Alleghany Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Clifton Forge, Virginia.
- Location
- 1725 Main Street, Clifton Forge, Virginia 24422
- CMS Provider Number
- 495141
- Inspections on file
- 14
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Alleghany Health And Rehab during CMS and state inspections, most recent first.
A resident was moved to a new room without being provided a consent form or proper notification to the resident or their representative. Staff interviews confirmed that the required process for room changes, including obtaining permission and documenting the reason for the move, was not followed. The clinical record lacked evidence of notification or consent, and the only documentation was a note about the resident's belongings being moved.
Facility staff failed to conduct thorough investigations into two separate allegations of inappropriate touching between residents. In both cases, required written witness statements from involved staff and residents were not obtained, and key details were omitted or inaccurately documented in the investigation reports. Facility policy requiring comprehensive documentation and witness statements was not followed.
Staff did not implement recommended behavioral interventions for a resident with inappropriate sexual behaviors, failing to update the care plan and communicate with the NP. Additionally, after an unwitnessed fall, another resident did not receive all required neuro checks, with missing documentation confirmed by the DON. Both deficiencies reflect failures to follow professional standards and facility policy.
Facility staff did not update care plans with fall prevention interventions for two residents after documented falls, despite multiple incidents and facility policy requiring such updates. The DON acknowledged the requirement but could not provide evidence that interventions were implemented.
Staff failed to maintain a sanitary environment in two units, with one bathroom found with dried feces around the commode and a resident's room observed with moist, puckered wallpaper and a strong urine-like odor. The housekeeper reported inadequate cleaning tools and difficulty accessing areas due to personal belongings, while the DON and RDCS confirmed the odor and moisture in the affected room.
The facility failed to protect residents from abuse and neglect, resulting in psychosocial harm. A resident's ongoing aggressive and sexually inappropriate behavior created a hostile environment, affecting other residents. Despite awareness of the behavior, staff interventions were insufficient, allowing the resident unrestricted access to others. Additionally, a resident's report of verbal abuse and neglect by a CNA was not properly addressed as an abuse allegation.
The facility failed to implement abuse policies and procedures, protect residents from aggressive behaviors, and conduct thorough investigations. A resident with known aggressive behaviors verbally abused another resident, causing psychosocial harm. Despite staff awareness, interventions were inadequate. In another case, a resident reported verbal abuse and neglect by a CNA, but the facility administrator treated it as a grievance, failing to report or investigate it. Additionally, the facility did not obtain a criminal background check for the interim administrator within 30 days of employment.
The facility failed to provide appropriate treatment and services to two residents with mental disorders and a history of trauma. One resident, with a known history of trauma, did not receive trauma-informed care, and her triggers were not identified, leading to ongoing distress due to another resident's abusive behaviors. The other resident, with a long-standing mental health history, was not seen routinely by a psychiatric provider, and his behaviors were inadequately managed, contributing to an Immediate Jeopardy situation.
The facility failed to post daily staffing information, with outdated postings observed in the lobby and time clock area. The DON confirmed the absence of current postings, and the regional VP of clinical noted system issues, instructing the HR director to handwrite postings, which was not done effectively.
The facility failed to protect residents from abuse and did not fully implement its abuse policy, affecting multiple residents. A resident with a history of trauma was subjected to ongoing verbal and mental abuse by another resident, while another resident reported verbal abuse and neglect by a CNA. Despite being aware of these issues, the facility administrator and staff did not take effective corrective measures or conduct thorough investigations, resulting in ongoing abuse and fear among residents.
The facility failed to provide evidence of an annual review of its facility assessment and did not involve direct care staff, residents, or family members in the process. A review revealed outdated data and a lack of documentation on participant involvement, with the Administrator and RVPO unable to provide further details.
The facility failed to maintain an active transfer agreement with a hospital, as required by federal regulation F843. During a survey, the administrator could not provide a current agreement, despite the facility's resident population having significant medical needs, including dementia and behavioral health issues. Outdated agreements from 2009 and 2006 were submitted, which were not valid under the current ownership.
The facility failed to provide a daily activity program for residents in the memory care unit. Interviews revealed that activities were not conducted daily, and the activity calendar was not consistently followed. Staff and residents expressed concerns about the lack of activities, with only two residents participating in activities in January. The facility's policy required daily activities to meet residents' needs, but this was not adhered to, resulting in the deficiency.
The facility failed to conduct timely annual performance reviews for a CNA, as required by policy. The CNA was hired in June 2022, but the first evaluation was only completed in January 2025, after surveyor intervention. The DON acknowledged the importance of these evaluations for monitoring performance and discussing improvement areas. The issue was discussed with facility leadership.
The facility failed to ensure ongoing psychiatric services for residents across all nursing units from October 2024 to January 2025. During this period, only one telehealth visit occurred, and mental health issues were managed by on-site medical providers. The facility had no routine psychiatric provider until a new one began visiting in late January 2025.
The facility failed to report and address multiple abuse allegations involving residents. One resident was repeatedly abused by another, with incidents documented but not reported. Another resident exhibited ongoing abusive behavior affecting others, which was not reported to authorities. Additionally, a resident reported verbal abuse and neglect by a CNA, but the facility did not treat it as an abuse allegation. The facility's policies for reporting abuse were not followed.
The facility failed to investigate allegations of abuse and neglect involving two residents. One resident reported verbal abuse by another resident, but the investigation was incomplete, lacking staff interviews and consideration of other complaints. Another resident alleged verbal abuse and neglect by a CNA, but the administrator dismissed it as a customer service issue, resulting in no investigation. This was contrary to the facility's abuse policy.
The facility failed to update care plans for two residents after one resident exhibited aggressive and inappropriate sexual behavior towards another. Despite staff awareness and an internal investigation, the care plans were not revised to address the ongoing issues. The care plan coordinator acknowledged the need for updates but could not explain the oversight.
The facility failed to provide necessary behavioral health services to two residents, one of whom was a trauma survivor with multiple psychiatric conditions and the other with a long-standing history of mental health issues. The trauma survivor reported feeling threatened by another resident and had not been seen by a mental health professional since September 2024. The other resident, known for behavioral issues, had not received regular psychiatric care since a hospitalization in December 2024. The facility lacked an on-site psychiatric provider since mid-October 2024, leading to inadequate behavioral health support.
The facility failed to serve meals at appetizing temperatures, as observed during a lunchtime meal where hot foods like a cheeseburger and mashed potatoes were served below the required temperature. The regional dietary manager confirmed the meal was not appetizing, and resident interviews supported the issue, noting food was often cold and menus not followed. Facility documentation required food to be served at proper temperatures, which was not met.
The facility failed to provide mandatory QAPI training for the DON, as identified during a survey of 10 employee records. The surveyor found that the DON had not completed the required training for 2024, only completing it after the surveyor requested the records. This deficiency was communicated to the regional VP of operations, the administrator, and the DON.
The facility failed to provide the required annual infection control training for the DON, who also served as the infection preventionist. During a survey, it was found that the DON had not completed her training for 2024, although she had proof for 2023. An interview confirmed her belief that she had completed the training, but no documentation for 2024 was available.
Failure to Notify and Obtain Consent for Resident Room Change
Penalty
Summary
Facility staff failed to notify a resident or their representative of a room change, as required by facility policy and regulatory standards. The resident was moved to a new room without being provided a room change consent form, and no signature was obtained to document agreement to the move. Interviews with the resident revealed initial confusion and reluctance about the move, which was later explained by staff as necessary for safety reasons. However, there was no documentation in the clinical record or facility paperwork to show that the resident or their representative was notified or that consent was obtained prior to the room change. Further review of facility documentation and interviews with staff, including the Social Worker Director, Administrator, and DON, confirmed that the standard process for room changes was not followed in this instance. The facility's own policy requires notification of the resident's legal representative at least twenty-four hours in advance, documentation of the reason for the change, and the resident's and roommate's reactions, none of which were completed. The only documentation found was a note indicating the resident's belongings had been moved, with no evidence of notification or consent.
Failure to Conduct Accurate Investigations of Abuse Allegations
Penalty
Summary
Facility staff failed to conduct accurate and thorough investigations into allegations of inappropriate touching between two residents. In the first incident, a resident reported that another resident touched her thigh in the hallway while she was writing a letter. The administrator, who was present at the time of the report, dismissed the possibility of the incident based on her own observations of the physical setup and the alleged perpetrator's routine. The investigation lacked written witness statements from both the staff member who reported the incident and the residents involved, as required by facility policy. In a second incident, the same resident reported being inappropriately touched by the same alleged perpetrator while in the weight room. Staff immediately separated the residents and provided follow-up care, including psychological services and changes to room assignments to ensure safety. However, the investigation into this incident was also incomplete. It did not include statements from the residents involved or from a Certified Nursing Assistant who witnessed the event, although the CNA's statement was later provided. Additionally, the investigation inaccurately documented the details of the incident and omitted relevant information from the nurse practitioner who followed up with the resident. Facility documentation reviews revealed that the required procedures for investigating abuse allegations were not followed. The facility's policies mandate obtaining written statements from all involved parties and witnesses, as well as accurate and detailed reporting of the events. In both incidents, these requirements were not met, resulting in incomplete and inaccurate investigations of the alleged violations.
Failure to Implement Professional Standards and Care Plan Updates
Penalty
Summary
Facility staff failed to follow professional standards of care for two residents. For one resident with a history of inappropriate sexual behaviors, the nurse practitioner recommended interventions such as providing visual aid materials and allowing private time to help manage the behaviors. However, these recommendations were not implemented, and the care plan was not updated to reflect these interventions. The nurse practitioner was not informed that her recommendations had not been carried out, and the care plan only included 15-minute checks and instructions to notify the physician if behaviors continued, omitting the suggested behavioral interventions. Facility policy required that care plans be updated and that staff notify clinical leadership if interventions could not be implemented, but this was not done. For another resident who experienced an unwitnessed fall, staff failed to complete and document all required neurological checks following the incident. The facility's fall management procedure required consistent neuro checks after a fall, but documentation showed that these checks were missing on some days. The Director of Nursing confirmed the absence of neuro check documentation, indicating that the facility did not follow its own procedures for post-fall assessment and monitoring.
Failure to Implement Fall Interventions on Care Plans
Penalty
Summary
Facility staff failed to implement fall prevention interventions for two residents following documented falls. For one resident, clinical record review showed a fall occurred, but no new interventions were added to the care plan as required. The Director of Nursing (DON) confirmed that interventions should be added to the care plan but was unable to provide evidence that this was done. The facility's own policy, which requires immediate team meetings and updating care plans with new interventions after a fall, was not followed. Another resident experienced multiple falls over several months, yet the care plan was not updated with new interventions after any of these incidents. The DON again acknowledged the requirement but could not show that interventions were implemented. Facility documentation reviewed confirmed that staff are required to establish and implement new interventions on the care plan after a fall, but this procedure was not followed for either resident.
Failure to Maintain Sanitary Environment in Resident Rooms and Bathrooms
Penalty
Summary
Facility staff failed to maintain a sanitary environment on two of three units, as evidenced by direct observations and interviews. In one instance, a bathroom in room B6 was found with dried brownish material consistent with feces on the base of the commode, the floor around the commode, and down the side of the commode. The housekeeper responsible for cleaning the area acknowledged the presence of feces and expressed concerns about inadequate cleaning tools and the inability to thoroughly clean due to restrictions on handling personal belongings. She also indicated that sometimes the rooms are not cleaned as thoroughly as they should be. In another instance, a resident's room on A wing (room A6) was observed to have puckered and moist wallpaper, accompanied by an odor resembling cat urine. The resident reported difficulty sleeping due to the odor and stated that staff attributed the issue to a possible roof leak or an animal or person urinating in the corner. The Maintenance Director confirmed the wallpaper was puckered and moist but did not detect an odor at the time. The DON and RDCS, upon entering the room, confirmed the presence of the odor and the moist wall. No formal policy for room sanitation and cleanliness was provided, only a form titled "Job to be done. Complete room cleaning."
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility staff failed to protect residents from abuse and neglect, resulting in psychosocial harm for two residents. On two of the three nursing units, residents were subjected to a hostile environment due to the ongoing aggressive and sexually inappropriate behavior of a resident. This resident made verbal threats of physical harm and death, as well as sexual comments, which affected other residents. Despite numerous documented incidents of aggressive behavior, including threats to blow up the building and harm others, the facility did not implement adequate safeguards to protect the residents. The staff was aware of the resident's behaviors, yet interventions were insufficient, and the resident continued to have unrestricted access to other residents. One resident, who had a history of trauma and mental health issues, reported feeling unsafe and was observed to be visibly distressed by the aggressive resident's behavior. The facility's documentation revealed a pattern of the aggressive resident's behavior, including making sexual comments and threats, which were not effectively addressed by the staff. The facility's social worker and other staff members were aware of the situation but failed to implement effective interventions to prevent further harm. Additionally, another resident reported an allegation of verbal abuse and neglect by a CNA, which was not appropriately identified or addressed as an abuse allegation by the facility. The resident expressed distress over the incident and hesitated to use the call light due to fear of further negative interactions. The facility administrator treated the incident as a customer service issue rather than an abuse allegation, and the CNA involved continued to work without any suspension or restriction.
Failure to Implement Abuse Policies and Conduct Investigations
Penalty
Summary
The facility staff failed to implement abuse policies and procedures to protect residents from aggressive behaviors, report instances of abuse, conduct thorough investigations, and implement appropriate safeguards. Resident #16, known for aggressive behaviors, verbally abused Resident #8, causing psychosocial harm. Despite staff awareness of Resident #16's behaviors, interventions were inadequate, and 15-minute checks were discontinued prematurely. Resident #16's history of aggression and threats was documented, yet no effective measures were taken to protect other residents, including Resident #8, from ongoing abuse. In another incident, the facility staff failed to protect Resident #17 from verbal abuse and neglect by a CNA. The resident reported the incident, but the facility administrator treated it as a grievance rather than an abuse allegation, failing to report or investigate it. The CNA continued to work without suspension, having access to Resident #17 and other residents. The facility's response to the incident was inadequate, as the administrator considered it a customer service issue rather than abuse. Additionally, the facility staff failed to obtain a criminal background check for the interim administrator, who also served as the abuse coordinator, within 30 days of employment. This oversight was discovered during a survey, and the administrator was suspended until a background check was completed. The facility's hiring policy requires background checks before employment, but this was not followed, leading to noncompliance with regulatory requirements.
Removal Plan
- Resident #16 was placed on 1:1 supervision to protect residents #2, #8, and #18. Resident #16 medications reviewed, and changes made to psychotropic dosing.
- FRI submitted and investigation initiated based on Resident #17 allegation identified by surveyor. The alleged employee was immediately suspended protecting Resident #17 and investigation initiated.
- Education will be completed with all current staff in the facility on the Abuse Policy which includes reporting and completing a thorough investigation. Staff not currently in the facility will not be able to work until education is completed.
- NHA conducting interviews with employees and residents related to resident #16 FRI.
- Current residents on A wing and B wing will be interviewed by the Regional President of Operations & Regional Clinical Director and other IDT members to determine if they had experienced any type of abuse, mental and/or sexually inappropriate, or lewd, aggressive, hostile or threatening comments that have been made toward them or others resulting in fear or feelings of being unsafe from either staff, residents or other visitors. Residents who are not interviewable will have a head-to-toe assessment.
- Medical Director notified.
Deficiency in Care for Residents with Mental Disorders and Trauma
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to two residents with mental disorders and a history of trauma, leading to deficiencies in their care. Resident #8, who had a known history of trauma, did not receive trauma-informed care to attain her highest practicable mental and psychosocial well-being. Despite having a care plan that included interventions such as psychiatric services and medication management, there was no evidence of identification of her triggers or interventions regarding another resident's repeated abusive behaviors towards her. Resident #8 reported feeling threatened and unsafe due to the actions of Resident #16, which exacerbated her anxiety and fear. Resident #16, who had a long-standing mental health history, was not being seen routinely by a psychiatric provider, and his care plan was not adequately updated to address his behaviors. Despite staff being aware of his inappropriate and aggressive behaviors, including making targeted sexual comments to Resident #8, the facility failed to implement effective interventions to manage his behaviors. The facility's response to his behaviors was limited to 15-minute checks and offering snacks, without any non-pharmacological safeguards to prevent further abusive behaviors. The facility's failure to ensure residents with mental disorders and a history of trauma received appropriate treatment and services resulted in an Immediate Jeopardy situation. The survey team identified that the facility did not have a consistent psychiatric provider on-site, and there was a lack of timely psychiatric services for residents like Resident #16. The facility's inaction and inadequate care planning contributed to the ongoing distress and safety concerns for Resident #8, highlighting significant deficiencies in the facility's approach to managing residents with complex mental health needs.
Removal Plan
- Psychosocial assessments were completed for Resident #8 and psych services were on-site to see the resident.
- Psychiatric services were onsite to see Resident #16. Completed review of Resident #16 medications and changes made to psychotropic dosing. Resident has been placed on 1-1 to provide diversion if behaviors are exhibited.
- Identify residents that have exhibited behaviors, residents with the diagnosis of PTSD, residents with a history of trauma and/or a mental disorder. The care plans of those residents identified will be reviewed to ensure they have the appropriate interventions and updated as indicated. They will also refer to psych services as indicated.
- All current residents will be reviewed to ensure they have received a trauma screening to identify triggers and care plans updated as indicated.
- Medical Director notified.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility staff failed to post daily staffing information, which is required for residents and visitors to view. During a walkthrough, the surveyor observed that the staffing postings in the lobby and time clock area were outdated, with dates from several days prior. The Director of Nursing (DON) confirmed the absence of current postings and acknowledged that the human resource director was responsible for updating them. The regional vice president of clinical mentioned that due to system issues, the human resource director was instructed to handwrite the daily postings, but this was not done effectively.
Failure to Protect Residents from Abuse and Implement Abuse Policy
Penalty
Summary
The facility staff failed to effectively administer the facility to ensure residents were free from abuse and did not fully implement their abuse policy, affecting residents on two of three nursing units. Resident #8, who had a history of trauma and abuse, was subjected to verbal and mental abuse by Resident #16, who exhibited ongoing aggressive and inappropriate behaviors. Despite being aware of these behaviors, the facility administrator and staff did not implement effective corrective measures to protect Resident #8 and other residents sharing common areas with Resident #16. The facility's documentation and interviews revealed that staff were aware of Resident #16's behaviors, yet interventions were inadequate, and the facility failed to conduct thorough investigations or implement necessary safeguards. Resident #16's chart documented numerous incidents of aggressive behavior, including threats and physical altercations with other residents. Despite these documented incidents, the facility did not take appropriate action to protect residents or investigate the incidents as required by their abuse policy. The facility administrator and staff were not fully aware of the severity of Resident #16's behaviors, and there was no evidence of psychiatric follow-up or appropriate medication management for Resident #16. The facility's failure to address these issues resulted in ongoing abuse and fear among residents, particularly Resident #8, who expressed feeling unsafe and traumatized by Resident #16's actions. Additionally, Resident #17 reported an allegation of verbal abuse and neglect by a certified nursing assistant, which resulted in psychosocial harm. The facility administrator reviewed and signed off on the grievance without effectively responding to the allegations, treating it as a customer service issue rather than an abuse allegation. The facility's abuse policy required immediate reporting and investigation of such allegations, but the administrator failed to follow these procedures. As a result, the certified nursing assistant continued to work without suspension or restriction, and the facility did not implement measures to protect residents from further abuse.
Lack of Annual Review and Stakeholder Involvement in Facility Assessment
Penalty
Summary
The facility staff failed to provide credible evidence that the facility assessment was reviewed at least annually and did not ensure the involvement of appropriate participants in the assessment process. This deficiency was identified during a review conducted on January 27, 2025, which revealed a lack of documentation indicating when the facility assessment was last reviewed and who participated in the process. The data within the assessment included outdated Quality Measure reports from December 2018 to February 2019 and more recent reports from August 2023 to October 2023. However, there was no evidence of active involvement from direct care staff, residents, resident representatives, or family members in the development or review of the facility assessment. The facility's Administrator and Regional Vice President of Operations were unable to provide further information regarding the review process or the participants involved. They assumed the assessment was discussed around July 2024, when it was uploaded online, but lacked evidence to support this claim. A meeting with the facility administrator, Director of Nursing, and corporate management staff confirmed the absence of credible evidence of involvement from key stakeholders in the assessment process. The facility's policy on facility assessment outlined the need for annual review and involvement of the governing body, but no additional information was provided to demonstrate compliance with these requirements.
Lack of Active Hospital Transfer Agreement
Penalty
Summary
The facility staff failed to maintain an active transfer agreement with a hospital, which is a requirement under federal regulation F843. This deficiency was identified during a survey conducted on January 27, 2025, when the facility administrator was unable to provide a current transfer agreement upon request. The survey team sought clarification from the administrator and corporate staff regarding the necessity of the transfer agreement, which is crucial for ensuring that residents can be moved quickly to a hospital when they require medical care. The facility's assessment indicated a resident population with significant medical needs, including 66 residents with dementia, 9 with sundowners, and 32 with behavioral health diagnoses. Despite these needs, the facility did not have an active transfer agreement with any hospital for psychiatric or emergency medical services. The administrator later submitted outdated agreements from 2009 and 2006, which were not valid under the current ownership, further highlighting the lack of compliance with the required regulations.
Failure to Provide Daily Activities in Memory Care Unit
Penalty
Summary
The facility staff failed to provide an ongoing activity program to meet the needs of residents on the memory care unit. Interviews with staff and residents revealed that activities were not conducted daily, and the activity calendar was not consistently followed. A Licensed Practical Nurse (LPN) noted the absence of a January activity calendar and mentioned that the activity director did not visit the unit daily, leading to residents feeling bored and neglected. The activity director assistant confirmed that activities were only conducted three to four times a week, not daily, as expected. Residents expressed dissatisfaction with the lack of activities, stating that scheduled activities like devotions were not conducted as planned. A review of the activity participation records for the 27 residents on the memory care unit showed that only two residents participated in activities in January, while the rest had no recorded participation. The activity calendar for January showed only three to four activities per week, with several days lacking scheduled activities. Previous months had more frequent activities, but staff reported that some scheduled activities never took place. The facility's grievance log contained several complaints about the lack of activities and failure to adhere to the calendar. The facility's policy stated that activities should meet various resident needs and be scheduled daily, but this was not being followed, leading to the deficiency.
Failure to Conduct Timely Annual Performance Reviews for CNA
Penalty
Summary
The facility staff failed to conduct annual performance reviews for a certified nursing assistant (CNA #14) as required. CNA #14 was hired on June 12, 2022, and the first evaluation in her record was completed on January 27, 2025, which was after the surveyor had requested the employee files. This indicates that the annual evaluation was not conducted in a timely manner. During an interview, the Director of Nursing (DON) acknowledged that the purpose of the annual evaluations was to monitor the employee's performance and discuss areas needing improvement. The facility's policy on performance evaluations states that these evaluations provide a formal opportunity for supervisors and employees to discuss work performance and developmental areas related to the job description. The deficiency was discussed with the administrator, regional vice president of operations, and the DON during an end-of-day meeting.
Failure to Provide Consistent Psychiatric Services
Penalty
Summary
The facility staff failed to utilize outside resources to ensure ongoing psychiatric services were available to residents needing such services. This deficiency affected residents across all three nursing units. The facility did not have a routine psychiatric provider from October 2024 until January 23, 2025. During this period, only one telehealth psychiatric visit was conducted, and mental health issues were managed by the medical providers on-site. The lack of a consistent psychiatric provider was confirmed during an interview with the medical nurse practitioner, who stated that there had been no on-site psychiatric provider since their tenure began. The facility's assessment indicated that there were 66 residents with dementia, 9 with sundowners, and 32 with a behavioral health diagnosis, with 32 residents being seen by behavioral health services. Despite this, the facility did not have a psychiatric provider available on-site or through telehealth consistently during the specified period. The facility administrator and Regional Vice President of Operations reported that routine psychiatric services were available until the provider resigned in mid-October 2024, and a new provider only began visiting the facility on January 24, 2025.
Failure to Report and Address Abuse Allegations
Penalty
Summary
The facility staff failed to implement policies and procedures for reporting reasonable suspicion of abuse, resulting in the failure to protect residents from further potential abuse. Resident #8 was a victim of abuse by another resident, Resident #16, on multiple occasions. Despite being cognitively intact and reporting incidents of verbal and physical threats, the facility did not report these occurrences to the state survey agency or other authorities as required. The clinical records of both residents documented several instances of aggressive behavior by Resident #16, including threats to harm Resident #8, but these were not reported as abuse. Resident #16 exhibited ongoing behavioral outbursts that adversely affected other residents. The facility documentation revealed multiple instances of abusive behavior by Resident #16, including making obscene sexual comments, threatening staff and residents, and physical aggression. Despite these documented behaviors, the facility staff failed to report these incidents to the appropriate agencies. The facility administration was unaware of the severity of Resident #16's behaviors until informed by the survey team. Resident #17 reported an allegation of verbal abuse and neglect by a certified nursing assistant, which resulted in psychosocial harm. The facility staff did not identify the incident as an allegation of abuse and failed to report it as required. The resident expressed emotional distress and hesitance to use the call light due to the staff member's behavior. The facility's social worker believed the incident rose to the level of abuse and neglect, but the administrator treated it as a grievance rather than an abuse allegation. The facility's abuse policy outlines the procedure for reporting abuse, but it was not followed in this case.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility staff failed to conduct a thorough investigation into allegations of abuse and neglect involving two residents. For Resident #8, who reported being verbally abused by another resident, the facility's investigation was inadequate. The incident reportedly occurred in a common area with other residents present, yet the investigation only included interviews with the involved residents and one other resident, omitting interviews with staff or other potential witnesses. Additionally, another resident had previously expressed concerns about the alleged perpetrator's behavior, which was not considered in the investigation. For Resident #17, who alleged verbal abuse and neglect by a certified nursing assistant (CNA), the facility did not initiate an investigation. The resident reported that the CNA was rude and refused to provide a requested shower, leading to emotional distress. Despite the social worker's belief that the incident constituted abuse and neglect, the facility administrator treated it as a customer service issue and did not report or investigate the allegations. The CNA continued to work without any restrictions following the report. The facility's failure to investigate these allegations is contrary to their abuse policy, which requires all reported events to be investigated by the Director of Nursing and forwarded to the administrator for further action. The administrator's decision to dismiss the allegations as poor customer service resulted in a lack of appropriate response to potential abuse and neglect.
Failure to Revise Care Plans Following Resident Aggression
Penalty
Summary
The facility staff failed to review and revise the care plans for two residents, Resident #8 (R8) and Resident #16 (R16), following multiple incidents of aggressive behavior and inappropriate sexual comments by R16 towards R8. R8, who was cognitively intact, reported feeling threatened and uncomfortable due to R16's behavior, which included threats of physical harm, inappropriate sexual comments, and physical aggression. Despite these ongoing issues, R8's care plan, which initially noted discomfort from other residents' comments, had not been updated since May 2024 to address the specific threats and inappropriate behavior from R16. R16's care plan, last revised in April and May 2024, identified behaviors such as foul language and verbal threats but did not include any updates or interventions following the reported incidents involving R8. Staff interviews revealed that multiple staff members were aware of R16's long-standing behaviors, including making sexual comments and threats, yet no revisions were made to either resident's care plan to address these issues. The facility's internal investigation into R16's behavior towards R8 began in January 2025, but the care plans remained unchanged. The care plan coordinator, RN #4, acknowledged that care plans should be reviewed quarterly and revised as needed, especially following incidents. However, she was unable to explain why the care plans for R8 and R16 were not updated. The facility's policy required the interdisciplinary team to review and update care plans at least every 90 days and after significant changes, but this was not adhered to in the case of R8 and R16. The survey team discussed these deficiencies with the facility's administration, but no additional information was provided.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to two residents, R8 and R16, as identified during a survey. R8, a trauma survivor with multiple psychiatric conditions, reported feeling threatened by another resident, R16, and expressed concerns about her safety. Despite having a care plan that included psychiatric services and medication management, R8 had not been seen by a mental health professional since September 2024, leading to a gap in her behavioral health care. R8's history of trauma and her current experiences with R16 were not adequately addressed by the facility, contributing to her ongoing distress. R16, who also had a long-standing history of mental health issues, was not receiving regular psychiatric care. His clinical record indicated diagnoses such as schizoaffective disorder and major depressive disorder. After a hospitalization in December 2024 due to threatening behaviors, R16 had not been seen by a psychiatric provider since his readmission to the facility. The facility's lack of consistent psychiatric services for R16, despite his known behavioral issues, further exemplified the deficiency in providing necessary behavioral health care. The facility's interim administrator and Regional Vice President of Operations acknowledged the absence of an on-site psychiatric provider since mid-October 2024, which contributed to the lack of regular psychiatric care for both residents. Although telehealth services were utilized for acute needs, the facility's plan for psychiatric services was not effectively implemented, resulting in inadequate behavioral health support for R8 and R16. This deficiency highlights the facility's failure to meet the behavioral health needs of its residents, as required by regulations.
Failure to Serve Meals at Appetizing Temperatures
Penalty
Summary
The facility staff failed to provide meals at an appetizing temperature for residents on one of three units. During a lunchtime meal observation, the surveyor noted that the hot foods served, specifically a cheeseburger and mashed potatoes, did not reach the appropriate temperatures to be considered appetizing. The cheeseburger was recorded at 90 degrees, and the mashed potatoes at 120 degrees, both below the required temperature to ensure palatability. The regional dietary manager, present during the observation, confirmed that the meal was not appetizing in appearance, taste, or temperature, as evidenced by the unmelted cheese on the burger. Interviews with residents further corroborated the issue, with one resident describing the food as "lousy and lukewarm" and another stating that the food is often cold and menus are not followed. Facility documentation reviewed during the survey indicated that food should be served at proper temperatures, outside the danger zone, which was not adhered to in this instance. The deficiency was discussed in an end-of-day meeting with the facility's administration, but no additional information was provided before the exit conference.
Failure to Provide QAPI Training for Director of Nursing
Penalty
Summary
The facility staff failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training for the director of nursing, as identified during a survey of 10 employee records. The surveyor requested the employee files on January 27, 2025, and upon review on January 28, 2025, it was found that the director of nursing had not completed the required QAPI training for the year 2024. The training was only completed on the morning of January 28, 2025, after the surveyor had requested the training records. This deficiency was communicated to the regional vice president of operations, the administrator, and the director of nursing during a meeting on January 28, 2025.
Infection Control Training Deficiency for DON
Penalty
Summary
The facility staff failed to provide the required annual infection control training for the director of nursing, who also served as the infection preventionist. During a survey, the surveyor requested and reviewed 10 employee files for training compliance. It was discovered that the director of nursing had not completed her annual infection control training for the year 2024, although she was able to provide proof of completion for the year 2023. An interview with the director of nursing confirmed her belief that she had completed the training annually, but no documentation for 2024 was available. A meeting with the regional vice president of operations, the administrator, and the director of nursing was held to discuss the issue, but no additional information was provided before the exit conference.
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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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