Albemarle Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlottesville, Virginia.
- Location
- 1540 Founders Place, Charlottesville, Virginia 22902
- CMS Provider Number
- 495420
- Inspections on file
- 26
- Latest survey
- October 25, 2025
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Albemarle Health & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with dementia and exit-seeking behaviors were not properly supervised or reassessed for elopement risk after repeated incidents, including one resident who eloped from the facility undetected. Staff failed to follow established protocols for missing residents, did not update risk assessments, and did not ensure wander guard devices were secure or that resident information was available in the elopement binder. These failures resulted in serious lapses in resident safety and noncompliance with accident prevention requirements.
A resident with severe cognitive impairment and a history of wandering was not accurately assessed in the MDS, as the assessment failed to document wandering behaviors that were noted in progress notes and by staff. Despite the resident's documented exit-seeking and the use of a wander guard, the MDS did not reflect these behaviors, and staff interviews confirmed the inaccuracy.
A resident admitted with alcoholic cirrhosis did not receive ordered doses of gabapentin and sucralfate as scheduled because the medications were not available at the time of administration, and there was no documentation explaining the missed doses. Although the facility had an automated medication system with gabapentin, many agency nurses lacked access, and the medications were not delivered until the next day. The MAR indicated the missed doses, but no explanation was found in the progress notes.
Administrative staff did not conduct a comprehensive investigation after a resident with exit-seeking behaviors eloped from the facility. The assigned LPN did not follow the missing person protocol, and the Administrator was not promptly notified. The facility failed to inform the resident's responsible party, and the investigation included only a single staff statement, omitting interviews with other involved staff.
A resident with known exit-seeking behaviors eloped from the facility without staff knowledge, and the assigned LPN did not follow the missing person protocol. The Administrator was not promptly notified, and the resident's family learned of the incident directly from the resident. The facility's investigation was incomplete, and the event was not reviewed by the QAPI committee as required by policy.
Facility staff did not follow abuse prevention policies for volunteer screening, as eight of nine volunteers lacked criminal background checks and seven did not complete required self-questionnaires. Volunteers, including church members and a former resident, participated in activities without proper pre-screening, contrary to facility policy.
Two residents were allowed to self-administer medications without a prior assessment or physician's order, as required by facility policy. An LPN left oral medications at the bedside for the residents to take unsupervised, and one resident was also found with an inhaler at the bedside without proper authorization. The DON and staff confirmed that no assessments or orders were in place, and the required procedures for self-administration were not followed.
An LPN prepared oral medications in advance and left them unattended and unsecured at the bedside for two cognitively intact residents, without observing one of them take the medications. Neither resident had been assessed or authorized for self-administration, and facility policy required medications to be administered at the time of preparation and under observation. The DON and staff development coordinator confirmed these actions did not meet professional standards.
A resident with multiple complex medical conditions did not receive a scheduled dose of IV Zosyn as ordered, with no documented reason or discontinuation order. Facility staff and administration could not explain the missed dose, and the responsible LPN was unavailable for clarification. Facility policy requires medications to be administered per prescriber orders, which was not followed in this case.
Staff failed to secure medications as required, with an inhaler left on a bedside table for a resident not authorized for self-administration, and oral medications prepared and left unattended in the rooms of two residents by an LPN. Facility policy requires medications to be locked and residents to be observed during administration, but these procedures were not followed.
A facility failed to include insulin administration in the baseline care plan for a resident admitted with an insulin pump. Despite the resident's ability to manage the pump independently, as confirmed by a nurse practitioner, the care plan lacked documentation of goals or interventions related to the insulin pump. This oversight was acknowledged by the regional nurse consultant, highlighting a deviation from the facility's care planning policy.
A resident's care plan was not updated to reflect their weight-bearing status, despite having physician's orders indicating changes. Interviews with staff revealed reliance on therapy evaluations and nursing reports for this information, but the care plan lacked the necessary updates. This deficiency was noted during a clinical record review and discussed with facility administration.
The facility experienced a deficiency in dietary staffing, resulting in delayed breakfast service. On a specific day, the scheduled cook and dietary aides were absent, leaving only the dietary manager to manage meal preparation. Consequently, a continental breakfast was served late, while lunch and dinner were on time. Communication issues between the new dietary manager and administrator contributed to the situation.
The facility failed to provide a timely breakfast service on four units due to the absence of kitchen staff. Scheduled breakfast times were not met, and residents received only cereal and milk around 10:30 a.m. The dietary manager, newly hired, decided to focus on lunch and dinner preparation. The administrator and DON were aware of the staffing issue but did not fully understand its impact on meal service. The facility's policy requires meals to be served at regular times, with no more than 14 hours between dinner and breakfast unless a substantial snack is provided.
The facility failed to provide therapeutic diets and serve meals accurately according to meal tickets for several residents. A resident with diabetes did not receive a diabetic diet, while another resident with congestive heart failure received meals not matching their dietary orders. The dietary manager acknowledged software issues causing meal ticket inaccuracies, but staff continued to serve incorrect meals. These issues were discussed with facility leadership without resolution before the survey ended.
The facility failed to maintain sanitary conditions in the main kitchen and two kitchenettes, with food stored beyond use-by dates, improper labeling, and unsealed items in the freezer. In the 200 and 300-unit kitchenettes, food was served below safe temperatures without reheating. The dietary manager acknowledged these issues, noting that policies for food safety and staff attire were not followed.
A resident with specific medical conditions did not receive the preferred number of showers twice weekly as requested, with records showing missed showers over several weeks. The responsible CNA was unavailable for comment, and the LPN confirmed the lack of documentation for any refusals. The DON, not present during the period in question, could not explain the deficiency.
A resident with multiple diagnoses did not have their treatments properly documented by nursing staff, despite physician orders and facility policy requiring immediate documentation. The Director of Nursing and an LPN confirmed the failure to document, although the treatments were reportedly completed.
A resident with multiple health conditions did not receive prescribed treatments, including topical powder, zinc cream, and leg wrap changes, as ordered by a physician. The treatment administration record was left blank, and no explanation was provided for the omission. The issue was confirmed by the LPN and DON, and the resident's care plan highlighted the risk of skin breakdown due to their condition.
The facility failed to serve food at an appetizing temperature on the 200-unit, with ongoing resident complaints about cold meals documented in council minutes. Observations revealed food items below the required temperature, and the dietary aide did not reheat them. Interviews with the RD and dietary manager showed a lack of awareness of the issue, despite frequent resident complaints.
A resident with specific dietary needs and preferences was not served meals according to their meal ticket, which included a heart-healthy, low-salt diet. The resident, who was cognitively intact and had conditions such as congestive heart failure, was served items not listed on the ticket and did not receive items that were listed. The dietary manager confirmed the discrepancy, and the issue was discussed with facility leadership.
Two residents with cognitive impairments and dysphagia did not receive necessary feeding assistance during meals. One resident was left with a meal unattended and without dentures, while another engaged in inappropriate eating behaviors without staff intervention, despite being identified as needing assistance. Facility guidelines for feeding assistance were not followed.
A resident who was always incontinent and required maximum assistance did not receive timely incontinence care, resulting in saturated clothing. The resident's daughter, who visits daily due to care concerns, reported that no staff provided care for several hours. The DON confirmed the lapse in care, acknowledging the standard of care was not met.
A resident admitted with traumatic brain injuries was enrolled in hospice care, but the facility failed to maintain a complete clinical record of hospice services, including documentation of care and involvement at the time of death. The DON confirmed the absence of hospice notes, which were later provided after the surveyor's review.
Failure to Prevent Elopement and Inadequate Supervision of Exit-Seeking Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for residents identified as having exit-seeking behaviors, resulting in multiple deficiencies. One resident with a history of dementia, cognitive impairment, and exit-seeking behavior was admitted and initially assessed as low risk for elopement, despite documentation of wandering and a prior history of exit-seeking at the hospital. The resident was provided with a wander guard, but staff did not accurately update the elopement risk assessment when the resident continued to display exit-seeking behaviors. On the day of the incident, the resident expressed a desire to leave, was redirected multiple times, and ultimately eloped from the facility without staff knowledge. The facility failed to promptly and correctly implement its missing resident protocol (Code Orange), with staff not announcing the code as required, not stationing staff at all exits, and not completing required documentation. The resident was later found offsite by local authorities after a family member was contacted by the resident. Another resident with dementia and moderate cognitive impairment also exhibited exit-seeking behaviors, including multiple attempts to exit the facility and setting off alarms. Despite these behaviors, the facility did not complete updated elopement risk assessments as required by policy. The resident was ordered to have a wander guard, but there was an incident where the resident removed the device, and it was not immediately replaced by staff. The resident's information was also missing from the facility's elopement binder, which staff relied upon to identify residents at risk for elopement. Staff interviews revealed a lack of awareness regarding the need for reassessment and inconsistent monitoring of the wander guard's placement and function. Throughout these incidents, facility staff demonstrated a lack of adherence to established policies for elopement risk assessment, care planning, and emergency response. Staff failed to communicate effectively, did not follow the required steps for Code Orange activation, and did not ensure that all staff were aware of their roles during a missing resident event. Documentation was incomplete or missing, and not all staff involved were interviewed during the facility's internal investigation. These failures affected at least two residents and resulted in noncompliance with federal requirements for accident prevention and resident safety.
Removal Plan
- Resident was placed on 1:1 supervision to ensure safety and to not leave the building unattended once returned to the building.
- Resident was evaluated by nursing staff with no new impairments and seen by the nurse practitioner (NP).
- Resident remained on 1:1 supervision and discharged from the facility.
- Resident was placed on 1:1 supervision as a precaution.
- The wander guard was placed back on Resident and secured the same day it was observed to be off.
- Admission Record for Resident was placed in the elopement binder at the front desk; all other binders on the units were already updated.
- The facility licensed nursing staff will conduct new elopement assessments on all residents to determine elopement risk with follow-up based on findings.
- Any newly identified residents will be assessed for a wander guard by Director of Nursing, and it will be placed appropriately.
Inaccurate MDS Assessment for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident who was reviewed for accidents. The MDS, which is used to assess behavioral symptoms such as wandering, did not accurately reflect the resident's behaviors during the required 7-day look-back period. Specifically, the MDS indicated that the resident did not exhibit wandering behaviors, despite documentation and staff interviews confirming that the resident had a history of exit-seeking behavior, had wandered to other units, and required a wander guard for safety. The resident had severe cognitive impairment, dementia, and other medical conditions that placed them at risk for elopement, as noted in the care plan and progress notes. Staff interviews, including those with the LPN who documented the wandering and the MDS Coordinator, confirmed that the MDS assessment was not completed accurately and should have indicated the presence of wandering. The Staff Development Coordinator/Infection Preventionist, who was acting as the Director of Nursing, and the Administrator both acknowledged that the MDS was inaccurate and that staff were expected to follow the RAI manual. The deficiency was identified through interviews, record review, and document review, which demonstrated a failure to accurately assess and document the resident's wandering behavior as required.
Failure to Provide Timely Ordered Medications Due to Access and Delivery Issues
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered as prescribed for a resident admitted with a diagnosis of alcoholic cirrhosis. Upon admission, the resident had physician orders for gabapentin and sucralfate to be administered at specific times, including a 9:00 PM dose on the day of admission. Review of the Medication Administration Record (MAR) showed that the 9:00 PM doses of both medications were not administered, and the MAR entry indicated 'Other / See Progress Notes,' but there was no documentation in the progress notes explaining the missed doses. Further investigation revealed that the medications were not delivered to the facility until the following morning, as confirmed by the pharmacy delivery manifest. Interviews with staff indicated that while the facility had an automated medication management system containing gabapentin, many agency nurses did not have access to it, and no medication was pulled from the system for this resident. The DON confirmed that most medications for the resident were not due until the next day, but the missed 9:00 PM dose was not addressed or documented appropriately.
Failure to Conduct Thorough Investigation After Resident Elopement
Penalty
Summary
The administrative staff failed to conduct a thorough investigation following the elopement of a resident identified as having exit-seeking behaviors. On the evening of the incident, the resident left the facility without staff knowledge, and the assigned LPN did not implement the facility's missing person protocol (Code Orange) as specified. The Administrator was not notified of the elopement until nearly two hours after the resident had left, and the resident's responsible party was not informed by the facility that the resident was missing. Instead, the resident contacted a family member directly, who then notified the facility of the resident's location. The resident was subsequently returned to the facility by local police and a staff member. The facility's investigation into the incident was incomplete, containing only a statement from the LPN involved and lacking interviews with other staff who were on duty or participated in the search for the resident. During interviews, the Administrator acknowledged that additional staff interviews should have been conducted and that a root cause analysis was necessary to determine where the process failed. The deficiency was identified through review of facility documents and staff interviews, which confirmed that the investigation did not meet the expected standards outlined in the job descriptions for the Administrator and Director of Nursing.
Failure to Review Resident Elopement in QAPI Committee
Penalty
Summary
The facility failed to ensure that a resident elopement incident was reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, as required by facility policy. A resident identified as having exit-seeking behaviors eloped from the facility without staff knowledge. The assigned LPN did not implement the facility's missing person protocol (Code Orange) as specified. The Administrator was not notified of the elopement until nearly two hours after the resident left, and the resident's responsible party was not informed by staff that the resident was missing. Instead, the resident contacted their family directly, who then notified the facility of the resident's location. The resident was subsequently returned to the facility by local police and a staff member. The facility's investigation into the incident was incomplete, containing only a statement from the assigned LPN and lacking interviews with other staff on duty or those involved in the search. Despite facility policies and QAPI guidelines requiring the committee to review reportable incidents and undesirable outcomes, the elopement was not brought before the QAPI committee for review. Both the acting DON and the Administrator confirmed in interviews that the incident had not been reviewed by the QAPI committee, contrary to expectations and established procedures.
Failure to Screen Volunteers per Abuse Prevention Policy
Penalty
Summary
Facility staff failed to follow established abuse prevention policies regarding the screening of volunteers. Specifically, eight out of nine volunteer records reviewed showed that no criminal background check had been performed, and seven out of nine volunteers did not have a completed self-questionnaire about past or pending criminal charges. The activity director confirmed that volunteers, including a pastor, a former resident, and several church members, assisted with activities such as games and music. The activity director stated that all volunteers were supposed to complete an application and a self-questionnaire, which would then be reviewed by the administrator and human resources (HR) before a criminal background check was conducted. However, review of facility records and staff interviews revealed that these steps were not followed for most volunteers. The HR manager, who had been in her position since April 2025, reported that no new volunteer screenings had been requested or performed during her tenure, and a search of her portal confirmed that eight current volunteers had no criminal background check on file. The administrator acknowledged that background checks were required prior to volunteer service and that the activity director was responsible for obtaining the necessary documentation, while HR was responsible for conducting the background checks. The facility's abuse prevention policy clearly outlined these pre-screening requirements, but they were not adhered to for the majority of volunteers reviewed.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
Facility staff allowed two residents to self-administer medications without conducting a prior assessment or obtaining a physician's order, as required by facility policy. Both residents were assessed as cognitively intact and had multiple medical diagnoses, including diabetes, asthma, atrial fibrillation, spinal stenosis, and hypertension. On the evening in question, an LPN prepared and left oral medications at the bedside for these residents to take upon returning to their rooms, without witnessing the administration or ensuring the medications were secured. The LPN stated this was done to expedite the medication pass, and later confirmed that one resident self-administered the medication while the other was observed taking it after the LPN returned to the room. Clinical record review revealed that neither resident had a physician's order or an interdisciplinary assessment authorizing self-administration of medications. Interviews with the DON and staff development coordinator confirmed that the facility's policy requires both an assessment and a physician's order before residents are permitted to self-administer medications, and that medications should not be left unattended at the bedside. The DON also stated that residents approved for self-administration are provided with a lock box for medication storage, which was not the case for these residents. Additionally, one resident was found with a Trelegy Ellipta inhaler at the bedside, which had been used, without a physician's order or assessment for self-administration. The resident reported self-administering the inhaler daily, and staff were unaware that the device was in the room. Facility policy requires a licensed nurse to assess the resident's ability to self-administer, with interdisciplinary team review and documentation in the medical record, none of which was completed for this resident.
Medications Left Unattended and Unsecured at Bedside
Penalty
Summary
Facility staff failed to follow professional standards of quality during medication administration for two residents. On the evening in question, an LPN prepared oral medications ahead of the scheduled administration time and left them unattended and unsecured at the bedside for two cognitively intact residents. The LPN did not observe one of the residents taking the prepared medications, and only later confirmed with the resident that the medications had been taken. For the other resident, the LPN found the medications still at the bedside later in the evening and then observed the resident taking them. Both residents had complex medical histories, including conditions such as diabetes, atrial fibrillation, chronic kidney disease, spinal stenosis, and hypertension. Interviews with the LPN revealed that the medications were prepared and left at the bedside to expedite the medication pass, despite the LPN's awareness that this practice was not permitted. Neither resident had been assessed for self-administration of medications, nor was there a physician's order or interdisciplinary team assessment indicating they were safe to self-administer. Facility policy required that medications be administered at the time they are prepared, not left unattended, and that residents be observed to ensure the dose is ingested. The facility's DON and staff development coordinator confirmed that the observed practices did not align with facility policy or professional standards.
Missed Dose of IV Antibiotic Due to Failure to Follow Physician Order
Penalty
Summary
Facility staff failed to follow physician orders for medication administration for one resident. The resident, who was cognitively intact and had multiple diagnoses including osteomyelitis, MRSA, end stage renal disease, protein-calorie malnutrition, anemia, hypertension, and diabetes, had a physician's order for Zosyn (piperacillin-tazobactam) IV to be administered every 12 hours for treatment of acute osteomyelitis. The medication administration record showed that the scheduled 6:00 a.m. dose on 2/11/25 was not given, and there was no documented reason or physician order to discontinue or stop the medication at that time. A nursing note ambiguously stated "Informed IV completed," but this was not supported by any discontinuation order or further explanation in the clinical record. Interviews with the DON, RN infection preventionist, and regional nurse consultant confirmed that the Zosyn order was not discontinued or completed on the date in question, and they were unable to explain why the dose was missed. The nurse practitioner confirmed awareness of the missed dose and stated that the resident's labs and vital signs remained stable, with no indication to alter the antibiotic regimen. The LPN responsible for the missed dose was unavailable for interview. Facility policy requires medications to be administered according to prescriber orders, which was not followed in this instance.
Medications Left Unsecured and Unattended in Resident Rooms
Penalty
Summary
Facility staff failed to ensure that medications were securely stored and not left unattended, as required by professional standards and facility policy. In one instance, a Trelegy Ellipta inhaler prescribed for a resident with asthma, diabetes, and other chronic conditions was found unsecured on the resident's bedside table. The resident had not been assessed or authorized for self-administration of medications, and both the LPN and the DON confirmed that medications should not be left at the bedside unless the resident is assessed and has a physician's order for self-administration, with medications kept in a locked box. Additionally, on another occasion, an LPN prepared oral medications for two residents and left them on their bedside tables while the residents were in the dining room. The LPN admitted to leaving the medications unattended to expedite her medication pass, despite knowing this was against facility policy. One resident reported taking the medication upon returning to her room, while the other was later observed by the LPN taking the prepared medication. There was no documentation or assessment indicating that either resident was permitted to self-administer medications. Facility policy clearly states that medications must be administered within 60 minutes of the scheduled time, medication carts must be locked when not in use, and residents must be observed to ensure medication ingestion. The DON and staff development coordinator confirmed that these policies were not followed in the incidents described, and that medications should not be left unsecured or unattended in resident rooms.
Failure to Include Insulin Pump Management in Baseline Care Plan
Penalty
Summary
The facility staff failed to include insulin administration in the baseline care plan for a resident who was admitted with an insulin pump. The resident, who was cognitively intact and oriented, had a medical history that included diabetes, Parkinson's, and other conditions. Upon admission, the resident's baseline care plan did not document any goals or interventions related to the use of the insulin pump, despite the resident's demonstrated ability to manage the pump independently as noted in the hospital discharge summary. The nurse practitioner assessed the resident and confirmed the resident's capability to manage the insulin pump, indicating that the resident could continue using the pump in the facility as they did in the hospital. However, the baseline care plan still lacked documentation regarding the insulin pump, which was acknowledged by the regional nurse consultant during an interview. The facility's care planning policy requires the development and implementation of an individualized care plan to provide effective, person-centered care, which was not adhered to in this case.
Failure to Update Resident Care Plan with Weight-Bearing Status
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for one resident, identified as Resident #13, regarding their weight-bearing status. During interviews, the therapy manager confirmed that Resident #13 was non-weight bearing on the right leg, and this information was not updated in the resident's care plan. A certified nursing assistant (CNA) and a licensed practical nurse (LPN) both indicated that they rely on therapy evaluations and nursing reports to understand a resident's weight-bearing status. However, the interim director of nursing and the regional nurse consultant both expected this critical information to be included in the care plan, which was not the case. A clinical record review revealed that Resident #13 had a physician's order dated 8/6/24 indicating non-weight bearing status on the right lower extremity, which was later updated on 8/26/24 to allow weight application to the foot during transfers. Despite these orders, the care plan did not reflect the resident's current weight-bearing status, leading to a deficiency in the facility's care planning process. This oversight was discussed in an end-of-day meeting with the facility's administration and regional representatives, but no additional information was provided to address the deficiency at that time.
Insufficient Dietary Staffing Leads to Delayed Breakfast Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal delivery on four units, as observed on 6/9/24. On this date, the dietary department's as-worked schedule showed that no dietary employees, except the dietary manager, were present in the main kitchen. The scheduled cook and five dietary aides either called out, went home, or were no-shows. Consequently, the dietary manager, who was newly hired, decided to serve a continental breakfast of cereal and milk around 10:30 a.m. to focus on preparing lunch and dinner. The dietary manager stated that she typically required one cook and at least four dietary aides for timely meal service. Interviews with the dietary manager, a dietary aide, the administrator, and the DON revealed communication issues and a lack of awareness about the staffing shortage. The administrator, also new to the facility, was informed of the call-outs but did not grasp the significance of the missing staff. The dietary manager did not fully communicate the situation, leading to the decision to serve a modified breakfast without the administrator's input. Despite the staffing challenges, lunch and dinner were served on time, and there were no reported issues experienced by residents due to the modified breakfast.
Failure to Provide Timely Breakfast Service Due to Staff Absence
Penalty
Summary
The facility staff failed to provide a timely breakfast service on four units due to a lack of kitchen staff on the morning of 6/9/24. The scheduled breakfast times were 8:00 a.m. for the 200 and 300 units and 8:30 a.m. for the 100 and 400 units. However, no cooked breakfast was served, and residents only received cereal and milk around 10:30 a.m. The dietary department's as-worked schedule revealed that no dietary employees worked in the main kitchen that morning, as the cook and five dietary aides either called out, went home, or were no-shows. The newly hired dietary manager, who started on 6/4/24, decided to provide a continental breakfast to focus on preparing lunch and dinner on time. The dietary manager stated that conflicts with the cook contributed to the absence of kitchen staff. The administrator and DON were informed of the staffing issue but did not fully comprehend the impact on meal service. The administrator acknowledged poor communication and stated that if she had been fully informed, she would have arranged for facility staff to assist. The facility's policy requires meals to be served at regular times, with no more than 14 hours between dinner and breakfast unless a substantial snack is provided. The failure to provide a timely breakfast service was reviewed with the administrator, DON, and regional director of clinical services, with no further information presented before the end of the survey.
Failure to Provide Therapeutic Diets and Accurate Meal Service
Penalty
Summary
The facility staff failed to provide a therapeutic diet and serve foods correctly per meal ticket for four out of five residents in the survey sample. Resident #2, who had diagnoses including diabetes, anemia, and anorexia, was not provided a diabetic diet for lunch and was missing items for breakfast. Similarly, Resident #3, with diabetes, gout, and obesity, was not served a diabetic diet for lunch. Resident #4, diagnosed with neuropathy and dysphasia, did not receive the correct breakfast items as per the meal ticket. Observations revealed that the serving line did not have pre-cut cupcakes for diabetic diets, and staff were unaware of missing items until prompted. Resident #1, who was cognitively intact and had diagnoses including congestive heart failure and hypertension, was not served foods according to the meal ticket. The meal ticket inaccurately documented a 1500 ml per day fluid restriction, which was not a current order. The resident frequently received meals that did not match the ticket, including items not wanted or supposed to be consumed. The dietary manager acknowledged the inaccuracies in the meal ticket system but was unsure how to correct them, leading to discrepancies in meal service. The dietary manager admitted to being aware of the software issues causing inaccuracies in meal tickets but did not know how to resolve them. The kitchen staff were expected to serve meals according to the tickets, which included resident preferences and therapeutic foods, but this was not consistently done. The findings were discussed with the administrator, director of nursing, and regional director of clinical services, but no further information was provided before the survey concluded.
Sanitation and Food Safety Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the main kitchen and two kitchenettes, leading to multiple deficiencies. In the main kitchen, food items were stored beyond their use-by dates, lacked proper labeling, and were unsealed in the freezer, exposing them to air. The bulk condiment storage containers, flour and sugar bins, and the manual can opener were found dirty. An employee was observed in the kitchen without a hair restraint during meal preparation, and personal food items were improperly stored in the walk-in refrigerator. In the 200 and 300-unit kitchenettes, food was held on steam tables below the recommended safe temperatures and served to residents without reheating. The dietary aides on both units failed to check food temperatures before serving, and when temperatures were checked, multiple food items were found below the required 135 degrees Fahrenheit. Despite this, the aides continued to serve the food without reheating it to the proper temperature. The dietary manager acknowledged the issues, stating that employee food should not be stored in the kitchen refrigerator and that scoops should not be stored in the flour and sugar bins. The manager also admitted that servers were supposed to check food temperatures at the steam tables and reheat any food below 135 degrees Fahrenheit before serving. The facility's policies and procedures, including those for food safety, staff attire, and cleaning schedules, were not adhered to, contributing to the deficiencies observed.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility staff failed to accommodate the bathing preferences of a resident, identified as Resident #1, who was admitted with diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema. The resident was assessed as cognitively intact and required supervision or touch assistance with bathing. During an interview, the resident expressed a preference for receiving two showers per week, which was not consistently met. The clinical records indicated that the resident did not receive the preferred number of showers during February and March 2024, with several weeks showing no showers or only one shower provided. The certified nurse's aide responsible for the resident's showers during the specified period was unavailable for interview, as she no longer worked at the facility. The LPN unit manager confirmed that residents requesting showers were scheduled for two per week and that any refusals should be documented, but found no such documentation in the resident's records. The DON, who was not employed at the facility during the time of the missed showers, could not provide an explanation for the oversight. The issue was discussed with the facility's administration, but no additional information was provided before the survey concluded.
Failure to Document Resident Care
Penalty
Summary
The facility staff failed to adhere to professional standards of care by not documenting treatments provided to Resident #1 at the time the care was administered. Resident #1, who was admitted with diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema, had physician orders for specific treatments such as Zeasorb-AF external powder, zinc barrier cream, and Circaid wraps. However, the treatment administration records (TARs) from September 1, 2024, through November 13, 2024, showed incomplete documentation for these treatments on multiple occasions. There were no notes indicating that the treatments were not performed or that the resident refused them. Upon review, the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the nurses failed to document the care provided, despite statements from the nurses indicating that the treatments were completed as ordered. The facility's policy requires documentation of medication administration immediately after care is provided, which was not followed in this case. The Lippincott Manual of Nursing Practice highlights the importance of prompt and accurate documentation, which was not adhered to, leading to this deficiency.
Failure to Administer Prescribed Treatments
Penalty
Summary
The facility staff failed to follow physician orders for a resident, identified as Resident #1, who was admitted with diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema. The resident was assessed as cognitively intact. The clinical record documented specific orders for the application of Zeasorb-AF external powder, zinc barrier cream, and the changing of Circaid leg wraps. However, on a specific date, these treatments were not administered as ordered, and the treatment administration record was left blank with no documentation of resident refusal or explanation for the omission. The issue was reviewed with the licensed practical nurse unit manager and the director of nursing, who confirmed that the treatments were not completed and that there was no explanation provided by the nurse responsible for the care on that day. The resident's plan of care, which was revised shortly after the incident, highlighted the risk of skin breakdown due to the resident's fragile skin and chronic health conditions, emphasizing the importance of the prescribed treatments. The deficiency was discussed with the facility's administration and clinical services team, but no further information was provided before the survey concluded.
Failure to Serve Food at Safe and Appetizing Temperature
Penalty
Summary
The facility staff failed to provide food at an appetizing temperature on the 200-unit, as evidenced by ongoing complaints from residents and observations made during the survey. Monthly resident council minutes from May 2024 through October 2024 documented repeated complaints about meals being served cold, with no documented follow-up or interventions noted. During an interview, the resident council president confirmed that residents frequently reported cold food, which had been a recurring topic in council meetings. On November 12, 2024, an observation of the meal service from the 200-unit kitchenette revealed that multiple food items were served below the required 135 degrees Fahrenheit. Despite this, the dietary aide did not reheat the foods, and service continued. Interviews with the registered dietitian and dietary manager indicated a lack of awareness and understanding of the source of the cold food complaints, with the dietary manager unaware of ongoing resident concerns and the specific issue of foods being served below the minimum temperature. These findings were discussed with the facility's administration, but no additional information was provided before the survey concluded.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility staff failed to provide food that accommodated the preferences of a resident, identified as Resident #1, who was part of the survey sample. Resident #1, who was cognitively intact and had diagnoses including congestive heart failure, hypertension, arthritis, and lymphedema, was observed during a meal service where the food served did not match the meal ticket. The meal ticket specified a heart-healthy, low-salt diet with no pork, fried, or breaded foods, and recommended baked chicken, fresh vegetables, fruit, and yogurt. However, Resident #1 was served items not listed on the ticket, such as mashed potatoes, a roll, and a chocolate cupcake, and did not receive a tossed salad that was listed. The resident expressed that meals rarely matched his preferences and often included items he did not want or was not supposed to have. The dietary manager confirmed that the meal tickets, which included resident preferences and therapeutic foods, were not followed for Resident #1. The manager was unable to explain why the resident was not served the salad as listed. The resident's care plan, revised shortly before the survey, documented the risk of complications related to obesity, heart failure, and diet non-compliance, with interventions including a therapeutic diet and honoring food preferences. This deficiency was discussed with the facility's administrator, director of nursing, and regional director of clinical services, but no further information was provided before the survey concluded.
Failure to Provide Adequate Feeding Assistance to Residents
Penalty
Summary
The facility staff failed to provide adequate feeding assistance to two residents, resulting in deficiencies in care. Resident #4, who was diagnosed with dysphagia and moderate cognitive impairment, required extensive feeding assistance. However, during a breakfast observation, the staff left the meal within the resident's reach without remaining in the room to assist. Additionally, the resident's dentures were not placed in her mouth before eating, which was acknowledged by the LPN who assisted her. Interviews with CNAs revealed that meals should not be left unattended for residents needing assistance, and dentures should be placed before feeding. Resident #5, diagnosed with dysphagia, oropharyngeal phase, and severe cognitive impairment, also required extensive feeding assistance. During breakfast, the resident was observed engaging in inappropriate eating behaviors, such as drinking syrup and mixing oatmeal with coffee, without any intervention from the CNAs present in the dining room. Despite other residents alerting staff to the need for assistance, no help was provided. Interviews confirmed that the staff was aware of the resident's need for assistance, yet failed to act accordingly. The facility's documentation, based on Mosby's Textbook for Long-Term Care Nursing Assistants, outlines proper feeding assistance procedures, which were not followed in these instances.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility staff failed to provide timely incontinence care to a resident, identified as R2, who was always incontinent of bowel and bladder and required maximum assistance with all activities of daily living. On the day of the survey, the resident's daughter, who visits daily due to concerns about the care provided, reported that no staff had entered her mother's room to provide care from shortly after noon until 3 p.m. When the daughter sought assistance, it was discovered that R2's incontinence brief and pants were saturated with urine, indicating a lack of care over an extended period. The director of nursing (DON) confirmed that the standard of care for incontinence is every two hours, or more frequently if needed, and acknowledged the failure to provide care in this instance. The resident's care plan highlighted the risk of pressure ulcers due to immobility and incontinence, with interventions to keep the skin clean and dry. However, the facility lacked a specific policy on incontinence care, relying instead on general standards of practice. The incident was brought to the attention of the facility administration, but no further information was provided regarding corrective actions.
Incomplete Clinical Record for Hospice Resident
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident who was receiving hospice services. The resident was admitted to the facility with diagnoses including traumatic subdural hemorrhage and subarachnoid hemorrhage. A hospice consult was ordered, and the resident was enrolled in hospice services. However, the clinical record lacked documentation regarding hospice care, treatment, or involvement at the time of the resident's death, except for a hospice contract and a Record of Death document indicating that a hospice nurse pronounced the death. During an interview, the Director of Nursing (DON) acknowledged that hospice records should have been part of the resident's clinical record and confirmed that the hospice notes were not available when the surveyor accessed the closed record. The DON later provided documentation from hospice, which included notes of hospice nurse visits and details about the medical examiner's involvement. The facility administrator was informed of these findings during an end-of-day meeting.
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Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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