Annandale Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Annandale, Virginia.
- Location
- 6700 Columbia Pike, Annandale, Virginia 22003
- CMS Provider Number
- 495155
- Inspections on file
- 16
- Latest survey
- October 16, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Annandale Healthcare Center during CMS and state inspections, most recent first.
A facility failed to assess residents' safety for independent leave, leading to a serious incident where a resident was involved in a hit-and-run accident. Despite high BIMS scores, residents with physical limitations and histories of intoxication were allowed to leave without proper safety evaluations. The facility's reliance on cognitive assessments and inadequate leave of absence procedures contributed to the deficiency.
Two residents in a facility did not receive scheduled medications, and the physician was not notified, leading to a deficiency. One resident missed multiple doses of various medications over several months, often due to being out on leave or intoxicated. Another resident missed an antibiotic dose due to pharmacy delays. Staff interviews revealed a lack of communication and awareness regarding these missed medications.
The facility failed to maintain a homelike environment, with staff yelling across rooms, unclean toilets, marijuana odors in hallways, and black film in shower rooms. A resident found the noise disruptive, while another was dissatisfied with the toilet cleanliness. The director of housekeeping confirmed the issues, and administrative staff were informed without further action reported.
The facility failed to maintain complete grievance records for 2022, as required by policy. The regional director of operations admitted that the social worker responsible for these records was no longer employed, and only partial grievance forms were found. The current director of social services confirmed that grievances should be documented and stored, but this was not done for 2022.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. A resident's activity preferences were not documented, another's dietary needs were ignored, and lab tests were not conducted as ordered. Medications were missed for some residents, and incontinence care was not provided as required. Additionally, a resident's hand splint was misplaced, and antibiotics were unavailable for another. These issues highlight significant lapses in care plan execution.
The facility staff failed to update comprehensive care plans for several residents, including those involved in incidents of aggression and those receiving specific treatments. This lack of documentation was noted by various staff members, highlighting the importance of care plans in guiding care and ensuring staff awareness of resident needs.
Two residents in a facility were not provided with activities based on their preferences, leading to deficiencies. One resident, with Alzheimer's Dementia, had interests in music and outdoor activities, but there was no evidence of participation. Another resident expressed interest in spending time outdoors, but their care plan lacked activity information, and there was no documentation of outdoor activities. The facility's policy emphasizes resident-centered care, but the failure to align activities with preferences resulted in a deficiency.
The facility staff failed to implement bed rail requirements for four residents, lacking evidence of consent, alternatives attempted, and review of risks and benefits before installation. Observations confirmed the use of bed rails without proper documentation or physician's orders. Interviews with staff revealed a lack of awareness and documentation of necessary assessments and consents.
The facility failed to ensure timely physician visits for four residents, with significant gaps between visits. One resident did not see a physician for over a year, while others experienced delays beyond the required 60-day interval. The medical records employee was responsible for tracking visits, but the system in place did not effectively ensure compliance. The executive director, DON, and regional director were informed of these deficiencies.
The facility staff failed to perform necessary lab tests for two residents as ordered by their physicians. One resident did not receive Hemoglobin A1C, lipid, and CMP tests for several months, while another did not have a TSH test completed as scheduled. The process involved night nurses printing lab orders for an outside lab company, but records showed no results for the required tests, indicating a lapse in execution.
The facility staff failed to conduct required bed inspections for four residents, leading to a deficiency in identifying potential areas of entrapment in bed rails. Observations showed residents using bed rails, but no formal assessments were conducted to identify entrapment risks. Staff interviews revealed that assessments for entrapment risk should be done during the admission process, but this was not documented.
Two residents experienced a lack of dignity in their care. One resident waited ten minutes to be served lunch after their roommate, while another wore a shirt with personal information displayed on the front. A CNA acknowledged these issues, noting the importance of timely service and discreet labeling for maintaining dignity.
A resident was found with over-the-counter eye drops on her bedside table without an assessment for self-administration or a physician order, as required by facility policy. An LPN stated that residents cannot keep such medications at their bedside due to safety concerns. The facility's policy requires an assessment and physician order for self-administration, which were not documented for this resident.
A resident sustained an undisplaced fracture of the left fourth metacarpal, which was not reported to the state agency within the required two-hour timeframe. Despite the facility's policy mandating immediate reporting of such injuries, the incident was reported four days later. Interviews with administrative staff confirmed the reporting delay, which was identified during a survey.
The facility failed to provide written notification to residents and their representatives, as well as notify the ombudsman, upon hospital transfers for two residents. One resident was transferred due to critical lab values related to chronic kidney disease, and another due to a dislodged nephrostomy tube and acute mental status change. Staff interviews revealed that written notices were not consistently provided, and there was no evidence of ombudsman notification.
The facility failed to provide bed hold notices for two residents during hospital transfers, as required by policy. One resident was transferred due to chronic kidney disease complications, and another for a dislodged nephrostomy tube and mental status change. Documentation of the bed hold notice was missing in both cases, despite the procedure requiring it. Facility leadership was informed of these issues.
A facility failed to complete a resident's MDS assessment by missing the BIMS, a crucial cognitive evaluation. The oversight was acknowledged by the RN responsible, and the facility lacked a specific policy, relying instead on the CMS RAI manual for guidance.
Two residents were not provided with a written summary of their baseline care plans within the required timeframe after admission. Staff interviews revealed that the responsibility for developing and distributing the baseline care plan lies with the nursing and social services teams, but the social worker did not provide the necessary documentation. The facility's policy mandates that a summary of the baseline care plan be provided to residents and their representatives, but this was not adhered to in these cases.
A resident received Acetaminophen without Ibuprofen due to unclear physician orders, which were not clarified by the facility staff. Interviews with LPNs revealed confusion over the orders, and the facility policy lacked guidance on clarifying such orders. The issue was reported to the executive director, DON, and regional director of operations.
A resident's discharge plan was incomplete, lacking a recapitulation of their stay, a final summary of their status, and medication reconciliation. The discharge summary was missing several sections, and there was no evidence that the resident received necessary prescriptions or a signed discharge summary. An LPN involved in the discharge process could not recall details about the resident, and the facility's discharge planning policy was not followed.
A facility failed to provide adequate ADL care to a resident who was severely impaired and required extensive assistance for toileting. The resident was frequently incontinent, but documentation showed no evidence of incontinence care or toileting assistance during specific night shifts. The care plan required such assistance, but it was not documented, and staff interviews confirmed the lack of evidence. The deficiency was reported to the facility's leadership.
The facility staff failed to administer medications as ordered for two residents, leading to deficiencies in care. One resident did not receive Ciprofloxacin for a UTI due to unavailability, despite the medication being in the emergency backup system. Another resident missed a scheduled dose of Cefepime for a wound infection, even though the medication was delivered and signed for. These issues were reported to the facility's leadership.
A resident with a right hand contracture did not receive a recommended splint due to misplacement and lack of staff awareness. The occupational therapist had discharged the resident with a splint and instructions, but these were not transcribed into physician's orders, leading to the splint not being used.
A resident was observed with an external catheter without a physician order, and staff were unaware of its use. The MDS assessment did not indicate catheter use, and the clinical record lacked documentation. Interviews with a CNA and LPN revealed a lack of awareness and adherence to facility policy, which requires a physician order and regular care for external catheters.
The facility failed to ensure two CNAs completed the mandatory 12 hours of annual in-service training, with one completing only 3.6 hours and the other 8.1 hours. Despite having a system to track training, the oversight was acknowledged by the DON, who stated that staff are notified of their training needs and are responsible for completion.
A facility failed to provide necessary medically related social services for a resident with severe cognitive impairment and behavioral disturbances. Despite the resident's lack of family support and legal representation, the facility did not pursue outside services or guardianship. Observations and interviews revealed a lack of awareness and action from staff regarding the resident's needs, and the clinical record lacked evidence of attempts to locate family or assess the resident's decision-making capacity.
A resident did not receive a scheduled dose of Zosyn for osteomyelitis due to the pharmacy's failure to deliver the medication on time. The LPNs did not follow the facility's protocol to notify the physician or document the actions taken, resulting in a lapse in medication administration procedures.
A resident's medication regimen review recommendations by a pharmacist were not acted upon by the facility staff. The resident required a lipid panel and CMP, which were not completed, and had an ongoing order for Trazodone without a stop date, which was not reassessed in a timely manner. Communication breakdowns among staff contributed to the deficiency.
A facility failed to implement interventions to prevent unnecessary medication administration for a resident. An as-needed order for Trazodone was not addressed by the provider within the regulatory 14-day limit, leading to its continuation without a stop date. Staff interviews confirmed awareness of the requirement, but it was not followed. The facility's policy aimed to review drug regimen recommendations, but no further information was provided.
A significant medication error occurred when a resident did not receive a scheduled dose of Zosyn due to the medication not being available from the pharmacy. The antibiotic was prescribed for osteomyelitis, and staff interviews revealed that the physician was not notified of the missed dose, contrary to facility policy.
A resident with moderate cognitive impairment and left-sided weakness was not provided meals in the required bite-sized form, despite physician orders and meal ticket instructions. Interviews with staff revealed that CNAs were responsible for cutting the food, but the facility lacked a specific policy to ensure compliance.
A resident's medical record was incomplete due to missing dermatology consultation notes and culture results, despite physician orders and progress notes indicating dermatology visits. Staff interviews revealed a lack of follow-up to obtain necessary documentation, and the facility's policy did not provide guidance on maintaining accurate records. Key facility leaders were informed of the deficiency.
A facility staff member failed to implement appropriate infection prevention measures during wound care for a resident. The RN did not wear a protective gown, violating the resident's enhanced barrier precautions due to their IV therapy and wounds. Interviews confirmed that both gloves and a gown are required to prevent MDRO transmission. The RN acknowledged the oversight, and the facility's leadership was informed.
The facility failed to document QAPI training for an employee, as required by its policy. The director of rehabilitation stated that QAPI training is not mandatory for the therapy department, although they participate in QAPI meetings. The executive director, DON, and regional director were informed of the issue.
The facility failed to document behavioral health training for a staff member, OSM #13, as required. The director of rehabilitation indicated that such training is not mandated for the therapy department, relying instead on in-service training. The facility's policy includes an assessment of needs based on regulatory requirements. Key administrative staff were informed of the issue.
Failure to Assess Resident Safety for Independent Leave
Penalty
Summary
The facility staff failed to adequately assess and ensure the safety of residents leaving the facility independently, leading to a serious incident involving a resident. Resident #421, who had a history of falls, alcohol use, and major depressive disorder, left the facility on a leave of absence and was involved in a hit-and-run accident on a highway, resulting in life-threatening injuries. Despite being cognitively intact according to the BIMS assessment, the resident had functional limitations and a history of intoxication upon returning from previous leaves of absence. The facility's documentation and interviews revealed that there was no comprehensive assessment of the resident's ability to safely navigate outside the facility, particularly in high-risk areas like the highway. Another resident, #164, was observed maneuvering a motorized wheelchair in potentially dangerous areas, such as a service road and a parking lot, without a proper safety assessment. This resident also had a high BIMS score but suffered from hemiplegia, hemiparesis, and other conditions that could impair safe mobility. The facility's procedures for allowing residents to leave independently relied heavily on cognitive assessments like the BIMS, which do not evaluate a resident's ability to recognize and avoid danger. Interviews with staff, including the executive director and director of nursing, highlighted a lack of formal safety assessments for residents leaving the facility independently. The facility's process for managing leave of absence forms was inadequate, as it did not include a thorough evaluation of residents' physical and mental capabilities to ensure their safety outside the facility. Staff interviews indicated that the leave of absence orders were intended for residents to go out with family, yet residents were signing themselves out independently without proper oversight. The absence of a structured assessment process for evaluating residents' safety outside the facility contributed to the incidents involving residents #421 and #164, highlighting a significant deficiency in the facility's duty to protect its residents from accident hazards.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility staff failed to notify the physician of medications that were not administered for two residents, leading to a deficiency. For one resident, medications such as Gabapentin, Indomethacin, Methocarbamol, Lamotrigine, Methadone, Trazodone, and Doxycycline were not administered on multiple occasions from May 2024 through September 2024. The reasons for the missed doses included the resident being out on leave of absence, returning to the facility intoxicated, or the medications not being available. However, the facility's progress notes did not document any notification to the physician regarding these missed medications, which is a requirement according to the facility's policy. In another case, a resident did not receive a scheduled dose of Piperacillin Sod-Tazobactam, an antibiotic for osteomyelitis, because it had not arrived from the pharmacy. The LPN involved acknowledged that the physician was not notified of the missed dose, which is considered a medication error. The facility's policy requires that the physician be informed of any missed medications so they can adjust the order if necessary. Interviews with facility staff, including a registered nurse and the director of nursing, revealed a lack of awareness and communication regarding the missed medications. The staff stated that the physician should be notified if a medication is not administered, but there was no evidence of such notifications in the residents' records. The facility's policy emphasizes the importance of timely medical needs and physician awareness of risk factors when medications are not administered as scheduled.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility staff failed to maintain a homelike environment for several residents, as evidenced by multiple observations and interviews. For one resident, staff were heard yelling to each other across rooms, which was disturbing to the resident who was not cognitively impaired and found the noise disruptive to rest. Despite the resident's complaints, no policy was provided to ensure a clean, comfortable, and homelike environment, and administrative staff were made aware of the issue without further information provided. Another resident's toilet was found to be in an unclean state, with a brown substance identified as feces smeared on the outside of the toilet bowl. The resident, who was moderately cognitively impaired, expressed dissatisfaction with the cleanliness of the toilet, which had not been cleaned for some time. The director of housekeeping confirmed that the toilet was not clean or homelike and stated that CNAs were responsible for wiping feces before housekeepers could disinfect the toilet. Additionally, the facility failed to maintain clean and homelike conditions in the hallways and shower rooms. A marijuana odor was detected in the hallways on multiple occasions, and the unit manager acknowledged the odor was not clean or homelike. In three shower rooms, a black film was observed on the tiles and walls, indicating inadequate cleaning. The director of housekeeping noted that the lack of air circulation contributed to the growth of the film, and the shower rooms required more attention from housekeeping staff. Administrative staff were informed of these concerns, but no further information was provided before the survey exit.
Failure to Maintain Grievance Records for 2022
Penalty
Summary
The facility staff failed to maintain evidence of grievances for the year 2022, as required by their policy. During a survey, grievance/concern forms for 2022 were requested but could not be fully provided. The regional director of operations acknowledged that the social worker responsible for these records in 2022 was no longer employed, and the staff were unable to locate all the grievance forms from that year. Only partial forms were found, despite the knowledge that more grievances had been completed. The current director of social services confirmed that grievances and their resolutions should be documented and stored in the social services office. The facility's policy mandates that evidence of grievance resolutions be kept for three years, but this was not adhered to for 2022.
Deficiencies in Care Plan Implementation Across Multiple Residents
Penalty
Summary
The facility staff failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. For Resident #228, the staff did not create a care plan for activities despite the resident expressing interest in outdoor activities and walking. The activities director acknowledged that many residents' activity care plans were incomplete, and the executive director and director of nursing were informed of this issue. Similarly, Resident #170's care plan for nutrition was not implemented, as the resident's meals were not prepared according to the dietary instructions, which required food to be cut into bite-sized pieces due to the resident's cognitive impairment and physical limitations. Resident #74's care plan for obtaining laboratory tests was not followed, as there was no evidence of the required TSH test being conducted as ordered. The facility's process for lab testing involved an outside lab company, but there was no documentation of the test being completed or any refusal by the resident. Additionally, Resident #421 did not receive scheduled medications, including antidepressants and antibiotics, on multiple occasions. The facility failed to notify the physician of these missed doses, and the resident's leave of absence was not managed to ensure medication administration. Other residents also experienced deficiencies in care plan implementation. Resident #219 did not receive incontinence care as documented in their care plan, with no evidence of care provided on specific night shifts. Resident #4 did not receive a scheduled dose of intravenous antibiotics due to a delay in pharmacy delivery. Resident #62's care plan for a resting hand splint was not implemented, as the splint was misplaced, and there was no documentation of its use. Lastly, Resident #82 did not receive a prescribed antibiotic dose for a urinary tract infection because it was not available, despite an emergency backup system being in place. These failures highlight significant lapses in care plan development and execution across multiple areas of resident care.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plans for five residents, leading to deficiencies in care documentation and planning. For one resident, the care plan did not include information about the use of bed rails, despite the resident being observed with them in use. This omission was noted by a registered nurse who emphasized the importance of care plans in guiding staff actions and ensuring proper care. Two residents who were involved in incidents of hitting other residents did not have their care plans reviewed or revised following these events. Despite being transferred to another unit and evaluated by a psychiatrist, the care plans remained unchanged, which was highlighted as a concern by the director of social services. This lack of revision could hinder staff awareness and intervention strategies for managing such behaviors. Another resident who was hit by other residents on two occasions also had no updates made to their care plan, which could affect staff's ability to address safety concerns and provide appropriate support. Additionally, a resident receiving treatment for a urinary tract infection did not have this treatment documented in their care plan, as noted by a licensed practical nurse. These failures in updating care plans were brought to the attention of the facility's executive director and director of nursing.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility staff failed to provide activities based on resident preferences for two residents, leading to deficiencies in meeting their psychosocial needs. For one resident, the facility did not offer activities aligned with their comprehensive assessment and care plan preferences. The resident, who was severely impaired in making daily decisions due to Alzheimer's Dementia, had expressed interests in music, group activities, and spending time outdoors, among others. However, there was no evidence of participation in these activities, and the activities director confirmed that records of activity participation were not maintained prior to her tenure. Another resident expressed a current interest in spending time outdoors, as documented in their activity preference interview. However, the comprehensive care plan did not include information regarding activities, and there was no documentation of the resident spending time outdoors during their stay. The activities director stated that the resident was content indoors, but there was no record of the resident being offered or refusing outdoor activities. The facility's policy on activities programs emphasizes providing resident-centered care that meets the psychosocial, physical, and emotional needs of residents. Despite this, the facility failed to document and provide activities that aligned with the residents' expressed preferences, resulting in a deficiency. The executive director and director of nursing were made aware of these concerns, but no further information was provided before the survey exit.
Failure to Implement Bed Rail Requirements
Penalty
Summary
The facility staff failed to adhere to bed rail requirements for four residents, resulting in deficiencies in the assessment and consent process. For Resident #48, the staff did not attempt alternatives before using bed rails, failed to assess the resident for risk of entrapment, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. The resident's clinical record lacked documentation regarding bed rails, and there was no physician's order for their use. Observations confirmed the presence of bed rails, and interviews with staff revealed a lack of awareness and documentation of the necessary assessments and consents. Similarly, for Resident #166, the facility staff did not provide evidence of consent for bed rail use, did not attempt alternatives, and did not review the risks and benefits before installation. The resident was cognitively intact and used the bed rails for mobility, but there was no physician's order or comprehensive care plan documenting their use. The admission assessment and bed safety evaluation failed to include necessary information about alternatives, risks, benefits, and consent. For Resident #187, who was severely impaired in decision-making, and Resident #221, who was cognitively intact, the facility staff again failed to provide evidence of consent, alternatives attempted, and a review of risks and benefits before bed rail installation. Observations confirmed the use of bed rails, but there were no physician's orders or comprehensive care plans documenting their use. Interviews with staff indicated a lack of clarity and documentation regarding the assessment and consent process for bed rail use.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility staff failed to ensure that required physician visits were conducted for four residents, leading to deficiencies in care. For Resident #52, the clinical record did not show any physician visits since March 21, 2024, despite the facility's policy requiring regular monitoring and notification of overdue visits. Interviews with the administrative staff member (ASM) #7, the physician, and ASM #2, the director of nursing, revealed that the medical records employee was responsible for tracking these visits, but the system in place did not effectively ensure compliance with the required schedule. Resident #164, who was cognitively intact, reported not seeing the physician for months, although they had a good relationship with the nurse practitioner. The clinical record showed physician visits on November 15, 2023, February 22, 2024, and August 15, 2024, indicating a failure to meet the 60-day visit requirement. The facility's policy outlines procedures for notifying physicians and administrative staff when visits are overdue, but these procedures were not effectively implemented. Resident #48 experienced a gap of 140 days between physician visits, from January 4, 2024, to May 23, 2024, while Resident #155 was not seen by a physician for 371 days after admission. Interviews with ASM #7 and ASM #2 confirmed the responsibility of the medical records employee to track and notify about physician visits, but the system failed to ensure timely visits. The executive director, director of nursing, and regional director of operations were informed of these deficiencies, but no further information was provided before the survey exit.
Failure to Perform Ordered Laboratory Tests for Residents
Penalty
Summary
The facility staff failed to perform necessary laboratory tests as ordered by the physician for two residents, leading to a deficiency. For one resident, the staff did not conduct Hemoglobin A1C, lipid, and comprehensive metabolic panel (CMP) tests for several months in 2023, despite orders specifying these tests. The facility's process involved night nurses acknowledging electronic medical record reminders and printing laboratory orders, which were then used by an outside laboratory company to perform the tests. However, the records showed no results for the required tests within the specified timeframe, indicating a lapse in the execution of these orders. For another resident, the facility staff did not obtain a thyroid stimulating hormone (TSH) test as ordered. The physician's orders required the TSH test every six months, but there was no evidence of the test being completed as scheduled. Interviews with staff revealed that the night nurse was responsible for printing lab orders, which were then flagged for the lab technician. Despite this process, the clinical record lacked evidence of the TSH test results, and there was no documentation of the resident refusing the test or any issues in obtaining the specimen. The deficiency was communicated to the facility's executive director and other administrative staff, but no further information was provided before the survey exit.
Failure to Conduct Bed Rail Safety Inspections
Penalty
Summary
The facility staff failed to conduct required bed inspections for four residents, leading to a deficiency in identifying potential areas of entrapment in bed rails. For Resident #48, the admission evaluation did not document information regarding bed rails, and a bed safety evaluation later failed to identify areas of possible entrapment. Observations showed the resident using bilateral grab bars, but no formal assessment was conducted to identify entrapment risks. Interviews with staff revealed that assessments for entrapment risk should be done during the admission process, but this was not documented. Resident #166 was observed using bilateral bar-shaped bed rails, but the admission assessment did not evidence the use of bed rails. A bed safety evaluation noted the use of grab bars but failed to inspect for entrapment risks. The resident, cognitively intact, stated they used the bars for bed mobility. Staff interviews confirmed that entrapment risk assessments should be documented during admission, but this was not done. For Resident #187, who was severely impaired in decision-making, the admission assessment did not evidence the use of bed rails. Observations showed the resident using bilateral bar-shaped bed rails, but the bed safety evaluation failed to inspect for entrapment risks. Similarly, Resident #221, cognitively intact, required grab bars, but the admission assessment and progress notes did not evidence an inspection for entrapment risks. Interviews with staff reiterated the need for documented assessments during admission, which were not completed.
Failure to Promote Resident Dignity
Penalty
Summary
The facility staff failed to promote dignity for two residents, leading to deficiencies in their care. For one resident, the staff did not serve lunch in a dignified manner. The resident's roommate was served lunch ten minutes earlier, causing the resident to wait while their roommate ate. A CNA explained that residents requiring assistance should be served within two to three minutes of their roommates, acknowledging that a ten-minute wait is too long and could make the resident feel bad. Another resident was observed wearing a shirt with their first name and room number written on the front, which is against the facility's policy. The CNA stated that names and room numbers should be written inside the back collar for laundry purposes. The CNA acknowledged that having personal information displayed on the front of a shirt is a dignity issue, as it exposes personal information to others. Both issues were brought to the attention of the executive director and the director of nursing.
Failure to Assess Resident for Self-Administration of Eye Drops
Penalty
Summary
The facility staff failed to assess a resident for self-administration of over-the-counter eye drops, leading to a deficiency. Resident #65 was observed with Opcon A eye drops on her over-the-bed table on two separate occasions, yet there was no evidence of an assessment for self-administration of medications in her clinical record. The resident confirmed using the drops to help her eyes, but there was no physician order for these drops, as required by the facility's policy. An interview with an LPN revealed that residents are not allowed to keep over-the-counter drops at their bedside due to safety concerns, such as potential overuse. The facility's policy mandates that a resident may not self-administer medication until an assessment is completed by the interdisciplinary team and a physician/provider order is obtained. Despite this policy, the necessary assessment and physician order were not documented for Resident #65, resulting in a failure to comply with the facility's procedures for self-administration of medications.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility staff failed to report an injury of unknown origin for a resident within the required time frame. The resident, identified as Resident #68, presented with swelling in the left hand, and an x-ray ordered on March 14, 2024, revealed an undisplaced fracture of the mid portion of the left fourth metacarpal. Despite the absence of a known cause for the fracture, the facility did not report the injury to the state agency until March 18, 2024, which was beyond the mandated two-hour reporting window for such incidents. Interviews with administrative staff members, including the director of nursing, confirmed that the fracture should have been reported to the state agency as soon as possible, but no later than two hours after the injury was identified. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of injuries of unknown origin, especially when they result in serious bodily injury. The delay in reporting this incident was identified during a survey, and no further information was provided before the survey exit.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility staff failed to provide written notification to the resident and/or responsible party and failed to notify the ombudsman upon transfer for two residents. For Resident #1, the facility did not provide evidence of a written notice to the resident or responsible party when the resident was transferred to the hospital due to critical lab values indicating chronic kidney disease. The nurse's notes documented the transfer process, including notifying the resident's daughter, but lacked written notification evidence. Interviews with staff revealed that if the family is not present, no written notice is given, and there was no evidence of ombudsman notification. For Resident #4, the facility also failed to provide written notification of the resident's discharge to the hospital on two occasions. The clinical record showed transfers due to a dislodged nephrostomy tube and an acute change in mental status, but there was no evidence of written notification to the resident, responsible party, or ombudsman. Staff interviews confirmed that written notices were not provided to the ombudsman, and the director of social services could not find evidence of ombudsman notification for the discharges.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility staff failed to provide a bed hold notice at the time of transfer for two residents, leading to a deficiency in compliance with the facility's bed hold policy. For the first resident, who was transferred to the hospital due to critical lab values indicating chronic kidney disease, there was no evidence that a bed hold notice was provided at the time of transfer. The nurse's notes documented the resident's condition and the transfer process, but did not include any mention of the bed hold notice being given to the resident or their responsible party. An interview with an LPN confirmed that the facility's procedure requires the nurse to provide the bed hold policy and document it in the progress notes, which was not done in this case. Similarly, for the second resident, who was transferred to the hospital on two separate occasions for a dislodged nephrostomy tube and an acute change in mental status, there was no evidence of a bed hold notice being provided. The clinical records lacked documentation of the bed hold notice for both hospital discharges. An LPN confirmed that the procedure requires the nurse to provide the bed hold policy and document it, which was not followed. The executive director, director of nursing, and regional director of operations were informed of these concerns, but no further information was provided prior to the survey exit.
Incomplete MDS Assessment Due to Missed BIMS
Penalty
Summary
The facility staff failed to maintain a complete Minimum Data Set (MDS) assessment for one resident, specifically missing the Brief Interview for Mental Status (BIMS) assessment during the quarterly MDS assessment. The resident's cognitive patterns were not assessed as required, with a dash coded in the section indicating the BIMS was not conducted. This oversight was identified during a survey, and the registered nurse responsible for the MDS assessments acknowledged that the BIMS was accidentally missed. The facility did not have a specific policy regarding MDS assessments and relied on the CMS Resident Assessment Instrument (RAI) manual for guidance. The manual emphasizes the importance of conducting structured cognitive interviews with all residents to accurately assess cognitive performance and inform care-planning decisions. The failure to conduct the BIMS interview for the resident could lead to mislabeling based on appearance or assumed diagnosis, as structured interviews provide essential insights into a resident's current condition.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility staff failed to provide a written summary of the baseline care plan to two residents, identified as Resident #468 and Resident #469, within the required timeframe after their admission. For Resident #468, who was admitted on 9/28/24, there was no evidence in the clinical record that the resident or their representative received a written summary of the baseline care plan. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Social Services, revealed that the responsibility for developing and distributing the baseline care plan lies with the nursing and social services teams. However, the social worker did not provide the necessary documentation to the resident or their representative. Similarly, for Resident #469, admitted on 9/25/24, the clinical record lacked evidence of a written summary of the baseline care plan being provided to the resident or their representative. Staff interviews indicated that the baseline care plan should be initiated by the admitting nurse and discussed by the interdisciplinary team (IDT) with the resident or their representative. Despite these procedures, the social services department did not fulfill its role in printing and delivering the summary. The facility's policy mandates that a summary of the baseline care plan be provided to residents and their representatives, but this was not adhered to in these cases.
Failure to Clarify Physician Orders for Pain Medication
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for a resident, identified as Resident #164, by not clarifying physician orders for the administration of Acetaminophen and Ibuprofen. The physician orders indicated that Acetaminophen 325 mg should be given every 6 hours as needed for pain, in conjunction with Ibuprofen, while Ibuprofen 200 mg was to be administered every 4 hours as needed for pain on a scale of 1-3, also in conjunction with Acetaminophen. However, the electronic medication administration record (eMAR) for August and September 2024 showed that the resident received Acetaminophen on two occasions without evidence of receiving Ibuprofen, indicating a lack of adherence to the prescribed orders. Interviews with two LPNs revealed confusion regarding the physician orders. One LPN interpreted the orders as allowing the medications to be given either together or separately, depending on the pain level, due to the differing timing instructions. Another LPN found the orders complicated and expressed the need to clarify them with the physician. The facility's policy on physician orders did not provide guidance on clarifying such orders, contributing to the deficiency. The executive director, director of nursing, and regional director of operations were informed of these findings, but no further information was provided before the survey exit.
Incomplete Discharge Planning for a Resident
Penalty
Summary
The facility staff failed to develop a complete post-discharge plan of care for Resident #227, who was part of the survey sample. Upon review of the resident's clinical record, it was found that the discharge summary lacked essential components such as a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of medications. Additionally, the facility staff did not ensure that the resident was able to obtain medications after discharge. The discharge summary dated 3/29/24 was incomplete, with several sections left blank, including nursing final summary, labs and radiology tests, physical function, dietary services final summary, and an activity director final summary. Furthermore, there was no evidence that the resident or their representative received a copy of the completed and signed discharge summary. An interview with LPN #8, who documented the discharge note on 3/30/24, revealed that the nurse was responsible for obtaining prescriptions and providing discharge instructions, but a registered nurse was supposed to complete the discharge summary. LPN #8 could not recall the specific details regarding Resident #227. The facility's policy on discharge planning requires documentation and timely completion of the discharge plan based on the resident's needs, which was not adhered to in this case. The executive director and director of nursing were informed of these concerns, but no further information was provided before the survey exit.
Failure to Provide ADL Care to Dependent Resident
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care to a dependent resident, identified as Resident #219, who was severely impaired in making daily decisions and required extensive assistance for toileting. The resident was frequently incontinent of bowel and bladder, as noted in the most recent Minimum Data Set (MDS) assessment. However, a review of the ADL documentation revealed that incontinence care, toileting assistance, or personal hygiene assistance was not provided during the night shifts on specific dates in September and November 2022. The comprehensive care plan for the resident, initiated in September 2022, indicated the need for assistance with toileting and peri-care after each incontinence episode. Despite this, the documentation did not reflect the provision of such care on the specified dates. Interviews with facility staff, including a certified nursing assistant, confirmed that care was supposed to be documented every shift, yet there was no evidence of care provided on the nights in question. The facility's ADL process policy also outlined the requirement for assistance, but the deficiency was noted by surveyors and reported to the facility's executive director, director of nursing, and regional director of operations.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility staff failed to administer medications as ordered by the physician for two residents, leading to deficiencies in care. For Resident #82, the staff did not administer Ciprofloxacin as prescribed for a urinary tract infection. The medication was not available at the time of administration, and the nurse's note indicated it was not available. Despite the availability of Ciprofloxacin 250 mg tablets in the emergency backup medication system, the medication was not administered. The facility's policy on missed medications requires notifying the pharmacy and checking the emergency kit, but these steps were not effectively followed. For Resident #221, the staff failed to administer Cefepime intravenously as ordered for a wound infection. The first scheduled dose was missed, despite the medication being delivered and signed for by facility staff earlier that day. The eMAR showed the first dose was not administered at the scheduled time, and there was no documentation of the reason for this omission. Interviews with staff revealed a lack of adherence to procedures for verifying and administering medications upon new admissions. The deficiencies were brought to the attention of the facility's executive director, director of nursing, and regional director of operations. The report highlights the failure to follow established procedures for medication administration, resulting in missed doses for residents with serious infections. No further information was provided before the survey exit.
Failure to Implement Splint for Contracture Prevention
Penalty
Summary
The facility staff failed to implement necessary interventions to prevent the worsening of a right hand contracture for Resident #62. The resident, who was assessed as having no cognitive impairment and an upper extremity range of motion impairment, was observed without a splint that was previously recommended by an occupational therapist. The occupational evaluation dated 6/11/24 recommended the use of a resting hand splint for four hours on and four hours off to improve passive range of motion and reduce pain. However, the resident reported not knowing the whereabouts of the splint, and staff interviews revealed that the splint was misplaced and not in use. Further investigation showed that the occupational therapist had discharged the resident with a splint and provided instructions for its use, which were not transcribed into the resident's physician's orders. Interviews with staff, including a licensed practical nurse and a certified nursing assistant, confirmed that they were unaware of the splint's use or its location. The occupational therapist confirmed that the splint was misplaced and that the discharge instructions included recommendations for its use. The facility's executive director and regional director of operations were informed of these concerns, but no further information was provided before the survey exit.
Failure to Obtain Physician Order for External Catheter
Penalty
Summary
The facility staff failed to provide appropriate care and services for a resident using an external catheter. Specifically, the staff did not obtain a physician order for the use of the external catheter for the resident. Observations were made of the resident in bed with a urinary collection bag, yet the most recent Minimum Data Set (MDS) assessment did not indicate the presence of an internal or external catheter. Additionally, a review of the physician orders did not show any order for an indwelling or external urinary catheter. Interviews with facility staff, including a CNA and an LPN, revealed a lack of awareness regarding the resident's use of an external catheter. The CNA stated she only became aware of a catheter when providing care, while the LPN confirmed that a physician order is required for its use and that it should be changed every two to three days with daily skin assessments. The clinical record lacked documentation related to the external catheter, and the facility's policy on external catheter care was not followed, as it requires checking physician orders and performing peri-care at least twice daily.
Failure to Complete Mandatory CNA Training
Penalty
Summary
The facility staff failed to meet the certified nursing assistant (CNA) requirements for two of the five employee records reviewed, specifically for CNA #7 and CNA #8. The deficiency was identified through staff interviews, employee record reviews, and facility document reviews. It was found that CNA #7, who was hired on August 27, 2007, had only completed 3.6 hours of in-service training in the past 12 months, while CNA #8, hired on July 30, 2012, had completed 8.1 hours of in-service training in the same period. This is below the mandatory 12 hours of annual in-service training required for CNAs. During an interview, the director of nursing, identified as ASM #2, stated that she tracks staff education using an electronic training program that indicates what training is due, past due, and completed. Despite this system, the oversight occurred, and the two CNAs were not compliant with the training requirements. ASM #2 mentioned that staff members are notified of their training needs and are held responsible for completing them, with the stipulation that they cannot be scheduled if their training is incomplete. The oversight was acknowledged by ASM #2 as a lapse in the system. The executive director, director of nursing, and regional director of operations were informed of these concerns, but no further information was provided before the survey exit.
Failure to Provide Medically Related Social Services for Cognitively Impaired Resident
Penalty
Summary
The facility staff failed to provide medically related social services for Resident #132, who was part of the survey sample. Resident #132 was admitted with diagnoses including dementia, major depressive disorder, and psychotic disorder with delusions. Despite being severely cognitively impaired, as indicated by a BIMS score of 3 out of 15, the facility did not identify the need for medically related social services or make attempts to ensure these services were pursued. The resident lacked effective support from family or community and had no legal representative, yet the facility staff did not contact any outside services for evaluation. Observations during the survey revealed that Resident #132 was pleasant but confused, with documented behavioral disturbances such as hoarding garbage, throwing meal trays, and attempting to strike staff. The comprehensive care plan for the resident included interventions to encourage active support by family or resident representatives, but there was no evidence of attempts to locate family, a power of attorney, or contact with Adult Protective Services (APS) regarding the case prior to admission. The clinical record also failed to show any assessments indicating that Resident #132 was capable of making decisions as their own responsible party. Interviews with facility staff, including the social services director and business office manager, revealed a lack of awareness and action regarding the resident's need for a guardian or responsible party. The social services director, who had only been at the facility for a week, was not aware of any specific policy for residents who were cognitively impaired with no responsible party. The business office manager mentioned that someone might be working on setting up a guardianship for the resident, but there was no confirmation. The facility's policy on social services emphasized the need for assessment and development of a care plan, but these steps were not adequately followed for Resident #132.
Pharmacy Fails to Provide Medication for Resident
Penalty
Summary
The facility pharmacy failed to provide the medication Zosyn for a resident, identified as Resident #4, on the scheduled date of administration, 9/7/24. The medication was ordered on 9/6/24 to be administered intravenously every 6 hours for the treatment of osteomyelitis, an infection of the bone. However, the 12:00 noon dose was not administered because it had not arrived from the pharmacy. The clinical record and progress notes indicated that the medication was pending delivery from the pharmacy, and there was no documentation that the physician was notified of the unavailability of the medication. Interviews with LPNs revealed that the standard procedure when a medication is unavailable includes checking the facility's emergency medication supply, contacting the pharmacy and the physician, and documenting the actions taken and the physician's instructions. The facility's policy on missed medications also requires the charge nurse to notify the physician immediately and attempt to obtain the medication from the pharmacy. Despite these protocols, there was no evidence that the physician was contacted regarding the missed dose of Zosyn for Resident #4, highlighting a lapse in following the facility's medication administration procedures.
Failure to Act on Pharmacist's Recommendations for Resident
Penalty
Summary
The facility staff failed to act on the pharmacist's recommendations for a resident, identified as Resident #130, regarding necessary laboratory tests and the reassessment of a psychotropic medication. The pharmacist had recommended a lipid panel and complete metabolic panel (CMP) for the resident, which were due in August, but the results were not available between October and December. Additionally, the resident had an ongoing order for Trazodone, a psychotropic medication, without a stop date, which required reassessment according to the State operations manual. This reassessment was not addressed until February of the following year. Interviews with facility staff revealed a breakdown in communication and responsibility regarding the pharmacist's recommendations. The Director of Nursing (ASM #2) was responsible for disseminating the pharmacist's recommendations to the unit managers and providers. However, the recommendations were not acted upon in a timely manner, as the providers relied on ASM #2 to bring these to their attention. The facility's policy required the Director of Nursing to ensure that medication irregularities were addressed with attending physicians, but this process was not effectively implemented, leading to the deficiency.
Failure to Implement Psychotropic Medication Protocols
Penalty
Summary
The facility staff failed to implement interventions to prevent unnecessary medication administration for one resident, identified as Resident #130. A review of the resident's physician orders revealed an as-needed order for Trazodone, a psychotropic medication, dated December 15, 2023, which was not addressed by the provider until February 21, 2024. This oversight resulted in the continuation of the as-needed medication order beyond the regulatory limit of 14 days without a stop date or reevaluation by the provider. Interviews with administrative staff members and a licensed practical nurse confirmed that they were aware of the regulatory requirement that psychotropic as-needed orders should only last for 14 days and should include a stop date. However, this protocol was not followed in the case of Resident #130. The facility's policy on Pharmacy and Therapeutics Monthly Meetings indicated a goal to review and address all non-responded-to Consultant Pharmacist Drug Regimen Review recommendations, but no further information was provided prior to the survey exit.
Significant Medication Error Due to Unavailable Antibiotic
Penalty
Summary
The facility pharmacy failed to prevent a significant medication error for one resident, identified as Resident #4, who was part of the survey sample. The error occurred when the staff did not administer a scheduled dose of Zosyn, an antibiotic, at noon on September 7, 2024. The medication was prescribed to treat osteomyelitis, an infection of the bone. The clinical record showed that the medication was ordered on September 6, 2024, to be given intravenously every six hours. However, the progress notes indicated that the medication was pending delivery from the pharmacy, and there was no documentation of the physician being notified about the missed dose. Interviews with facility staff, including two LPNs, revealed that the medication was not available in the medication cart or the emergency supply. The LPNs acknowledged that failing to administer the medication as ordered constituted a medication error. They also stated that the physician should have been notified to provide guidance on how to proceed, and any instructions should have been documented in the progress notes. The facility's policy on missed medications requires the charge nurse to check the emergency kit and notify the physician if the medication is unavailable, which was not followed in this case.
Failure to Provide Food in Required Form for Resident
Penalty
Summary
The facility staff failed to provide food in a form designed to meet the needs of Resident #170, who was moderately cognitively impaired and had a physician's order for a regular diet with food cut into bite-sized pieces. Despite the meal tickets clearly documenting the need to cut the food into bite-sized pieces, the resident was repeatedly served meals that were not prepared according to these instructions. This included meals such as toast with sausage gravy, spaghetti with meat sauce, and sliced turkey with mixed vegetables, none of which were cut into bite-sized pieces as required. Interviews with facility staff, including a CNA and an LPN, confirmed that the responsibility for cutting the food lay with the CNAs, who were expected to follow the instructions on the meal tickets. The LPN noted that the resident's food needed to be cut due to left-sided weakness. However, the facility lacked a specific policy regarding the provision of food in a form to meet residents' needs, contributing to the oversight in care for Resident #170.
Failure to Maintain Accurate Medical Records for Dermatology Consultations
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, specifically regarding dermatology consultation documentation. The resident had physician orders for dermatology consultations due to a blister that was not improving, with appointments scheduled on two occasions. The progress notes indicated that the resident attended these appointments and that the resident's power of attorney (POA) reported a positive MRSA result from the dermatologist. However, the clinical record did not contain any consultation notes or culture results from the dermatologist. Interviews with facility staff revealed that there was an expectation for follow-up with the dermatologist to obtain a hard copy of the culture report, which was not done. Additionally, it was noted that when residents returned from consulting physicians, they typically brought back paperwork that should be reviewed and included in the medical record. The facility's policy on maintaining discharged clinical records did not provide guidance on ensuring a complete and accurate medical record. The executive director, director of nursing, and regional director of operations were informed of these findings, but no further information was provided before the survey exit.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility staff failed to implement appropriate infection prevention interventions for one resident, identified as Resident #4, during a wound care procedure. On October 4, 2024, a registered nurse, identified as RN #5, was observed changing the pressure injury dressings of Resident #4 without wearing a protective gown, despite wearing gloves. This was in violation of the resident's orders for enhanced barrier precautions, which were in place due to the resident's intravenous therapy and wounds. These precautions require the use of both gloves and a gown to prevent the transmission of multidrug-resistant organisms (MDROs). Interviews conducted on October 8, 2024, with a licensed practical nurse (LPN #3) and the infection preventionist (LPN #9) confirmed that the facility's protocol for enhanced barrier precautions mandates the use of both gloves and a gown during wound care. The infection preventionist emphasized the risk of bacteria transmission to other residents if a gown is not worn. RN #5 acknowledged the oversight and admitted that she should have worn a gown to protect herself, the resident, and others. The facility's executive director and regional director of operations were informed of these concerns, but no further information was provided before the survey exit.
Deficiency in QAPI Training Documentation
Penalty
Summary
The facility failed to meet the training requirements for its Quality Assurance and Performance Improvement (QAPI) program for one of the five employee records reviewed. Specifically, there was no evidence of documentation for QAPI training for Other Staff Member (OSM) #13. During an interview, OSM #11, the director of rehabilitation, mentioned that QAPI training is not required for the therapy department, although they do attend QAPI meetings. The facility's policy on Staff Education and Competency Testing includes annual regulatory requirements, but it appears that this was not adhered to in the case of OSM #13. The executive director, director of nursing, and regional director of operations were informed of these concerns, but no further information was provided before the survey exit.
Deficiency in Behavioral Health Training Documentation
Penalty
Summary
The facility failed to meet the training requirements for behavioral health training for one of the five employee records reviewed, specifically for a staff member identified as OSM #13. The review of OSM #13's completed trainings did not show evidence of behavioral health training documentation. During an interview, OSM #11, the director of rehabilitation, stated that behavioral health training is not required for the therapy department and that any necessary information is typically provided through in-service training by the staff in the building. The facility's policy on Staff Education and Competency Testing includes an assessment of needs based on facility requirements, including annual regulatory requirements. The executive director, director of nursing, and regional director of operations were informed of these concerns, but no further information was provided before the survey exit.
Latest citations in Virginia
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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