steps that were not documented as completed for this resident.
Failure to Notify Physician and Family After Resident Fall With Significant Injuries
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after an accident that resulted in injury and had the potential to require physician intervention. The affected resident was an elderly male with severe cognitive impairment, Spanish-speaking only, with diagnoses including anemia, HTN, DM, CKD stage 2, Alzheimer’s dementia, and non-Alzheimer’s dementia. His admission MDS showed a BIMS score of 00, indicating he was unable to complete the interview, and he required supervision or partial assistance with mobility, transfers, toileting, and ADLs. He had a history of wandering and behaviors such as restlessness, disorganized speech, abusive or resistant behavior, and was care planned as at risk for falls and wandering, with interventions including frequent visual checks and redirection. On the morning in question, the resident was reported by the primary nurse (LVN-L) to have been roaming in and out of other residents’ rooms and requiring frequent redirection. According to LVN-L’s later interview, at approximately 7:30 AM the resident became angry when redirected, attempted to swing at the nurse, lost his balance, and fell hard against a hallway handrail, striking his face/head and torso. LVN-L stated he observed an abrasion to the right temple/cheek area, helped the resident off the floor, cleaned and bandaged the area, and claimed he completed vitals, skin, fall, and neuro assessments with regular observations, and that the resident was ambulatory, not in pain, and functioning at baseline. However, the resident’s electronic health record for that date contained no clinical documentation of vital signs, fall assessment, post-fall monitoring, neurological assessments, pain assessments, or any change-in-condition assessments related to the fall. There were also no completed post-fall assessments by LVN-L in the record. Later that day, the resident’s family visited and, at about 5:00 PM, observed a bloody bandage on his face and noted a change in his mental status. During a conference call with LVN-L, the family learned for the first time that the resident had fallen and hit his head on the rail earlier that morning. The family questioned why they had not been notified and expressed concern about increased confusion. LVN-L acknowledged to the family and to the surveyor that he had not notified the responsible party, the physician, the DON, the ADON, or the weekend supervisor about the fall and injury, stating he was not aware he needed to notify the family and that he was busy with 60 residents and ongoing behaviors. He told the family the resident was fine and allowed them to sign the resident out and transport him to the hospital on leave rather than arranging emergency transport. Hospital records later showed the resident had right 6th and 7th rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s medical provider (NP-A) reported he was not notified of the fall details until two days later and stated he expected immediate notification when a resident falls with a head injury. Interviews with the Administrator, DON, ADON, weekend supervisor, other nurses, and CNAs consistently described that facility protocol required immediate assessment, documentation, and notification of the physician, responsible party, and nursing leadership after a fall or change in condition, and that this did not occur in this case.
Removal Plan
- Medical Director notified
- Ad hoc QA completed to address notification protocols of family and physician for incident/accidents and change of condition
- DON/designee to educate licensed nurses on proper notification of physician and family for incident/accidents to include any resident change of condition
- DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer
- DON/designee performed assessments on all residents with falls in the past 30 days to ensure proper notifications and assessments in place
- MDS/designee updated care plans for all residents with falls in the last 30 days
- All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment prior to working their next assigned shift
- DON and/or designee will monitor residents with falls daily to ensure notifications were appropriately made to physician and family
- Administrator to review with the DON weekly to ensure continued compliance
- Results of all audits will be brought to the QAPI committee by DON to review for continued recommendations and compliance
- Protocol will be covered on new-hire orientation by DON/designee
Failure to Assess and Notify After Witnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the resident’s care plan, and the resident’s choices following a witnessed fall. An elderly male resident with severe cognitive impairment (BIMS score 00), Alzheimer’s dementia, non‑Alzheimer’s dementia, HTN, DM, CKD stage 2, and a history of wandering and fall risk was observed roaming in and out of other residents’ rooms on the memory unit. On the morning in question, an LVN reported that the resident became angry when redirected from another resident’s room, attempted to swing at the nurse, lost his balance, and fell, striking his face/head and torso against a hallway rail. The LVN observed an abrasion to the resident’s right temple/cheek area and applied a bandage. Despite this witnessed fall with head impact and visible injury, the LVN did not complete an immediate, comprehensive post‑fall assessment as required by facility policy and nursing standards. The electronic health record for that day contained no documentation of vital signs, head‑to‑toe assessment, neurological checks, fall assessment, post‑fall monitoring, pain assessment, or any change in condition related to the fall. The LVN later stated he had performed these assessments but acknowledged he did not document them and did not call for assistance from other clinical staff. He also did not notify the physician, DON, ADON, or weekend supervisor of the fall and injury, although he claimed to have verbally informed an unidentified weekend supervisor who, according to the weekend supervisor interviewed, was never notified. The resident’s family was not informed of the fall or injury at the time it occurred. When the responsible party and another family member visited later that day, they observed a bloody bandage on the resident’s cheek and noted increased confusion and changes in alertness. During a three‑way call with the LVN, the nurse disclosed that the resident had fallen earlier that morning, admitted he had not notified the family because he was unaware he needed to do so, and reassured them that the resident was “fine” and being monitored. Concerned about the resident’s condition, the family requested to take him to the hospital and signed him out on leave. At the hospital, the resident was found to have sustained right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s records showed that required post‑fall assessments and notifications were not completed at the time of the incident, and key facility staff, including the DON, ADON, weekend supervisor, and NP, confirmed they were not promptly notified of the fall or the resident’s head injury.
Removal Plan
- Notify the Medical Director.
- Complete an ad hoc QA review to address notification protocols for family and physician for incidents/accidents and change of condition, including proper assessments and documentation.
- DON/designee to educate licensed nurses on proper assessments and documentation for incidents/accidents, including any resident change of condition.
- DON/designee to educate licensed nurses to notify the DON and Administrator of all incidents/accidents and change of condition that require hospital transfer.
- DON/designee to assess all residents with falls in the past 30 days to ensure proper notifications and assessments are in place.
- MDS/designee to update care plans for all residents with falls in the last 30 days.
- Educate all licensed nurses on incident/accident protocols, including notification of the DON, Administrator, physician and family, and resident assessment and documentation prior to working their next assigned shift.
- DON/designee to monitor residents with falls daily to ensure notifications, assessments, and documentation are in place.
- Administrator to review with the DON weekly to ensure continued compliance.
- DON to bring results of all audits to the QAPI committee for review and continued recommendations/compliance.
- Include this protocol in new-hire orientation by DON/designee.
Failure to Timely Report Fall-Related Serious Injuries to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged incident of abuse/neglect and serious injury to the appropriate authorities as required by regulation and by its own policies. A cognitively impaired, Spanish‑speaking male resident with Alzheimer’s dementia, non‑Alzheimer’s dementia, anemia, HTN, diabetes, and on antipsychotic and antidepressant medications was admitted with severe cognitive impairment (BIMS score 00) and required supervision or assistance with mobility, transfers, toileting, and ADLs. His care plan identified him as at risk for falls and wandering, with interventions including frequent visual checks, redirection, and assistance with standing and moving. The facility’s written policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation be reported to the Administrator/Abuse Coordinator and, when reportable, to the State Survey Agency and other authorities within 2 hours if involving abuse or serious bodily injury, or within 24 hours otherwise. On the date of the incident, according to a late entry progress note by the DON, the resident was reported to have been roaming in and out of rooms and requiring frequent redirection. At approximately 7:00 a.m., when redirected from a room, he became aggressive and attempted to swing and hit the nurse, lost his balance, and fell against a handrail on his left side. The primary nurse reportedly noted a small abrasion to the left temple area, with no other injuries observed at that time, and documented that the resident was ambulatory and functioning at baseline after the fall, with plans for frequent monitoring post‑fall. The facility’s fall management policy required assessment for injury, investigation of the reason for the fall, completion of an incident/accident report, and notification of the physician and family when a fall occurs. Later that same day, the resident’s family requested hospital evaluation for change of condition with nausea and vomiting, and the resident was sent to the hospital, placed on leave of absence, and medications were put on hold. Hospital records documented that the resident was admitted with a chief complaint that he had fallen, and he was found to have right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration involving segments 5 and 8. The hospital nurse informed the DON that the resident had fallen at the facility earlier that day, had an abrasion to the cheek, a bruised liver, and rib fractures. The Administrator and DON acknowledged they did not report the incident to the State agency (HHSC) or other required authorities. The DON stated she did not submit a report because, after her assessments and interviews, she ruled out abuse and neglect, and the Administrator stated he did not report because the fall was witnessed and the family transported the resident to the hospital at their discretion. This failure to report an allegation involving a fall with serious bodily injury within the required timeframes constituted the cited deficiency.
Failure to Investigate and Report Serious Injury After Fall
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an allegation of neglect after a resident sustained serious injuries related to a fall. The resident was an elderly male with severe cognitive impairment (BIMS score 00), Spanish-speaking only, with diagnoses including anemia, hypertension, diabetes mellitus, Alzheimer’s dementia, and non-Alzheimer’s dementia. His care plan identified impaired functional abilities, need for assistance with ADLs, and risk for falls and wandering, with interventions such as assistance with mobility and frequent visual checks. On the date of the incident, a late-entry nursing note documented that the resident had been roaming in and out of rooms, became aggressive when redirected, attempted to swing at the nurse, lost his balance, and fell against a handrail, sustaining a small abrasion to the left temple; he was noted to be ambulatory and at baseline afterward. The resident was later sent to the hospital for a change of condition with nausea and vomiting per family request, and the progress note documented the transfer but did not reference the earlier fall as a cause. Hospital records showed that he was admitted with a chief complaint of a fall and was found to have right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration involving segments 5 and 8, and he was admitted for trauma-related monitoring and pain control. The facility’s records and interviews revealed that the LVN who witnessed the fall did not report the incident to the Administrator, did not notify the physician, and did not notify the resident’s family member at the time of the fall. Interviews with the Administrator and DON confirmed that, after being notified by the hospital that the resident had sustained serious internal injuries and fractures from a fall that occurred at the facility, they did not initiate a timely, thorough investigation at that time. The Administrator acknowledged he had not investigated the incident when first notified of the hospitalization and injuries. The DON stated she did not investigate when first notified that the resident was in the hospital for a fall, despite knowing of the bruised liver and fractured ribs. The facility had an Abuse, Neglect and Exploitation and Misappropriation of Resident Property Internal Investigation Guidelines policy requiring timely investigation of all allegations of abuse, neglect, and exploitation, but there was no evidence that such an investigation was promptly initiated and documented when the serious injuries and unreported fall were first identified.
Failure to Provide Privacy Covers for Urinary Collection Bags
Penalty
Summary
The facility failed to ensure dignity and privacy for two residents who had urinary collection bags. Resident #169, an [AGE]-year-old female with Alzheimer’s disease, heart failure, adult failure to thrive, severe cognitive impairment, and dependence for all ADLs, had a urinary catheter for wound healing. During observation, her catheter bag was hanging on the right side of the bed, full of urine, facing the entry door, and not placed in a privacy bag. Facility staff stated that catheter bags should have privacy bags in place for privacy and dignity, and that nurses could provide them from the supply room if needed. Resident #195, an [AGE]-year-old female with a history of stroke leaving her paralyzed in all four extremities, pressure ulcers, contractures, severe cognitive impairment, and dependence for all ADLs, also had a urinary collection bag that was visible from the hall without a privacy cover. The bag was observed in the same uncovered position on multiple occasions while the resident remained in bed. Staff interviews reflected that residents with urinary bags were required to have privacy covers in place, including while in bed, and that the covers were used for dignity and privacy. The DON stated that privacy covers were a dignity issue and that bags without covers usually came in with the system in place and staff had not changed them out.
Resident Records Exposed and Room Privacy Not Maintained
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when a red notebook labeled "Elopement Binder South Building" was observed on a table in the south building lobby. The binder contained the policy and procedure for elopement management and 33 admission records from the memory care unit, including 28 records for current residents on Halls 200 and 300. The admission records included resident names, Social Security numbers, Medicare numbers, Medicaid numbers, responsible party information, addresses, and phone numbers. During interview, the ADM stated the binder was normally kept at the nurses' station on the memory care unit and was used to keep a list of residents with pictures who were at risk of elopement. The ADM acknowledged that leaving the binder in the lobby created a risk that personal information could be seen by unauthorized individuals. LVN A stated the binder should have been on the memory care unit at the nurses' station and said the information in it could be seen by others who should not have access to it. The DON stated nursing staff, the business office, and administration had access to resident medical records and confirmed the binder was normally kept in the lobby but would now be kept at the nurses' station. The facility also failed to ensure full visual privacy in resident rooms. In room [ROOM NUMBER]-B, the resident was visible from the hallway while using a urinal, and the resident stated the curtain at the end of the bed had been taken down about a month earlier and never replaced, and the curtain between the two beds was not long enough to provide privacy. In room [ROOM NUMBER], there were no blinds in the window facing a parking lot, and the resident stated there had been no blinds since admission the previous month and that he did not like being easily seen at night when the lights were on. Staff interviews identified housekeeping as responsible for privacy curtains and maintenance as responsible for window blinds.
Failure to Provide Routine Nail Care and Grooming
Penalty
Summary
The facility failed to ensure Resident #15, a male with a stroke affecting the left side of his body, dementia, and legal blindness, received routine nail care. His quarterly MDS indicated he required staff assistance with all ADLs, and his care plan noted Alzheimer’s disease, inability to speak, and self-care deficit. During observation, he was found in bed with his left arm and hand contracted and a cloth roll in his left hand, and the fingernails on his left 4th and 5th digits were extremely overgrown. The nails were later measured at about 1/4 inch and almost 1/2 inch long, with an upward curve, and they remained untrimmed on a later observation. The facility also failed to ensure Resident #69, a cognitively intact female with a stroke affecting her left side, substance abuse, chronic pain, short-term memory loss, mobility issues, self-care deficit, diabetes, and visual impairment, received routine grooming and nail care. She required staff assistance with ADLs and was observed in bed with a contracted left hand, no soft roll in her palm, and overgrown fingernails on the left 4th and 5th digits. She stated staff rushed through care, that her family had shaved her about a month earlier, and that staff had not shaved her since then. Her chin hair was about 1/2 inch long. A PTA noted she needed a soft roll in her palm to help with finger contractures, and an LVN stated he was unaware she needed to be shaved or have her nails cut and that diabetic residents had to be shaved and their nails trimmed by a nurse, although the facility policy did not state that diabetic residents required a nurse to shave them.
Food storage, thawing, and temperature monitoring failures in kitchen operations
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in both the North Kitchen and South Kitchen. In the North Kitchen, surveyors observed thawed and soft-to-touch chicken cubes, beef in sauce, crumbled pork sausage, breaded chicken patties, a pork roast, and unidentified pies in a reach-in freezer. The freezer temperatures were documented at 40 degrees Fahrenheit outside and 50 and 48 degrees Fahrenheit on two internal thermometers, and the temperature log was blank for the AM shift. Bagels marked to keep frozen were also observed with condensation in the bags and soft bread. Staff interviews showed the freezer had recently been repaired, that staff were responsible for checking and documenting temperatures, and that the Dietary Manager was not notified until the surveyor observation revealed the temperature problem. In the South Kitchen, surveyors observed three bags of shredded lettuce in a reach-in refrigerator without dates, including one bag with brown and wilted pieces, along with an unlabeled and undated bowl of chocolate pudding and another unlabeled, undated bowl containing a dark red thick substance. In dry storage, a large container of cereal was covered with plastic wrap but was not labeled or dated. In the reach-in freezer, surveyors observed unlabeled and undated meat in a resealable bag leaking onto a box and shelf, along with other packaged meats stored on a towel. The freezer temperatures were 50 degrees Fahrenheit and 46 degrees Fahrenheit on two thermometers, and the freezer temperature log showed missing entries for multiple shifts across several days. The South Kitchen also had beef patty fritters sitting on the counter, and staff stated they had been pulled out early that morning. When opened, two boxes of the patties were soft to touch. Staff interviews reflected differing understandings of responsibility for temperature checks and thawing procedures, and one staff member stated the freezer had been out for a week and that no residents had been served food from it. The Dietary Manager stated the patties should not have been sitting out to thaw and should have been in the freezer. The facility policy required food to be covered, labeled, and dated, freezer temperatures to be checked and logged at least twice daily, and frozen items to be thawed in a refrigerator for 24 to 72 hours.
Unsafe Freezer Temperatures and Equipment Maintenance Failures
Penalty
Summary
The facility failed to maintain mechanical and electrical equipment in safe operating condition by allowing freezers in both the North Kitchen and South Kitchen to remain at unsafe temperatures while food was stored inside. In the North Kitchen, surveyors observed thawed and soft food items in a reach-in freezer, including unlabeled and undated chicken cubes, beef in sauce, crumbled pork sausage, breaded chicken patties, a pork roast, and two unidentified pies. The freezer temperature was observed at 40 degrees Fahrenheit outside and 48 to 50 degrees Fahrenheit on two thermometers inside the unit. A rack in the kitchen also held two boxes of bagels marked to keep frozen at zero degrees Fahrenheit or below, but the bagels had condensation in the bags and were soft to touch. Staff interviews showed that the freezer temperatures were not being checked and documented as required. The temperature log for the North Kitchen freezer was blank for the AM shift, and the cook stated she had not completed temperature checks since her shift started. The cook, dietary aides, and the dietary manager each identified different staff responsibilities for checking temperatures and reporting equipment problems. The dietary manager stated the cooks were responsible for checking temperatures at the start of their shifts and contacting her if equipment was not functioning properly. The maintenance supervisor stated the freezer had recently been repaired and that the doors were not fully closed, which he believed caused the temperature to rise. In the South Kitchen, surveyors observed a reach-in freezer with unlabeled and undated meat leaking onto the shelf and box below, along with other packaged meats and frozen items. The freezer temperature was observed at 46 to 50 degrees Fahrenheit. Staff stated the freezer had been out for a week, and the temperature log showed only one documented temperature of -3 degrees Fahrenheit with no entries for multiple shifts over several days. Interviews reflected that staff knew the freezer was not working, but there was confusion about who was responsible for checking temperatures, reporting the problem, and discarding food. The maintenance supervisor stated the vendor had identified a frozen evaporator coil and later a controller issue, and the dietary manager stated the freezer had been known to be not working since Friday. The report also identified that Resident #147’s bed was not in proper working condition, but no additional details about the bed condition were provided in the narrative.
Missing Privacy Curtains in Resident Rooms
Penalty
Summary
Rooms #115, #116, and #119 did not have privacy curtains in place to provide full visual privacy for residents. During observations on 03/08/26, surveyors found that room #115 had no privacy curtain for the resident in the bed closest to the door, even though a ceiling-mounted track and hanger clips were present. In room #116, there was no privacy curtain at the foot of the bed closest to the window, despite the same curtain track and hanger clips being installed. In room #119, there was also no privacy curtain at the foot of the bed for the bed closest to the window, with the track and hanger clips present but no curtain installed. During interviews, CNA-D, LVN-E, and LVN-F each stated that resident privacy was important for dignity and that privacy curtains were part of that privacy. They also stated that housekeeping was responsible for changing privacy curtains, while maintenance handled window blinds and other maintenance issues. The Housekeeping Supervisor stated nursing staff were responsible for notifying her when a privacy curtain needed to be changed, and she had clean curtains in storage. The Maintenance Supervisor stated nursing staff had to notify him of maintenance issues, and he would usually address them the same day. The DON stated she was unaware of the missing privacy curtains and said she would have a sweep of the facility done to identify rooms needing privacy curtains. The Administrator was unable to provide a policy addressing privacy curtains or resident privacy prior to the end of the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of gnats in Resident #232’s room, the North Kitchen, and the 700 Hall. During observation on 03/08/26, gnats were seen in the kitchen dishwasher area, and the kitchen staff member interviewed said she was aware of the gnats and that dishwashers were responsible for reporting them to the Dietary Manager and Maintenance Supervisor. She also stated maintenance staff were aware of the problem. In Resident #232’s room, about 8-10 gnats were observed at the bedside table, in the resident’s orange juice, and on a sandwich. Resident #232 stated the gnats had been an ongoing problem, that he had reported them to nursing staff, and that he did not eat food in his room because of the gnats. An LVN in the room also observed 8-10 gnats flying around the bedside table and stated he was aware of the gnats in the facility and had notified the Maintenance Supervisor. A Dietary Aide reported seeing gnats on the 700 Hall while serving meals, and another Dietary Aide stated she had observed gnats in the kitchen but had not reported them. The Dietary Manager acknowledged gnats in the kitchen and stated kitchen staff were responsible for reporting them to her or maintenance. The Maintenance Assistant and Administrator both stated they were aware of gnats in the building, and the Administrator said the facility had a pest control vendor entering biweekly. The facility’s pest control policy stated the facility shall maintain an effective pest control program and keep the building free of insects and rodents.
Unapproved Bedside Medication Storage and Self-Administration
Penalty
Summary
The facility failed to ensure residents had the right to self-administer medications only when the interdisciplinary team determined that the practice was clinically appropriate. For Resident #102, the record showed diagnoses of asthma and COPD, a BIMS score of 7, and an order for Atrovent 17 mcg HFA inhaler four times daily. During observation, the resident had an inhaler in the TV room and stated a staff member had given it to him to keep. He said he used it when short of breath and daily, but he could not identify the staff member who gave it to him or how often he used it in a day. The record contained no interdisciplinary team determination or self-administration assessment for this resident. For Resident #232, the record showed severe cognitive impairment with a BIMS score of 6 and diagnoses including radiculopathy, low back pain, and vertebral compression fractures. The resident had orders for eye drops twice daily and Voltaren gel four times daily. Observation found a bottle of eye drops and arthritis pain cream at the resident’s bedside table and nightstand. The resident stated he had kept the medications at his bedside since admission from the hospital and used the eye drops as needed for dry eyes and the pain cream for left lower back pain. The record contained no assessment showing the resident could self-administer medications and no interdisciplinary team determination regarding bedside medication storage. Facility staff stated they were not aware of any resident being assessed to self-administer medications and said medications should be kept on the medication cart unless a self-administration assessment and physician order were in place. The DON stated the facility did not have residents who self-administered medications and that residents were not allowed to keep medications at the bedside unless they had been assessed and approved. The facility’s bedside medication storage policy stated bedside storage was permitted only for residents able to self-administer medications, upon written prescriber order and interdisciplinary team approval.
Ceiling Plaster Hanging in Resident Room
Penalty
Summary
The facility failed to ensure Resident #147 had a safe, clean, comfortable, and homelike environment when the ceiling plaster in the resident’s room was peeling and hanging from the ceiling, with drywall visible. During observation, the resident stated that it had rained a couple of days earlier and the peeling had started then and was getting bigger. The resident also stated she was not sure whether anyone was going to fix it and could not recall whether she had notified anyone about the condition. Staff interviews showed the condition was not consistently communicated or documented. A CNA stated she had just noticed the ceiling and was not aware of any report from the resident, and she was unsure whether the ceiling issue was documented in the maintenance logbook. The assigned RN stated she was aware of the ceiling and thought it was being fixed, while the Maintenance Supervisor stated he was not aware of the ceiling and that staff were responsible for notifying him of problems. The Administrator stated the facility had a maintenance logbook at each nurse’s station and expected staff to document environmental concerns there, but the maintenance logbook review showed no request for ceiling repair.
Incomplete Care Plans for Feeding Tube and Central Line Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For Resident #54, the record showed an admission MDS with moderate cognitive impairment, dependence on staff for eating and oral hygiene, diagnoses including cancer and malnutrition, and physician orders for NPO status, PEG tube feedings, residual checks, and aspiration precautions. The baseline care plan addressed IV therapy but did not address the feeding tube or the resident’s desire to eat and drink by mouth. During observation, the resident was seen with tube feeding and water hanging, drank from a cup at bedside, and pointed out snacks, cold drinks, and foods he said he enjoyed from the facility. Staff interviews confirmed the feeding tube and the resident’s oral intake preferences were not documented in the care plan. For Resident #36, the admission MDS reflected severe cognitive impairment and diagnoses including metabolic encephalopathy, bacterial infection, chronic kidney disease, hypertension, and Alzheimer’s disease, and it identified an IV access central line for IV medications/antibiotics. The care plan did not address antibiotic treatment or the CVC line. Physician orders included weekly midline dressing changes and IV daptomycin every 48 hours. During observation, the resident had a CVC line on the right chest with a dressing peeling off, the IV tubing was not labeled with date, time, and initials, and the resident could not recall when the last antibiotic dose was given. Staff interviews confirmed the resident was receiving antibiotics and had a central line, but these items were not included in the care plan. The facility’s policies stated that assessment data are to be used to develop a person-centered comprehensive plan of care and that the interdisciplinary team coordinates an appropriate care plan based on the resident’s needs or wishes within required time frames. Despite this, the care plans for these two residents did not reflect the feeding tube, NPO/noncompliance with oral intake orders, antibiotic therapy, or central line care that were documented in the assessments, orders, and observations.
Failure to Follow Enteral Feeding Orders and Labeling Requirements
Penalty
Summary
The facility failed to ensure appropriate enteral feeding care for two residents with feeding tubes. For one resident with cancer, malnutrition, moderate cognitive impairment, and dependence on staff for eating and oral hygiene, the tube feeding and water bags were observed hanging without the resident’s name, formula name, feeding rate, date, time, or staff initials. The resident’s orders included Osmolite 1.5 Cal at 70 mL/hr, water flushes every 2 hours, residual checks each shift, aspiration precautions, and NPO status. During observation, the resident was seen drinking from a cup and pointed to snacks and cold drinks in the room, while staff acknowledged the bags were not properly labeled and stated this could place the resident at risk of improper feeding times, expired formula, or upset stomach. For the second resident, who had dementia, diabetes, stroke, dysphagia, adult failure to thrive, and protein-calorie malnutrition, the physician order was for Glucerna 1.2 at 55 mL/hr for 22 hours daily with a downtime from 8 AM to 10 AM. The formula bag observed in the room was dated 03/06/26 and still contained about 200 mL of formula. Staff interviews showed the resident had been disconnected from the feeding tube around 8:15 AM, but the resident was not reconnected at the ordered 10 AM time. The morning nurse stated she thought the resident was on bolus feedings and gave bolus feedings later in the day without reviewing the current physician orders or MAR. Interviews with nursing staff and the DON showed conflicting understanding of the resident’s feeding schedule and bag-change expectations. One nurse stated the formula bag should have been changed every 24 hours, another stated the bag was changed by the night shift, and the DON stated formula bags should be changed and dated after every feeding. The dietitian stated the resident’s orders were changing frequently due to residuals, but nurses still needed to follow the physician orders as written. The facility policy reviewed by surveyors stated to change the irrigation bottle every 24 hours and reconnect the tube to the pump at the prescribed rate if a pump is utilized.
IV Therapy Not Labeled or Administered per Orders
Penalty
Summary
The facility failed to ensure IV fluids and medications were administered in accordance with physician orders and professional standards for two residents receiving IV therapy. For one resident with diagnoses including metabolic encephalopathy, chronic kidney disease, hypertension, and Alzheimer’s disease, the record showed a central venous access device used for IV antibiotics. During observation, the resident’s chest dressing was peeling off and dated several days earlier, and the IV medication bag and tubing were not labeled with the date, time, and initials. The resident’s care plan did not address the use of antibiotics or the PICC/CVC line. The same resident’s physician orders included weekly dressing changes for the midline/CVC site and IV daptomycin every 48 hours. Staff interviews confirmed the dressing should have been changed every 7 days and that the tubing and medication bag should have been dated and initialed. The DON stated the IV bag and tubing should have been removed after treatment was completed, and the ADON and wound care nurse stated the dressing should be changed every 7 days and when loose. The dressing remained partially detached, and the IV bag and tubing were still present without required labeling. For the second resident, newly admitted with an intraspinal abscess and granuloma, the physician ordered cefazolin 2 gm IV twice daily. During observation, the PICC line was dated, but the IV bag was hanging half administered and was not connected to the resident, and it was not labeled with the date, time, and initials. The assigned LVN stated the resident had disconnected from the IV, that the dose was not completed, and that she did not notify management or the physician. Another nurse reported the resident had left the room and the IV was only half administered. The ADON and DON stated staff were expected to date and initial IV bags and tubing and to notify the physician when the dose was not completed.
Expired Medications and Missed Resident Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs by leaving expired medications in storage areas and by not ensuring ordered medications were administered to a resident. On 03/09/2026, surveyors observed the Hall 600 B nurse medication cart with an expired bubble pack of ibuprofen 400 mg dated January 2025 and Buspirone 7.5 mg dated 2/26/26. In the Hall 600 medication room and refrigerator, surveyors observed two bottles of multivitamins dated 11/05/25 and a bag of Daptomycin 500 mg dated 03/04/26. Staff interviews reflected that nurses were responsible for checking carts, medication rooms, and refrigerators for expired medications, and the DON stated expired medications were to be removed for destruction. Resident #54 was a [AGE]-year-old male with a BIMS score of 10 and diagnoses including iron deficiency anemia, cancer, malnutrition, multidrug-resistant organism, and HIV. His orders included multiple enteral medications, including Dovato, Omeprazole, Hydromorphone, Methadone, Thiamine, Amoxicillin/Clavulanate potassium, and Apixaban. Review of the MAR for 03/10/26 showed missed morning doses of Dolutegravir/lamivudine, Omeprazole, Hydromorphone, Thiamine, Amoxicillin/Clavulanate potassium, and Apixaban, along with missed Methadone doses at 08:00 AM and 03:00 PM. During interview, Resident #54 stated he had not received his morning medications and said he was given only a pain medication dose, not the other ordered medications. LVN Q stated she had not worked with Resident #54 that day and was unaware she was supposed to provide his care and medications, saying she worked the back end of the hall and her cart did not include his medications. ADON J reviewed the MAR and confirmed the missed doses, and the DON stated LVN Q was responsible for Resident #54's care and medication administration, while all nursing staff were expected to follow physician orders.
Missed Scheduled Medications for a Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when Resident #54 did not receive multiple scheduled morning medications. Resident #54 was a male with moderate cognitive impairment and diagnoses including iron deficiency anemia, cancer, malnutrition, multidrug-resistant organism, and HIV. His orders included Dovato, hydromorphone, methadone, amoxicillin/clavulanate potassium, and apixaban administered via enteral tube at scheduled times. Review of the MAR showed missed 8:00 AM doses of Dovato, hydromorphone, amoxicillin/clavulanate potassium, and apixaban, as well as missed methadone doses at 8:00 AM and 3:00 PM. During interview, Resident #54 stated he had not been given his morning medications and said he was supposed to have pain medication and several other medications that had not been administered. LVN Q stated she had not worked with Resident #54 that day and was unaware she was to provide his care and medications, explaining that she worked the back end of the hall and did not have medications for him on her cart. ADON J reviewed the MAR and confirmed the missed medications, stating nursing staff were responsible for ensuring residents received their medications and treatments. The DON stated LVN Q was aware she was to provide care to Resident #54 and that all nursing staff had been notified before the shift, and the policy required licensed nursing staff to provide medications and treatments as ordered by the physician.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when MA NN did not disinfect a reusable blood pressure cuff between resident blood pressure checks during morning medication administration. Resident #107 was a [AGE]-year-old female with severely impaired cognition, a BIMs of 6, hypertension, and physician orders for amlodipine besylate 2.5 mg daily and metoprolol 25 mg twice daily. During observation, MA NN checked Resident #107's blood pressure and then placed the cuff on top of the medication cart without disinfecting it. MA NN then continued the medication pass and used the same blood pressure cuff on Resident #125 without disinfecting it first. Resident #125 was a [AGE]-year-old male with severely impaired cognition, a BIMs of 3, essential hypertension, and an order for lisinopril 5 mg daily. During interview, MA NN stated reusable equipment such as blood pressure cuffs should be disinfected between each resident use and acknowledged she did not have wipes on her cart. The DON stated staff were expected to disinfect blood pressure cuffs between residents and that failure to do so could spread infection.
Resident with Dementia Left Unattended in Transport Van for Several Hours in Cold Weather
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from accident hazards and received adequate supervision, resulting in the resident being left unattended in the facility’s transport van for several hours in cold weather. The resident was an older male with kidney failure requiring dialysis, dementia, and paranoid schizophrenia, with a BIMS score of 6 indicating severe cognitive impairment. He used a wheelchair for mobility, required assistance with ADLs, and resided on a memory care unit. His care plan reflected delirium, impaired mobility, and a need for dialysis three times a week. On the day of the incident, the resident returned from dialysis in the late afternoon, typically between 4:30 PM and 5:00 PM, according to staff and family interviews. The facility’s driver stated he brought the resident back to the unit around that time and informed staff that the resident had returned. However, later that evening, a CNA noted that the resident was not in the common area or in his room when she checked around 8:00–8:30 PM and notified the nurse that she could not locate him. Staff then began searching the unit and other units in the facility. During the search, the CNA went out to her car and noticed movement inside the facility’s transport van parked under the portico. She found the driver’s side door locked, returned to get the nurse, and staff were able to open the passenger side doors. They found the resident seated in the van, buckled into a seat with his seat belt on, wearing a coat and sweater, and his wheelchair stored in the back of the van. Nursing staff present at the scene stated they did not believe the resident, given his dementia and physical condition, was capable of independently exiting the locked unit, wheeling himself outside, folding and loading his wheelchair into the van, and then buckling himself into a seat. The resident told staff that the driver had left him in the van and that he thought the driver was going to come back. Weather records showed outdoor temperatures in the mid-30s Fahrenheit during the time the resident was in the van. The resident’s electronic health record contained no progress notes documenting the incident, the interventions performed, or who was notified. The facility’s policy titled "Safety System for Residents" addressed general resident safety but did not address leaving residents outside. Interviews with the DON and Administrator reflected differing views on how the resident came to be left in the van, with the driver and Administrator asserting the resident had been returned to the unit and somehow made his way back to the van, while nursing staff expressed doubt that the resident could have done so independently. The incident was determined to constitute non-compliance that rose to the level of Immediate Jeopardy for a period of several days, during which the resident remained at risk of harm related to exposure to cold temperatures, discomfort, pain, and anxiety.
Missed Wound Treatments for Pressure Ulcers and Skin Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer and wound care to multiple residents, as documented by missing treatments on wound care administration records and lack of corresponding progress notes. For one resident with severe cognitive impairment and multiple pressure ulcers on admission, including an unstageable left heel wound and several stage 4 pressure wounds on the left foot and toes, the wound care administration records for January and February showed numerous dates on which ordered treatments were not documented as completed. These missed treatments included care for the unstageable left heel wound and stage 4 pressure wounds of the left medial first toe, left fourth toe, and left distal medial foot across multiple days in January and February. Progress notes for this period contained no documentation of wound treatment, and later observation of the resident at a hospital showed wounds on the left heel, right buttocks, and left medial first toe covered with dry dressings. Another resident, an older female with severe cognitive impairment and a diagnosis including open lesions, had a care plan identifying severely impaired skin integrity related to end-stage skin failure of the sacrum, with interventions including cleansing and application of specific dressings such as honey-coated absorbent dressings and later Dakin’s 1/4 strength–soaked gauze. The order summary report detailed daily and as-needed wound care orders for the sacral wound. However, the February wound care administration record showed no entries for multiple dates; instead, those dates were marked as “Missed,” indicating that the ordered wound care was not provided on those days. Progress notes for January and February also lacked documentation of wound treatment. During an observation in early March, the wound care nurse performed sacral wound care, and the old dressing was noted to be dated the previous day, demonstrating that treatments were being done at that time but not on the earlier missed dates. A third resident, an older female with severe cognitive impairment, peripheral vascular disease, and a Kennedy terminal ulcer on the right ischium, had orders for cleansing the site and applying Dakin’s 1/4 strength–soaked gauze with a dry dressing on the day shift and as needed. The wound care administration record for February showed that on two specific dates the wound care entries were marked as “Missed,” indicating the ordered treatments were not provided. The resident’s care plan, revised in early March, noted the need for hospice care due to a terminal cerebrovascular condition and included interventions to administer treatments as ordered and monitor for skin breakdown. Observation with the wound care nurse showed that when wound care was performed, the old dressing on the sacrum was dated the previous day and the nurse followed the ordered cleansing and dressing procedure. In interviews, the wound care nurse stated he had not noticed wound care was being missed because he had not paid attention to the treatment administration records, and explained that he worked Monday through Thursday (later Monday through Friday per the DON), with floor nurses responsible for wound care on other days. The DON stated her expectation that all wounds were treated per physician orders and acknowledged that missing wound care could lead to increased risk of infection or worsening wounds. Overall, across these three residents, the surveyors identified repeated failures to provide and document wound care as ordered, including for pressure ulcers, end-stage skin failure, and a Kennedy terminal ulcer. The wound care administration records showed multiple missed treatments, and there was no supporting documentation in progress notes for the relevant periods. Staff interviews confirmed that the wound care nurse relied on floor nurses to perform treatments when he was not present and that management reviewed treatment records in morning meetings but believed some wound care was missed while staff were learning a new system. The facility’s own wound care policy emphasized that effective prevention and treatment are based on consistently providing routine and individualized interventions, which contrasted with the documented pattern of missed wound care for these residents. These failures placed residents at risk of developing new or worsening pressure ulcers, infection, and pain, as explicitly stated in the report.
Failure to Timely Report Alleged Neglect After Resident Left in Transport Van
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged incident of neglect involving a cognitively impaired resident who was left in a transport van for several hours in cold weather. The resident was an elderly male with kidney failure requiring dialysis, dementia, and paranoid schizophrenia, with a BIMS score of 6 indicating severe cognitive impairment. He used a wheelchair for mobility, required assistance with ADLs, and resided on a memory care unit. His care plan reflected delirium, impaired mobility, and a scheduled dialysis regimen three times a week. Despite this, the facility’s electronic health record contained no progress notes documenting the incident, the interventions taken, or who was notified. On the day of the incident, the resident returned from dialysis in the late afternoon, typically between 4:30 and 5:00 PM. A family member reported being notified later that evening, around 8:30 PM, that the resident was not on the memory care unit, and then around 9:00 PM that he had been found in the transport van. A CNA working that evening stated she noticed the resident was not in the common area or his room around 8:00–8:30 PM and informed the nurse. Staff searched the unit and other units, and the CNA, upon going to her car, observed movement in the transport van. The van’s driver-side door was locked, but staff were able to open the passenger side and found the resident seated with his seat belt fastened; they used another wheelchair because they could not access his wheelchair in the van without the keys. The CNA reported the resident said that the driver had left him in the van and that he thought the driver would return. Interviews with staff revealed conflicting views about how the resident came to be in the van. The driver stated he had returned the resident to the unit around 5:00 PM, informed staff of his return, and did not know how the resident got back to the van. The DON recalled being called at home that the resident could not be found, instructed staff to search the grounds, and was later informed the resident was found in the van; she believed the resident was capable of taking himself back to the van after following a visitor off the secured unit. An LVN, however, stated she did not believe the resident was capable of leaving the locked unit, wheeling himself out, folding and loading his wheelchair, and buckling himself into the van given his dementia and physical condition. The Administrator concluded from his investigation that the driver had returned the resident to the unit and that the resident managed to get back to the van, and he stated he did not report the incident to the state agency because there was no harm to the resident and the driver had brought him back to the unit. This decision was inconsistent with the facility’s written abuse, neglect, and exploitation policy, which required reportable allegations to be reported to the state regulatory agency and other authorities within specified timeframes.
Failure to Use Required Mechanical Lift and Report Pain During Transfer Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices during transfers, resulting in a serious leg fracture for one resident. The resident was an older female with a history of stroke and end-stage renal disease, bedbound with residual left-sided weakness, who used a wheelchair for mobility and required substantial/maximal assistance. Her MDS showed moderately impaired cognition (BIMS 10) but no dementia, no inattention, disorganized thinking, altered consciousness, or behavioral issues, and no reported pain. Her care plan, with an original date of 02/12/26, specified that she was to be lifted mechanically using a Hoyer lift with two or more staff due to impaired mobility, and that she did not attempt to stand from sitting because of medical and safety concerns. On the morning of 12/23/25, the resident was being prepared for transport to her dialysis appointment. According to the resident’s later account to surveyors, her family, and dialysis staff, she was normally transferred via Hoyer lift, but that day several staff, including a chubby female aide and a tall bald male aide, manually transferred her from bed to wheelchair using their hands instead of the mechanical lift. During this transfer, the resident reported that her left leg went between the male aide’s legs and twisted, causing immediate severe pain. She stated she told staff, “I think you broke my leg,” but was nonetheless placed in her wheelchair and transported by van to the dialysis center. The resident consistently stated that the incident occurred at the nursing facility and that she was never transferred out of her wheelchair at the dialysis center because of her pain. At the dialysis center, multiple dialysis staff observed the resident crying and complaining of severe left knee/leg pain. The dialysis RN, dialysis tech, and dialysis nurse manager each reported that the resident said nursing home aides had twisted or hurt her leg during the transfer to the wheelchair, and that she arrived with a Hoyer sling still under her. On assessment, the dialysis RN noted the resident’s pain was 10/10, she could not move her leg, and she cried out when her left knee was touched or when attempts were made to reposition her. EMS was called, and the resident was transported to the hospital, where imaging showed an acute comminuted fracture of the distal left femur, documented as occurring when her leg was twisted during transfer to dialysis, without a fall. Facility nursing staff, including the LVN on duty, ADON, and DON, acknowledged that the resident required a Hoyer lift for transfers, but they did not initially obtain or document a clear account from the resident about the transfer incident, and the DON did not contact the dialysis center to clarify whether an incident had occurred there. Interviews with facility CNAs involved in the transfer revealed inconsistent accounts and confirmed that the resident was not transferred in accordance with her care plan. CNA B, who worked as needed, stated he was called by CNA A to assist with a transfer because the resident was late for dialysis and the Hoyer lift was broken. He reported that he, CNA A, and two other aides transferred the resident from bed to wheelchair using the Hoyer sling under her and a draw sheet, and that the resident complained of leg pain once in the wheelchair. He did not report this pain to the nurse, assuming the primary aides would do so. CNA A denied asking CNA B to help transfer the resident with a Hoyer sling and draw sheet and did not recall the resident reporting pain. CNAs E and F, also as-needed staff, denied recalling a transfer using a Hoyer sling and draw sheet or any specific details from that date. The facility’s own policies required use of mechanical lifts according to manufacturer guidelines and required CNAs to report any change of condition, but the resident’s care plan requirements for mechanical lift use and prompt reporting of pain during transfer were not followed, leading to the identified deficiency.
Removal Plan
- Medical Director notified
- Ad hoc QA completed to address employee transfer techniques using mechanical lifts
- DON/designee to educate all clinical staff on mechanical lift transfers including 2-person assist
- DON/designee to educate all clinical staff to notify nurse of any pain or change of condition during transfers
- DON/designee performed assessment on all residents requiring mechanical lift transfers to ensure safety
- Residents who require mechanical lift transfers will be added to ADL Kardex by DON/designee
- MDS/designee updated care plans for all residents requiring mechanical lift transfers
- All clinical staff will be educated on proper transfer techniques including mechanical lifts prior to working their next assigned shift
- DON/designee will monitor residents requiring mechanical lifts for transfers to ensure compliance
- Administrator to review with the DON the monitoring to ensure continued compliance
- Results of all audits will be brought to QAPI committee by DON to review for continued recommendations and compliance
- This protocol will be covered on new-hire orientation by DON/designee
Failure to Report Alleged Neglect After Improper Transfer Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of neglect related to a serious injury sustained by a resident during a transfer, as required by regulation and by the facility’s own abuse/neglect policy. The resident was an older female with a history of stroke and end-stage renal disease, with moderately impaired cognition (BIMS score of 10) but no diagnosis of dementia or Alzheimer’s disease, and no documented inattention, disorganized thinking, altered level of consciousness, or behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair for mobility, did not attempt to stand due to medical/safety concerns, and required substantial/maximal assistance. The care plan specified that all transfers were to be done with a mechanical Hoyer lift and two or more staff due to impaired mobility. On the day of the incident, the resident was transferred from her bed to her wheelchair at the facility prior to going to dialysis. The resident later consistently reported to multiple individuals that facility aides had manually transferred her instead of using the Hoyer lift, and that her left leg became twisted between a staff member’s legs during the transfer, causing immediate severe pain. She stated she told staff at the time, saying she thought they had broken her leg, but she was nonetheless placed in the wheelchair, transported by van, and sent to dialysis. At the dialysis center, multiple dialysis staff (RN, tech, nurse manager, and case manager) observed the resident crying in severe pain, unable to move her leg, and still sitting in her wheelchair with a Hoyer sling under her. The resident told them that nursing home staff had twisted her leg during the transfer to the wheelchair and that she had reported her pain to facility staff before being sent to dialysis. Dialysis staff did not transfer her to a dialysis chair due to her pain and arranged for EMS transport to the hospital. Hospital records documented an acute comminuted fracture of the distal left femur, with the admission assessment noting that the patient’s leg had twisted during a transfer and that she had not fallen. Facility nursing notes show that the DON and LVN C were informed by hospital staff that the resident had a femur fracture and that the injury was reported as occurring during transfer at the dialysis center. The DON later documented a late entry describing a call from the dialysis RN about the resident’s complaints of leg pain and transfer to the hospital. Interviews with facility staff revealed that the resident was known to require a Hoyer lift for all transfers, that the Hoyer lift was reportedly broken that day, and that multiple CNAs manually transferred the resident using a sling and/or drawsheet. One CNA acknowledged assisting with the transfer and hearing the resident complain of leg pain afterward but did not report this to a nurse, assuming the primary aides would do so. Other CNAs gave conflicting or limited recollections of the transfer. Despite the resident’s repeated statements to dialysis staff and to her family that the injury occurred during a manual transfer at the facility, the Administrator stated the incident was not reportable because it was believed to have occurred at the dialysis center, and the facility did not report the allegation of neglect to the State Survey Agency as required by policy and regulation. The facility’s written policy on Abuse, Neglect, and Exploitation required that all staff ensure alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property are reported to the Administrator (Abuse Coordinator), that the Abuse Coordinator initiate an investigation, and that reportable allegations be reported to the State Regulatory Agency. The report shows that the DON was informed of the resident’s severe leg pain and subsequent hospital transfer, and that the resident’s statements to dialysis staff implicated facility staff in twisting her leg during transfer. However, the DON did not contact the dialysis center to clarify events, relied on staff statements that “nothing happened,” and concluded there was no incident at the facility. The Administrator similarly concluded the event was not reportable because they believed it occurred at the dialysis center. As a result, the allegation of neglect—specifically, failure to follow the resident’s care plan requiring Hoyer lift transfers and the resident’s report that staff twisted her leg during a manual transfer—was not reported to the State Survey Agency within the required timeframe, constituting the cited deficiency.
Failure to Thoroughly Investigate Alleged Neglect After Resident Sustained Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of neglect related to a resident’s left distal femur fracture and to have evidence that all alleged violations of abuse, neglect, exploitation, misappropriation, and mistreatment, including injuries of unknown origin, were fully investigated. The resident was an elderly female with a history of stroke and end-stage renal disease, moderately impaired cognition (BIMS 10), no dementia diagnosis, and no documented behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair, did not attempt to stand due to medical/safety concerns, and required mechanical (Hoyer) lift transfers with assistance from two or more staff. On the date of the incident, she was sent to dialysis by third‑party transport and later diagnosed in the hospital with an acute comminuted closed fracture of the distal left femur, with hospital documentation stating that her leg was twisted during a transfer to the dialysis chair and that there had been no fall. Multiple accounts from the resident and dialysis staff indicated that the resident consistently reported that her leg was twisted and injured during a transfer performed by facility staff from her bed to her wheelchair, and that she normally used a Hoyer lift but was instead manually lifted. The resident told surveyors that several staff, including a chubby female aide and a tall bald male aide, transferred her by hand rather than using the Hoyer lift, and that during the transfer her left leg went between the male aide’s legs and twisted, causing immediate severe pain. She stated she told staff at the facility that she thought they had broken her leg, but she was still placed in her wheelchair and transported to dialysis. At the dialysis center, the resident arrived in severe pain, crying, with a Hoyer sling still under her, and repeatedly told the dialysis RN, dialysis tech, and dialysis nurse manager that nursing home aides had twisted her leg during the transfer to the wheelchair and that she had reported pain to facility staff before being sent to dialysis. Dialysis documentation and staff interviews corroborated that the resident arrived already in severe pain, was never transferred out of her wheelchair into a dialysis chair due to pain, and that she requested to be sent to the hospital. The dialysis RN and dialysis tech both reported that the resident, who was normally calm, pleasant, and cognitively appropriate during treatments, stated that facility staff had twisted her leg during transfer. The dialysis RN reported telling the DON that the resident said the injury occurred at the facility, and the dialysis nurse manager stated that at no time did dialysis staff tell the facility that the incident occurred at the dialysis center. Within the facility, the DON documented that a hospital nurse had said the injury occurred at dialysis and later stated she saw no reason to call the dialysis center to clarify events, did not interview CNA B at the time, and only noted that she had written staff statements “on a notepad somewhere,” with no evidence of a complete investigation. The Administrator stated the incident was not reportable because it happened at the dialysis center. Interviews with facility staff were inconsistent: one LVN did not ask the resident what happened when she returned, the ADON never spoke with the resident about the transfer, CNA B admitted assisting with a manual transfer using a sling and drawsheet because the Hoyer lift was allegedly broken and the resident was late for dialysis, and other CNAs either denied or could not recall the described transfer. Collectively, these actions and omissions demonstrate that the facility did not conduct and document a thorough investigation of the resident’s allegation of neglect and injury as required by its abuse/neglect policy.
Failure to Provide Timely and Adequate Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically timely incontinence care, for two residents who were dependent on staff for these needs. Both residents had severe cognitive impairment, hemiplegia or hemiparesis, and were largely confined to bed, requiring substantial to maximal assistance for toileting and hygiene. Their care plans included interventions such as scheduled toileting, use of briefs, frequent turning and repositioning, application of barrier lotion, and regular skin inspections to prevent skin breakdown and maintain hygiene. On the day of observation, one resident was found in bed with soaked linens and was unable to recall when her brief was last changed. The other resident reported her brief had last been changed the previous night and stated she was wet. During incontinence care, both residents were found to be heavily soaked in urine, with one also having a bowel movement. The CNA providing care did not cleanse the perineal area for either resident, only cleaning the abdominal folds and buttocks. Additionally, the CNA did not change gloves or perform hand hygiene between cleaning different areas after a bowel movement. Interviews with the CNA, LVN, ADON, and DON revealed that staff were expected to perform incontinence rounds every two hours and as needed, but the CNA admitted to not following this schedule due to being busy with other residents. The LVN and nursing leadership confirmed their responsibility to monitor CNA rounds, but could not specify when rounds were last completed. Training records indicated that while staff had received instruction on perineal care, the training did not specifically address the requirement for incontinence care every two hours. The facility's policy required perineal care in accordance with standard practice to prevent skin breakdown and infection.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA D during incontinence care for two residents. CNA D was observed providing incontinence care to two female residents with significant medical histories, including hemiplegia, hypertension, heart failure, renal insufficiency, and severe cognitive impairment. Both residents were dependent on staff for toileting and hygiene, and their care plans included interventions to prevent skin breakdown and maintain skin integrity. During the observed care, CNA D performed hand hygiene before initial resident contact and donned gloves. However, he did not cleanse the peri area for either resident, only cleaning the abdominal folds and buttocks. He failed to change gloves or perform hand hygiene after handling soiled linens and before applying clean briefs and linens, using the same gloves throughout the process. One resident was noted to have a bowel movement, yet the same lapses in infection control were observed. CNA D later acknowledged forgetting to perform hand hygiene and peri care as required. Interviews with the LVN, ADON, and DON confirmed that CNA D did not follow expected infection control practices, including changing gloves and performing hand hygiene during and after care, and completing peri care before applying clean briefs. Facility policy and recent staff training records indicated that proper hand hygiene is required before and after resident contact, and after contact with soiled or contaminated articles. The observed failures were inconsistent with these policies and training.
Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another nursing home. The resident, an elderly female with severe cognitive impairment, dementia, hypertension, and malnutrition, was discharged as documented in the MDS assessment and progress notes. While a progress note and a physician discharge summary were present, there was no evidence in the clinical record of a comprehensive discharge summary that included a recapitulation of the resident's stay, diagnoses, course of illness or treatment, pertinent lab, radiology, and consultant results, and a final summary of the resident's status at discharge. Interviews with facility staff revealed that the nurse responsible for the discharge did not complete the discharge summary due to unfamiliarity with a new system and only documented a progress note after being advised by the ADON. The ADON and DON both stated that the nursing team was responsible for ensuring the discharge summary was completed, but neither was aware that it had not been done. The facility's policy required notification of the resident or representative, documentation of the discharge, and provision of written discharge instructions, but these requirements were not fully met in this case.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving resident-to-resident altercations. In the first incident, a male resident with severe cognitive impairment and psychiatric diagnoses was physically assaulted by his roommate. The altercation escalated from verbal arguments to physical violence, with the aggressor striking the resident with a ruler multiple times and then stabbing him with a pen, causing scratches and lacerations to the abdomen and neck. The assaulted resident was found on the floor in a disheveled room, exhibiting signs of emotional distress and physical injury, and was subsequently sent to the hospital for evaluation. Staff interviews confirmed that the altercation was not witnessed, but the aftermath indicated significant violence had occurred. In the second incident, a female resident with severe cognitive impairment, a history of hip fracture, and impaired mobility was pushed by another resident while standing near a wheelchair in a common area. This resulted in the resident falling and sustaining a left hip fracture and left wrist fracture, requiring hospitalization and surgery. Staff accounts indicated that the aggressor had a known history of aggressive behavior and required frequent redirection and monitoring. The incident was witnessed by staff, who responded after hearing raised voices and observed the resident in pain with an obvious injury. Both incidents involved residents with known behavioral or cognitive issues, and in each case, the facility did not prevent the altercations that led to physical harm. The facility's failure to ensure adequate supervision, monitoring, and intervention allowed these resident-to-resident altercations to occur, resulting in injury, hospitalization, and emotional distress for the affected residents. The events were substantiated through observation, interviews, and record reviews, confirming that the residents were not protected from abuse as required.
Elopement Due to Inadequate Supervision of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and exit-seeking behaviors was not provided with adequate supervision to prevent elopement. The resident, diagnosed with severe unspecified dementia, schizophrenia, and delusional disorders, had a BIMS score of 00, indicating severe cognitive impairment. The care plan identified the resident as high risk for elopement, with interventions including 15-minute location checks and various diversions. Despite these interventions, the resident was able to break a window and leave the facility undetected. On the day of the incident, the resident was last observed in her room at 7:30 AM. At 7:45 AM, a CNA discovered the resident missing and the window broken when attempting to summon her for breakfast. Staff immediately initiated a search of the unit and grounds, confirmed all other exits were secure, and notified the police when the resident could not be located. The resident was found by police approximately five minutes away from the facility and was exhibiting psychotic behaviors, including hallucinations and delusions, at the time of recovery. Interviews and record reviews confirmed that the resident had previously been on 1:1 supervision, which was later reduced to 15-minute checks due to observed behaviors such as pacing and wandering into other residents' rooms. Staff reported that the required 15-minute checks were being completed, but the resident was able to elope between checks. The incident resulted in the resident being transported to the hospital for evaluation, and the event was classified as Immediate Jeopardy due to the risk of harm and/or serious injury.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL), specifically incontinence care, for two residents who were unable to perform these tasks independently. Both residents had severe cognitive impairment, as indicated by a BIMS score of 00, and were dependent on staff for toileting and personal hygiene. Care plans for both residents required staff to provide incontinence care every two hours and as needed, as well as to avoid doubling briefs to prevent skin breakdown. For one resident, observations revealed that he was found wearing two briefs, both heavily soaked with urine, and had not been changed for several hours. The assigned CNA admitted to not knowing when the resident was last changed and acknowledged awareness of the policy against double briefing. Another CNA from the previous shift also could not recall the last time the resident was changed and confirmed knowledge of the facility's protocols. Staff interviews indicated that training on proper incontinence care and rounding every two hours had been provided, but these practices were not consistently followed. The second resident, who was always incontinent and had a history of diabetes, acute respiratory failure, and stage 4 pressure ulcers, was observed in a room with a strong urine odor and a wet mattress cover. Staff provided incontinence care only after a significant lapse in time, with the assigned CNA stating the last change occurred before breakfast, several hours prior. Both the ADON and DON confirmed that staff were expected to perform rounds every two hours and as needed, and that nurses were responsible for monitoring CNAs. Despite these expectations and documented training, the required care was not delivered as outlined in the residents' care plans.
Failure to Provide Pressure Ulcer Care per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers did not receive wound care according to physician orders. The resident, an elderly female with severe cognitive impairment and several medical conditions including stage 3 and stage 4 pressure ulcers, was admitted with existing wounds. The care plan outlined specific interventions such as frequent repositioning, skin inspections, and the use of pressure-relieving devices. Physician orders for wound care, including the use of specific dressings and cleansing routines, were provided on admission and detailed in the resident's records. Despite these orders, the facility failed to enter the wound care orders into the electronic treatment administration record (eTAR) system in a timely manner. As a result, wound care was not documented or possibly not provided from the time of admission until several days later, when the orders were finally entered. Interviews with the wound care nurse, nurse practitioner, and DON confirmed that the orders were not in the system and that it was the responsibility of nursing staff to ensure orders were entered and followed. Documentation showed that at least one scheduled wound care treatment was missed, and there was uncertainty about whether care was provided during this period due to lack of documentation. The facility's policies required that physician orders be recorded accurately and that wound care treatments be performed as ordered. The failure to enter and follow the wound care orders as prescribed led to a lapse in the resident's wound care regimen. This deficiency was identified through record review and staff interviews, which revealed gaps in both documentation and the provision of care as ordered.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral nutrition via feeding tube was provided with the appropriate treatment and services as ordered by the physician. The resident, a male with severe cognitive impairment, multiple diagnoses including anemia, diabetes mellitus, Alzheimer's disease, and malnutrition, was dependent on a feeding tube and had specific physician orders for the administration of Glucerna 1.5 Cal via PEG tube every four hours. The care plan also included detailed interventions for monitoring and maintaining the resident's nutritional status, including water flushes and head-of-bed elevation. Record review revealed that the resident did not receive the prescribed Glucerna 1.5 feedings on three occasions, as documented in the medication administration record (MAR). Interviews with nursing staff and the DON confirmed that these feedings were missed, and there was no documentation in the clinical record to explain the omissions or indicate that the orders had been placed on hold. Nursing staff were unable to recall or provide reasons for the missed feedings, and the DON verified that the missed administrations were not supported by any progress notes or documentation. The facility's policy required that physician orders be implemented and documented promptly, with any changes or holds to be recorded in the resident's medical record. The lack of adherence to these orders and the absence of documentation for the missed feedings constituted a failure to follow physician directives and provide the necessary care for the resident's enteral nutrition needs.
Failure to Maintain Infection Control Program Due to Lapses in Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to proper hand hygiene protocols during the provision of incontinence and wound care for two residents. Certified Nursing Assistants (CNAs) were observed providing incontinence care without performing hand hygiene before, during, or after the procedure. Specifically, one CNA donned gloves before washing hands, failed to perform hand hygiene after removing gloves, and continued care and handling of supplies without appropriate handwashing. This was confirmed during interviews, where the CNAs acknowledged forgetting to perform hand hygiene and recognized the expectation to do so before and between care tasks, as well as after glove removal. In another instance, two CNAs provided incontinence care to a resident with a stage 4 pressure ulcer and did not perform hand hygiene before donning gloves or after removing them. They also failed to cleanse the peri area as required and handled both soiled and clean items with the same gloves. The wound care nurse, RN, also failed to perform hand hygiene before donning gloves, did not disinfect the area where wound care supplies were placed, and did not change gloves or perform hand hygiene between dirty and clean tasks during wound care. The nurse placed soiled gauze on a clean bedsheet and did not have a designated area for contaminated materials. These actions were confirmed in interviews, where staff admitted to forgetting required hand hygiene steps and not following established protocols. Record reviews indicated that both residents involved had significant medical conditions, including severe cognitive impairment, incontinence, and, in one case, a stage 4 pressure ulcer. Facility policies required hand hygiene before and after resident contact, after contact with soiled items, and during wound care procedures. Despite these policies and reported staff training, the observed failures in hand hygiene and infection control practices were not in compliance with facility protocols. Training records requested by surveyors were not provided.
Failure to Ensure Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as mandated by CMS regulations. Specifically, four residents were not seen by their attending physician at least once every 60 days, and in some cases, not at all within the past 12 months. Instead, all required visits were conducted solely by a nurse practitioner, without alternating with the physician as required. This was confirmed through record reviews, which showed no documentation of physician visits for the residents in question, only visits by the nurse practitioner. The residents affected had complex medical histories, including conditions such as hypertensive chronic kidney disease, paraplegia, dementia, heart failure, and schizophrenia. Their care plans and medication regimens reflected significant needs, including the use of multiple psychotropic and at-risk medications, management of chronic pain, and assistance with activities of daily living. Despite these needs, there was no evidence in the clinical records that the attending physician had conducted face-to-face visits as required, with all documented visits being completed by the physician extender. Interviews with the attending physician revealed an acknowledgment of falling behind on documentation and delegating visits to the nurse practitioner. The physician stated that he would see residents in person if requested by nursing staff but admitted to not keeping up with required face-to-face visits. The facility administrator confirmed there was no specific policy regarding physician visits and that they followed regulatory language. The lack of physician visits was further corroborated by the absence of documentation in the residents' clinical charts.
Failure to Administer and Document Medications for Resident with Dementia
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with multiple complex diagnoses, including dementia, chronic kidney disease, and Alzheimer's disease. On two consecutive mornings, the resident was not administered her prescribed morning medications, which included critical drugs for blood pressure, cholesterol, depression, and other conditions. The medication administration record (MAR) indicated that the medications were marked as refused, but there was no documentation of further attempts to administer the medications or of appropriate follow-up actions. Interviews with staff revealed that the medication aide attempted to administer the medications but, after the resident refused and spit out the medications, did not make additional attempts or notify the charge nurse as required. The charge nurse, when notified, did not document the refusals or attempt to encourage the resident to take the medications, citing being too busy as the reason for inaction. There was also no documentation in the nursing progress notes regarding the refusals, the reasons for non-administration, or any notification to the physician as required by facility policy. The facility's policy required that if a resident refused two consecutive doses of a vital medication, the physician should be notified, and all refusals should be documented. However, these procedures were not followed. The lack of proper documentation, follow-up, and physician notification resulted in the resident missing multiple doses of essential medications over two days, with no evidence of appropriate interventions or communication among staff.
Unnecessary Prescription of Austedo Without Adequate Indication
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, specifically regarding the prescription of Austedo to two residents without adequate indications for its use. For one resident, who had diagnoses including hypertensive chronic kidney disease, osteoarthritis, morbid obesity, and dementia, there was no documented diagnosis of tardive dyskinesia or evidence of involuntary movements prior to the prescription of Austedo. Multiple AIMS assessments showed no signs of tardive dyskinesia, and nursing notes did not document any movement disorders. The decision to prescribe Austedo was influenced by a pharmaceutical representative's presentation and a subsequent observation of minor pill rolling, but there was no substantial clinical evidence supporting the need for the medication. For the second resident, who had paraplegia, chronic pain, and a history of depression and anxiety, there was also no documented evidence of tardive dyskinesia or abnormal involuntary movements in AIMS assessments or nursing notes prior to the prescription of Austedo. The resident herself reported that her head movements were voluntary and used as a coping mechanism for anxiety, not as a result of uncontrolled movements. Staff interviews confirmed a lack of awareness of any movement issues or the purpose of the Austedo prescription. The facility’s policy required a formal diagnosis of tardive dyskinesia by a physician or extender before initiating treatment, and interdisciplinary team involvement in treatment decisions. However, in both cases, Austedo was prescribed based on limited or subjective clinical observations rather than documented evidence or formal diagnosis, and without clear interdisciplinary team involvement. This resulted in the administration of a potentially unnecessary medication to both residents.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident's call light was observed on the floor and out of reach, despite the resident's care plan specifying that the call light should be within reach due to a high fall risk. The resident, an elderly female with Alzheimer's disease and esophagitis, required substantial to maximum assistance with transfers and sit-to-stand activities, as documented in her medical records. During the observation, the resident was only able to answer yes or no questions, indicating limited communication abilities. Staff interviews revealed that the call light should have been within reach at all times, and that staff are expected to check the call light's placement each time they enter a resident's room. The last staff member to enter the room believed the call light was within reach but was unsure of the risks if it was not. The Director of Nursing confirmed that staff are responsible for ensuring call lights are accessible, acknowledging that failure to do so could prevent residents from reaching staff when needed. The facility's Resident Rights policy did not address the right to reasonable accommodations.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was fully implemented for a resident identified as a fall risk. The resident, an elderly female with Alzheimer's disease and esophagitis, required substantial to maximum assistance with transfers and sit-to-stand activities. Her care plan included specific fall prevention interventions such as keeping the call light within reach, using a half bed rail, ensuring the bed was in the lowest position, and placing a fall mat on the floor. However, during observations, the bed was not in the lowest position, the fall mat was not in place, and the bed rails were not raised as required by the care plan. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan interventions. An LVN acknowledged that the fall mat and bed rail should have been in place but was unsure why they were not. A CNA admitted to forgetting to lower the bed and place the fall mat after providing care and was unaware of the risks associated with not following these interventions. The DON confirmed that all staff were responsible for ensuring fall interventions were in place each time they entered the room, as outlined in the facility's care plan policy.
Failure to Provide Feeding Assistance to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and esophagitis, who was on a puree diet with thickened liquids and required total assistance with eating, was not provided with the necessary feeding assistance. The resident's care plan did not address the need for feeding assistance, despite documentation in the MDS and physician's nutrition notes indicating the requirement for partial to full assistance and a risk for malnutrition. On the day in question, the resident's breakfast remained untouched on the bedside table, and the resident confirmed she had not been assisted with feeding, although she expressed a desire to eat. Staff interviews revealed that the CNA responsible for the resident attempted to feed her but was unsuccessful and failed to report to the LVN that the resident had not eaten. The LVN was unaware of the missed meal until later and then provided feeding assistance. The facility's policy required staff to report to a licensed nurse if food consumption was 25% or less, but this was not followed. The Assistant Executive Director and DON confirmed that CNAs are responsible for assisting with feeding and notifying nursing staff if a resident does not eat, and acknowledged the risk of unwanted weight loss if meals are not consumed.
Resident-to-Resident Altercation Leads to Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in a serious injury. On the specified date, a resident with severe cognitive impairment and a history of being a fall risk was involved in an altercation with another resident. The altercation occurred when the second resident, also with severe cognitive impairment and a history of anxiety and neurological conditions, pushed the first resident as she attempted to stand from a couch. This push caused the first resident to fall and sustain a right hip fracture, necessitating hospitalization and surgery. The incident was witnessed by staff members who reported that the second resident was verbally aggressive and had a history of paranoia, believing that others were stealing her belongings. Despite this behavior, her care plan did not reflect any interventions for such behaviors. On the day of the incident, the second resident was reportedly agitated and accused the first resident of entering her room, which led to the physical altercation. Staff members intervened immediately, but the first resident had already sustained a significant injury. Interviews with staff revealed that the second resident had been verbally aggressive in the past but had not previously exhibited physical aggression. The facility's failure to adequately monitor and address the second resident's behaviors, as well as the lack of appropriate interventions in her care plan, contributed to the incident. The deficiency was identified as an Immediate Jeopardy situation, indicating a serious threat to the health and safety of the residents involved.
Misappropriation of Resident's Medication by ADON
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when the Assistant Director of Nursing (ADON) took two morphine pills prescribed for the resident. The resident, who was moderately cognitively impaired and had a history of lung and brain cancer, was admitted with a bottle of morphine pills and liquid morphine. On the morning of the incident, the ADON informed a Licensed Vocational Nurse (LVN) that there was a change in the resident's medication orders, stating that the morphine pills were discontinued, and took the pills and the count sheet to her office. Later that day, it was discovered that the resident's Medication Administration Record (MAR) indicated he was due for a morphine pill, but there were none available on the cart. The ADON returned the pills with a new count sheet showing fewer pills than expected. Upon investigation, it was found that the original count sheet had been altered to show fewer pills than the resident had initially. The ADON was suspended pending further investigation. The facility's policy on abuse, neglect, and misappropriation of resident property was not adhered to, leading to this deficiency.
Failure to Administer Cancer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of the cancer medication Ibrance. The resident, a female with a history of breast cancer, heart failure, and mild cognitive impairment, was prescribed Ibrance to be taken daily for 21 days, followed by a week off. However, the resident missed four doses of the medication over a four-day period. This lapse occurred between August 26 and August 29, 2024, as documented in the Medication Administration Records (MARs). The Director of Nursing (DON) acknowledged issues with the delivery of Ibrance from a specialty pharmacy, which was not the facility's usual pharmacy. Despite these logistical challenges, the DON confirmed that there was no valid reason for the missed doses, emphasizing the importance of maintaining therapeutic blood levels for cancer medications. The facility's Medication Administration policy mandates that medications be administered as prescribed, and nurses are required to return to residents who are unavailable during medication passes to ensure they receive their doses.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene services to three residents, leading to deficiencies in their care. Resident #23, an elderly female with severe cognitive impairment, was observed with long facial hairs on multiple occasions, despite expressing a desire for their removal. The facility's records showed no documentation of shaving refusals, and interviews with staff revealed that showers and personal hygiene tasks, including facial hair removal, were not consistently performed due to staffing issues. Resident #55, a legally blind female requiring assistance with all activities of daily living, was also observed with unwanted facial hair. She expressed embarrassment over her facial hair, yet there was no record of her being shaved. Interviews with staff indicated a reliance on CNAs to perform these tasks, but there was a lack of follow-up to ensure completion. The facility's policy stated that hair care and shaving should be provided according to standard practice guidelines, which were not adhered to in this case. Resident #81, a female with a history of cardiovascular disease and cognitive impairments, did not receive consistent showers or baths as required. Documentation showed numerous instances where bathing did not occur, and interviews with staff highlighted issues with staffing and scheduling that prevented showers from being completed. The facility's policy required documentation of bathing procedures, which was not consistently done, leading to a deficiency in the resident's hygiene care.
Food Safety and Hygiene Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in both the North and South kitchens, as observed during a survey. In the North kitchen, several food items, including cooked chicken and rice soup, cheese, sautéed mushrooms, cooked meatloaf, and a bag of uncooked biscuits, were found without labels or dates indicating when they were opened or prepared. Additionally, ground meat was thawing in the fridge without a date indicating when it was removed from the freezer. This lack of labeling and dating was acknowledged by staff members, who confirmed that it was their responsibility to ensure all food items were properly labeled and dated to prevent foodborne illnesses. In the South kitchen, Nutrition Aides M and L were observed not wearing beard guards while handling food and clean dishes, despite having facial hair. Nutrition Aide M was preparing drinks for the lunch meal, and Nutrition Aide L was putting away clean dishes. Both aides admitted to forgetting to wear beard guards, and it was revealed that there were no beard guards available for them to use at the time. The Dietary Manager (DM) confirmed that it was his responsibility to ensure beard guards were available and that staff were trained to wear them to prevent hair contamination in food. The facility's policies on the use of leftovers and employee infection control were not followed, as evidenced by the lack of proper labeling and the absence of beard guards. The Federal Food Code requires that ready-to-eat, time/temperature-controlled foods be clearly marked with a date for consumption or disposal, and that hair restraints be used effectively. The failure to comply with these standards could place residents at risk for foodborne illnesses and contamination.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's right to dignity and respect was upheld by not providing a privacy cover for the resident's catheter urine collection bag. This deficiency was observed in the case of a male resident with multiple medical conditions, including an indwelling catheter. The resident's catheter bag was repeatedly observed without a privacy cover, lying on the floor beside the bed, which the resident expressed made him feel uncomfortable, especially during visits. Interviews with facility staff, including an LVN, ADON, and DON, revealed a lack of awareness and communication regarding the absence of a privacy cover for the resident's catheter bag. The staff acknowledged the importance of maintaining privacy and dignity by covering catheter bags and ensuring they are not placed on the floor. The facility's policy on catheter care emphasized the need for privacy and proper positioning of catheter bags, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,056 citations issued within 25 miles in the last 12 months — including the 46 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Desoto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lennwood Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 4 | 0 |
| Duncanville Healthcare And Rehabilitation Center | 0.8 mi | ★★★★★ | 18 | 0 |
| Five Points Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 6 | 0 |
| The Laurenwood Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 8 | 0 |
| Desoto Nursing & Rehabilitation Center | 2.7 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Williamsburg Village Healthcare Campus.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.