Ashland Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Virginia.
- Location
- 906 Thompson Street, Ashland, Virginia 23005
- CMS Provider Number
- 495362
- Inspections on file
- 28
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 43 (2 serious)
Citation history
Health deficiencies cited at Ashland Nursing And Rehabilitation during CMS and state inspections, most recent first.
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 maintain a clean, comfortable, and homelike environment and appropriate grooming on two nursing units, as evidenced by pervasive urine and feces odors in common areas and resident rooms, stained bed linens, dirty privacy curtains, damaged baseboards and furnishings, and clutter and trash on floors, including discarded wound dressings and gloves. Several residents were observed with wet pants, stained clothing, oily hair, and facial hair growth, and food particles were noted on clothing and wheelchairs. A bariatric resident reported that bariatric sheets and towels were not always available when linens needed changing, while housekeeping aides described cleaning 18–20 rooms per day, focusing mainly on floors and bathrooms and wiping tables only on request. A CNA reported that towels and bariatric sheets were sometimes insufficient at the start of shifts, requiring staff to obtain supplies from other units.
Facility staff failed to follow self-administration protocols when an LPN left two 500 mg Tylenol tablets at the bedside of a resident with alcoholic cirrhosis, ascites, and GERD, who had mild cognitive impairment, after the resident requested pain medication. Later observations found a medicine cup with multiple colored tablets still on the overbed table, but the two oblong white tablets were no longer present and the resident was not in the room. Record review confirmed there were no physician orders for the medications found at the bedside and no orders or interdisciplinary assessment authorizing self-administration, despite facility policy requiring such assessment and orders before residents may self-administer medications.
Staff failed to implement abuse and neglect prevention policies for a cognitively impaired, ambulatory resident with known wandering and exit-seeking behaviors, resulting in an elopement from an unsecured, unalarmed courtyard and multiple sexual contact incidents with other residents. Despite a physician order for a Wander-Gard and care plan focuses for elopement risk, behaviors, and 1:1 monitoring, the device was not consistently in place, interventions were not implemented or documented, and staff were unaware of the 1:1 requirement. The facility’s courtyard gate alarm was turned off with unaccounted-for keys, and an elopement and a later incident where the resident entered a female resident’s room without pants were not reported to the state agency. For a separate sexual incident between two residents, the facility produced only limited documentation, could not locate the initial facility-reported incident, had no confirmation of a 5-day follow-up being sent, and had no investigation notes or staff statements, despite a policy mirroring federal and state abuse/neglect reporting requirements.
Facility staff did not hold or document resident council meetings for several months, leaving residents to organize meetings themselves and express grievances without formal support. During this time, concerns such as unmade beds, delayed medications, and staff-resident respect issues were repeatedly raised in meetings, but there was no evidence that these grievances were resolved or addressed according to facility policy.
The activities program was overseen by an individual who did not meet the required professional qualifications, as determined by surveyor review of staff credentials.
Facility staff did not update the facility-wide assessment after a change of ownership, continuing to use an outdated assessment that referenced previous leadership and staff competencies. The current executive director confirmed the assessment had not been revised to reflect new ownership or changes in contracts and staffing.
Following a change in ownership, facility staff did not provide updated contracts for mobile imaging, imaging equipment, and dialysis services, as all existing agreements were still under the previous owner's name. The executive director confirmed that new contracts had not yet been secured, and no policy for updating such agreements was provided.
Facility staff did not ensure the infection preventionist attended a required QAPI meeting, as shown by missing sign-in documentation. The infection preventionist had resigned, and the assistant DON covering the role was not present at the meeting, resulting in noncompliance with facility policy requiring infection preventionist participation in QAPI.
Staff did not maintain or provide infection surveillance logs for two consecutive months, and administrative and clinical leaders could not locate required documentation for infection tracking during that period. An LPN responsible for infection prevention confirmed that surveillance processes were not in place for the months in question, despite facility policy requiring ongoing monitoring.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards.
Facility staff did not follow required policies for investigating abuse allegations, as evidenced by incomplete documentation and missing interviews after multiple resident-to-resident altercations. In several cases, only clinical records or a single witness statement were present, and key investigative steps such as interviewing involved parties and witnesses were not documented, despite residents sustaining injuries and administrative staff acknowledging the incomplete investigations.
Facility staff did not conduct or document thorough investigations into multiple abuse allegations involving residents with cognitive impairments. In several cases, only basic clinical records and a single LPN witness statement were present, with no evidence of interviews with involved residents, staff, or other witnesses, despite significant injuries and repeated incidents. Administrative staff confirmed that required investigative documentation was missing.
Staff failed to develop and implement comprehensive care plans for multiple residents, resulting in unmet needs such as toileting assistance, structured activities, care planning for memory care and complex medical treatments, one-on-one behavioral monitoring, and personal hygiene support. Documentation and staff interviews confirmed that required interventions were not consistently provided or recorded, and in some cases, care plans did not address all relevant diagnoses or treatments.
Staff did not update or revise care plans for four residents after significant changes, including discontinuation of wanderguard devices, changes in safety check requirements, unaddressed activity preferences, and incidents of resident-to-resident altercations. Observations and staff interviews confirmed that care plans were not accurate or individualized as required.
Facility staff failed to provide and document required ADL care, including bathing, grooming, toileting, and personal hygiene, for four dependent residents. Documentation was incomplete or missing for multiple care opportunities, and observations revealed unmet hygiene needs, such as untrimmed facial hair and lack of evidence for toileting or bathing assistance. Staff interviews confirmed that care should have been provided and documented, but records did not support that these essential services were consistently delivered.
Facility staff did not provide or document required activities for multiple residents, including those with cognitive impairment and dementia, over several months. Due to the absence of an activities director and staffing challenges, activities such as music, group events, and outdoor time were not consistently offered or recorded, despite being identified as important in care plans and assessments. Staff and administrative interviews confirmed the lack of structured activities and documentation during this period.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Insufficient staffing in the kitchen resulted in delayed meal delivery, with the last lunch tray served to a resident significantly later than scheduled. Staff interviews confirmed that the kitchen was understaffed, and the account manager for dietary acknowledged the delays were unacceptable and not in line with facility policy.
Staff failed to serve palatable food at appropriate temperatures on one unit. A test tray with chicken stir-fry, chopped spinach, and potatoes was found to be served at temperatures below the required 140°F, with food described as lukewarm and not palatable. Dietary management confirmed the food was not at a safe or appetizing temperature, contrary to facility policy.
Lunch was served late to residents on one unit due to insufficient dietary staff, with the last food cart arriving much later than scheduled and the final tray served well after typical mealtime. Staff interviews confirmed the delay was caused by staffing shortages, and the dietary manager acknowledged the situation was not acceptable for residents.
Facility staff did not invite two residents and/or their representatives to participate in care plan meetings, including one cognitively intact resident and another with memory difficulties. Interviews and record reviews confirmed that the process for sending care plan invitations had lapsed after a staff change, resulting in no evidence of invitations or attendance for these residents' care planning.
Staff did not maintain a female resident's facial hair despite her need for substantial assistance with personal hygiene and no documentation of refusals or attempts to address the issue. Additionally, trash-filled food tray domes were left on dining tables during meals, contrary to facility policy and staff acknowledgment that this was undignified.
Facility staff did not inform a resident's responsible party when the resident displayed aggressive behaviors, refused medication, and was transferred to the ER for evaluation. Documentation confirmed the transfer and behavioral issues, but there was no evidence that the responsible party was notified, contrary to facility policy and staff expectations.
Staff did not maintain a clean and sanitary room for a resident with severe cognitive impairment, as evidenced by persistent food debris, dust, and a soiled fall mat. Additionally, strong, lingering urine odors were repeatedly observed in a memory care unit, despite established cleaning protocols and staff awareness of the issue.
Staff did not report an allegation of abuse involving a resident hitting another in the face within the required timeframe, and the investigation file lacked necessary documentation such as witness statements and interviews.
Facility staff did not provide required written notices of transfer and bed hold policies to two residents and/or their representatives during hospital transfers. In both cases, although forms were completed or available, there was no evidence that the notices were actually sent or received, as confirmed by interviews with the director of social services and the social worker.
A resident with severe cognitive impairment and a history of refusing care was observed with long, untrimmed toenails, and there was no documentation of recent foot care or refusals after the last podiatry visit. Staff interviews confirmed that care refusals should be documented, but the clinical record lacked evidence of toenail care or proper documentation, contrary to facility policy.
The facility did not provide adequate nursing staff each day to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Facility staff did not complete the required annual performance evaluation for a CNA, and could not provide documentation of this evaluation when requested by surveyors. Administrative staff cited a recent facility sale and lack of access to old personnel records as reasons for the missing documentation.
Facility staff did not assess or document the psychosocial status of a resident after the individual was physically abused by another resident. Although the resident received a physical assessment and medical follow-up, there was no evidence that required psychosocial interventions or monitoring were provided or recorded, as outlined in facility policy.
Staff did not maintain complete and accurate clinical records for two residents, including missing documentation of scheduled showers for a resident with severe cognitive impairment and failure to record an incident where one resident inappropriately touched another. Administrative staff confirmed these documentation lapses.
Facility staff did not provide evidence of communication between the hospice provider and the facility for a resident admitted to hospice care. Hospice visit notes were not promptly available in the medical record, and there was no established process to ensure all staff, including physicians, had access to hospice-related information, contrary to facility policy.
Staff failed to provide required communications training for a CNA, as administrative staff could not produce documentation due to a recent facility sale and lack of access to old records. The assistant director of clinical services, new to her role, was unable to explain the lapse in training, and the facility's policy requiring annual training was not met.
The facility did not provide required resident rights training to a registered nurse and an operations staff member. Administrative staff were unable to produce documentation of the training due to a recent change in facility ownership and lack of access to previous records. The assistant director of clinical services, new to her position, was not aware of the reasons for the missed trainings. Facility policy requires annual training on required topics, but no additional information or documentation was provided to the survey team.
A registered nurse did not receive required annual training on abuse, neglect, and exploitation prevention, and facility staff could not provide documentation of this training due to lack of access to old personnel records following a recent facility sale. Policy review confirmed that such training is required annually, but no evidence was available for this staff member.
The facility did not provide mandatory QAPI training to a registered nurse and a dietary staff member, as required by policy and regulations. Administrative staff cited a recent change in ownership and lack of access to old personnel records as reasons for the missing documentation, and no further information was provided to surveyors.
A registered nurse did not receive mandatory infection control training as required by facility policy and regulations. Administrative staff were unable to provide documentation of the training due to a recent facility sale and lack of access to old records. The deficiency was identified during a review of staff education records and interviews with administrative staff.
A registered nurse did not receive the required compliance and ethics training, as confirmed by a review of staff records and facility policy. Administrative staff were unable to provide documentation due to a recent facility sale and lack of access to previous records. The assistant director of clinical services, new to the position, acknowledged the gap in training and the importance of staff education for resident care.
The facility did not ensure that two CNAs received the required 12 hours of annual education, and administrative staff were unable to provide documentation of this training due to a recent change in facility ownership and lack of access to previous records.
The facility did not provide required behavioral health training to a registered nurse and a dietary staff member, as revealed by staff interviews and document review. Administrative staff cited a recent change in ownership and lack of access to old records as reasons for the missing documentation. The facility's policy requires annual training, but no evidence was provided to show compliance for these staff.
The facility failed to ensure the activities program was directed by a qualified professional, as the director of activities was not certified at the time of hire and only completed the necessary certification months later. The job description required a Bachelor's Degree, NCCAP certification, and experience in therapeutic recreation, which the director did not possess initially.
The facility failed to investigate and report an alleged abuse incident involving two residents who had a physical altercation. Despite initial reporting to the state agency, no follow-up investigation was conducted, and the required documentation was missing. The facility's policy mandates investigation by the DON or designee, but this was not followed due to an oversight during a staff transition.
The facility failed to provide adequate documentation during hospital transfers for three residents, leading to deficiencies in care transition. Staff interviews revealed that only limited documentation was typically sent, and if not recorded in progress notes, there was no evidence of what was sent. The facility's policy requires comprehensive documentation, but this was not consistently followed.
The facility failed to provide written bed hold notices to resident representatives upon hospital transfers for three residents. In each case, the clinical records lacked evidence of the notices, and staff interviews revealed confusion about the responsibility for issuing them. The facility's policy did not address the requirement for such notices.
The facility staff failed to provide adequate respiratory care for six residents, including improper storage of nebulizer and BiPAP equipment and incorrect oxygen administration. Residents with cognitive impairments and respiratory conditions were affected, with equipment left uncovered and oxygen flow rates not matching physician orders.
A resident with chronic pain did not receive non-pharmacological interventions before being administered prn pain medications, despite having a care plan that included such interventions. The eMAR for December and January showed multiple instances of medication administration without attempts at non-pharmacological methods. Interviews confirmed the lack of these interventions, contrary to the facility's pain management policy.
The facility did not meet RN coverage requirements on two days when the DON served as the charge nurse due to staffing shortages. The DON worked on the floor during weekends, in addition to his full-time role, and the facility's staffing policy did not address this issue.
The facility failed to complete annual performance reviews for five CNAs, despite having a policy that mandates continual and annual evaluations. The director of human resources, responsible for ensuring these reviews are conducted, was unable to provide the necessary documentation for the CNAs, who were hired between 1976 and 2022.
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 Maintain Clean, Homelike Environment and Adequate Grooming
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and appropriate grooming for residents on Units W1 and W2. Upon entering the facility lobby, surveyors noted a strong pervasive odor resembling old dried urine. On Unit W1, observations during the initial tour included privacy curtains with dark smeared substances, baseboards buckling away from the wall, and bed linens with yellow-brown halos of stains. Foul odors of feces and urine were noted at various times of the day. Residents were observed with food particles on their clothes and in their wheelchairs, as well as wearing wet pants, stained clothing, and having oily hair. On Unit W2, multiple rooms were observed to be unclean and in disrepair. In one room, the baseboard near the HVAC unit was not attached to the wall and appeared to be crumbling, window blinds were bent, and paint on the wardrobe was scuffed; both residents in that room had hair under the chin and there was a very foul odor. Another room had a bedside table with a missing drawer, yellow-orange (rust-colored) stains and various trash on the floor under the sink, including a wound dressing, glove, and straw. A different room had bedside and overbed tables with liquid spills and dried substances and a very foul odor. One resident in a bariatric bed reported that bariatric sheets were not always available when linens needed changing and that towels sometimes ran out at the start of shifts, though she confirmed her linens had been changed that day and had extra towels and washcloths at bedside. Housekeeping aides reported they typically clean 18–20 rooms per day, focusing on floors and bathrooms and only wiping tables if residents request it. A CNA stated that sometimes there were not enough towels at the beginning of a shift and that staff would go to another unit to obtain more, and that bariatric sheets were available most of the time but occasionally not.
Medications Left at Bedside Without Self-Administration Assessment or Orders
Penalty
Summary
Facility staff failed to ensure it was clinically appropriate for a resident to self-administer medications when medications were left at the bedside without required assessment or physician orders. During an initial tour, surveyors observed a medicine cup containing seven colored tablets and two oblong white tablets on the overbed table of Resident #7, who was not in the room. Later the same day, during an evening tour, the medicine cup with the seven colored tablets remained on the overbed table, but the two oblong white tablets were no longer present, and the resident was again not in the room. Review of the clinical record showed that the resident had no active order for the medication found at the bedside and no order for self-administration of medications. Resident #7 had been admitted with diagnoses including alcoholic cirrhosis of the liver with ascites and gastro-esophageal reflux disease without esophagitis, and had a BIMS score of 13/15, indicating mild cognitive impairment. An interview with an LPN revealed that the resident had requested Tylenol after breakfast and was given two 500 mg Tylenol tablets at approximately 10:00 a.m.; the LPN stated the resident must have put them down instead of taking them as he said he would. The LPN also stated that medications should never be left at the bedside without a self-administration assessment and physician orders, and that no residents on the unit had such assessments or orders. Review of the facility’s Self-Administration of Medication and Treatments Policy showed that residents have the right to self-administer medications only if the interdisciplinary team has determined it is clinically appropriate and safe, which had not been done for this resident.
Failure to Supervise High-Risk Resident and Report Sexual and Elopement Incidents
Penalty
Summary
Facility staff failed to implement abuse, neglect, and theft prevention policies and procedures in relation to a resident with severe cognitive impairment and known wandering and exit-seeking behaviors, resulting in elopement and sexual contact incidents. One resident, diagnosed with Wernicke's encephalopathy, dementia, alcohol use disorder, and other conditions, had a BIMS score of 99 indicating severe cognitive impairment and was fully ambulatory. Despite multiple documented episodes of wandering into other residents' rooms, disrupting care, and seeking exits, staff did not consistently apply ordered safety measures such as a Wander-Gard device or supervision. The resident had a physician order for a Wander-Gard dated 11-13-25, but the device was not on the resident during surveyor observation, and documentation showed the resident had removed it on 3-8-26 without replacement. The same resident had a documented elopement on 12-15-25, when he went to the outside patio/courtyard and pushed open the gate, exiting to the parking lot before being redirected back inside by staff from another unit. This elopement was not reported to the state agency. The facility’s courtyard gate alarm was found by surveyors to be turned off, with the Maintenance Director acknowledging that the alarm had been shut off and that multiple unaccounted-for keys existed. The courtyard exit door lacked an activated alarm, and surveyors observed the gate standing open for approximately five minutes with no staff present and residents in the courtyard. An Elopement Evaluation completed on 2-16-26 documented that the resident’s wandering was not likely to affect the safety or well-being of self or others and not likely to affect the privacy of others, despite prior documented incidents of elopement and intrusion into other residents’ rooms during personal care. The resident was also involved in multiple sexual incidents. On 2-23-26, staff documented that the resident was found in another male resident’s room on his knees performing oral sex; the cognitively impaired resident later had no recollection of the event. On 3-5-26, the same resident was found sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; this third resident was not identified and the incident was not reported to the state agency. The care plan was updated over time to include behavior and elopement focuses, including a 1:1 monitoring intervention added on 3-9-26 for obsessive-compulsive behavior and a psychosocial problem related to sexual/physical contact with another resident, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR. The facility failed to follow its abuse/neglect policy and regulatory reporting requirements for allegations and incidents of abuse and neglect. For the 2-23-26 sexual incident, the only documents produced were limited notes, a skin check, unsigned typed interview notes, and a purported final facility-reported incident (FRI) follow-up referencing an initial FRI that could not be located. The interim administrator could not produce the initial report, and there was no fax confirmation showing that the follow-up was successfully sent to the state agency; the state agency had no record of receiving it. No investigation notes or staff witness statements were found, and the facility’s abuse/neglect policy, which mirrored federal and state requirements for timely reporting and 5-day follow-up investigations, was not implemented. Additionally, the elopement on 12-15-25 and the 3-5-26 intrusion into a female resident’s room were never reported to the state agency. The report identifies these failures as neglect, defined as withholding required goods and services, including necessary supervision for a resident known to be a danger to self and others.
Failure to Facilitate Resident Council Meetings and Resolve Grievances
Penalty
Summary
Facility staff failed to facilitate resident council meetings for three consecutive months, as evidenced by the absence of meeting minutes from early May through the time of the survey. During this period, there was no activities director, and residents, including one who was cognitively intact, reported that they had to organize meetings themselves to discuss concerns and grievances. The facility's own policy required monthly resident council meetings, facilitated and documented by staff, but this was not followed, potentially affecting all residents. Additionally, for two months, the facility did not provide evidence that grievances raised during resident council meetings were resolved. Multiple meeting minutes from November and December showed recurring and new concerns, such as unmade beds, delayed pain medication, lack of housekeeping, missing personal items, and staff-resident respect issues. There was no documentation in subsequent meeting minutes that these grievances were addressed or resolved, despite the facility's policy to make prompt efforts to resolve complaints and inform residents of progress. Interviews with administrative staff confirmed the lack of meeting minutes and the absence of documentation showing grievance resolution for the specified period. The executive director, who had recently started, acknowledged that there was no evidence of resolution for grievances from the months in question and described a process for tracking and resolving concerns that was not in place during the deficiency period.
Unqualified Professional Directing Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. Surveyors identified that the individual responsible for overseeing the activities program did not meet the required qualifications as specified by regulations. This deficiency was based on direct observation and review of staff credentials during the survey.
Failure to Update Facility Assessment After Change of Ownership
Penalty
Summary
Facility staff failed to review and revise the facility-wide assessment following a change of ownership that became effective on 6/1/2025. The most recent facility assessment available was dated 7/18/2024 and included information pertaining to the previous executive director, director of clinical services, and staff training/education and competencies under the former owner. During an interview, the current executive director confirmed that the assessment provided was from before the change of ownership and acknowledged that updates had not yet been made, as they were planning to address this in an upcoming QAPI meeting. No updated assessment reflecting the new ownership, leadership, or revised contracts was available at the time of the survey.
Failure to Secure Updated Contracts with Outside Service Providers After Ownership Change
Penalty
Summary
Facility staff failed to provide evidence of updated contracts with outside service providers following a change in facility ownership. During the survey, administrative staff were unable to produce current contractual agreements for mobile imaging services, mobile imaging equipment, and contract dialysis services. The contracts available were all in the name of the previous owner, a company that no longer exists due to bankruptcy and subsequent sale of the facility. The executive director acknowledged that the facility had not yet secured new contracts with these vendors under the new ownership. Additionally, the facility did not provide a policy related to updating contracts with outside providers. The lack of updated agreements potentially affects all residents, as required services may not be properly secured or documented. No further information or documentation was provided to the survey team prior to the exit interview.
Infection Preventionist Absent from Required QAPI Meeting
Penalty
Summary
Facility staff failed to ensure the attendance of the infection preventionist at one of five reviewed QAPI (Quality Assurance Performance Improvement) meetings, specifically the Q4 2024 meeting. Review of QAPI meeting sign-in sheets did not show the infection preventionist present at this meeting. Interviews with the director of clinical services revealed that the infection preventionist had resigned in November 2024, and although the assistant director of nursing was covering the role at the time, this individual was not present at the meeting. The executive director confirmed that QAPI meetings are held at least quarterly and are attended by an interdisciplinary team, which should include the infection preventionist as per facility policy. The facility's QAPI policy requires the infection preventionist to be a member of the Quality Assessment and Assurance Committee.
Failure to Maintain Infection Surveillance Documentation
Penalty
Summary
Facility staff failed to implement a complete infection prevention and control program for the months of November and December 2024. During this period, there was no evidence of an infection surveillance system in place to identify possible communicable diseases before they could spread within the facility. When asked, administrative and clinical leadership were unable to provide infection surveillance logs for the specified months, stating that both the director of clinical services and the current infection preventionist had only started their roles after the period in question and could not locate the required documentation. Interviews with the infection preventionist revealed that she began her role in mid-December 2025 and recalled a gastrointestinal issue affecting a few individuals, but no overarching trends or specific pathogens like Norovirus were identified. The infection preventionist described her current responsibilities for tracking infections and antibiotic usage, but this process was not in place or documented for the months under review. Facility policy requires ongoing surveillance for healthcare-associated infections, but no additional information or evidence of compliance for the deficient period was provided.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Abuse Investigation Policies and Procedures
Penalty
Summary
Facility staff failed to implement established policies and procedures for investigating allegations of abuse, neglect, and theft involving multiple residents. In several incidents involving residents with cognitive impairments and dementia, staff did not complete or document required investigative steps. For example, after a nurse witnessed one resident strike another, the facility's documentation lacked evidence of interviews with the residents involved, staff, or other potential witnesses, and did not include a summary of the investigation or supporting documentation. Similar deficiencies were noted in subsequent incidents involving the same resident and others, where only clinical records were present in the investigation files, and final reports to the state agency were missing from the facility's records. In another case, a resident sustained significant injuries, including a laceration, bloody nose, and orbital fracture, following an altercation with a roommate. The facility's documentation included only a single witness statement from an LPN and lacked evidence of interviews with the residents involved, other staff, or a comprehensive review of medical records. The executive director confirmed that the investigative file was incomplete and did not meet the facility's own standards for a thorough investigation. Throughout these incidents, the facility's failure to follow its own abuse investigation policy was evident. Required steps such as obtaining statements from all involved parties, conducting thorough assessments, and maintaining complete investigative files were not performed or documented. Administrative staff acknowledged these deficiencies during interviews, and no additional information or corrective documentation was provided prior to the survey exit.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
Facility staff failed to thoroughly investigate multiple allegations of abuse involving several residents with cognitive impairments. In one instance, a resident with vascular dementia and a low BIMS score was witnessed striking another resident in a memory care unit. The facility's documentation included a synopsis of the event and notification of the medical doctor and responsible parties, but lacked evidence of a comprehensive investigation. There were no documented interviews with the residents involved, staff, or other potential witnesses, nor were there detailed assessments or observations beyond basic skin checks. Similar deficiencies were noted in subsequent incidents involving the same resident, including an event where the resident was seen removing his hand from around another resident's neck. In each case, the investigation files contained only clinical records and lacked required investigative documentation such as witness statements and interview notes. Another incident involved a resident with severe cognitive impairment who sustained significant injuries, including a laceration to the lip, bloody nose, and swelling to the face, after an altercation with a roommate. The facility's investigation included a synopsis of the event and a single witness statement from an LPN, but did not include interviews with the residents involved, additional staff, or other residents. The documentation failed to provide a comprehensive account of the incident or demonstrate that a thorough investigation was conducted, as required by facility policy. Interviews with administrative staff confirmed that the investigative files were incomplete and did not meet the facility's own standards for abuse investigations. The facility's policy requires statements from all involved parties and witnesses, as well as a detailed summary and supporting documentation, none of which were present in the reviewed files. The lack of thorough investigation and documentation was acknowledged by facility leadership during the survey.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for six residents, resulting in unmet needs across multiple domains. For one resident with severe cognitive impairment and incontinence, documentation showed repeated failures to provide and record toileting assistance as required by the care plan over several months. Staff interviews confirmed that toileting assistance should have been provided and documented, but records did not support consistent implementation. Another resident, also with severe cognitive impairment, did not receive structured activities as outlined in their care plan. Staff and administrative interviews revealed that for months, there were no regular activities in the memory care unit due to staffing challenges, and the facility could not provide evidence of activity participation for the resident during that period. Additional deficiencies included the lack of a care plan addressing the needs of a resident on the memory care unit, despite documentation of severe cognitive impairment. For another resident with brain cancer and a seizure disorder, the care plan failed to address critical aspects such as radiation therapy, chemotherapy, anticonvulsant use, and the cancer diagnosis, even though these treatments and diagnoses were documented in the medical record. The regional MDS coordinator confirmed that these omissions meant the care plan was not comprehensive for the resident's needs. Further, the facility did not implement one-on-one monitoring for a resident with behavioral issues as required by the care plan, with no documentation to show monitoring occurred on multiple dates or that it was discontinued. In another case, a resident with quadriplegia and total dependence for personal hygiene had no documentation of care provided or refusal of care on a specific date, despite the care plan requiring total staff assistance. Staff interviews confirmed that care plans are intended to be individualized and updated as needed, but the required interventions were not consistently documented or implemented.
Failure to Update and Individualize Resident Care Plans After Changes in Status and Incidents
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following significant changes in their care needs and status. For two residents, the care plans continued to document the use of wanderguard devices and every 15-minute safety checks, despite the absence of current physician orders and the devices not being in use. Observations confirmed that these residents were not wearing wanderguards, and staff interviews acknowledged that the care plans were not accurate or up to date. The facility's own policy required care plans to be reviewed and revised based on changing needs and interventions, but this was not followed. Another resident's care plan was not updated to reflect the resident's preferences for activities, despite the most recent assessments indicating specific interests and needs. The care plan contained only general interventions and did not individualize activities according to the resident's stated preferences. Staff interviews confirmed that every resident should have an individualized activity care plan, and the current plan did not meet this standard. Additionally, the care plans for two residents were not reviewed or revised after incidents of resident-to-resident altercations. One resident was the victim of an assault, resulting in a skin tear and facial bruising, while another resident was the aggressor in two separate incidents. Despite documentation of these events in the clinical records and staff acknowledgment that care plans should be updated following such incidents, there was no evidence that the care plans were reviewed or revised to address the new risks or interventions needed.
Failure to Provide and Document ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide and document activities of daily living (ADL) care for four residents who were unable to perform these tasks independently. For one resident, records showed significant gaps in bathing and showering documentation over several months, with only a small fraction of opportunities for care being recorded and most entries left blank. When additional documentation was requested, only two shower sheets were produced for a three-month period, despite policy requiring regular review and documentation of bathing preferences and frequency. Another resident, assessed as severely impaired in decision-making and requiring substantial assistance with personal hygiene, was repeatedly observed with untrimmed facial hair over several days. The care plan indicated the need for daily grooming and assistance, and staff interviews confirmed that grooming, including shaving, should be performed daily or as needed. However, there was no documentation of care refusals or attempts to address the facial hair, and ADL records showed minimal entries for personal hygiene during the review period. A third resident, also severely impaired and requiring supervision for toileting, had multiple dates across three months where there was no evidence of toileting assistance being provided or documented on various shifts. The care plan specified the need for staff assistance with toileting, but ADL records showed numerous blank entries. For a fourth resident, who was totally dependent on staff for personal hygiene due to quadriplegia, there was no documentation of personal hygiene care or refusal on a specific date, despite the care plan requiring daily assistance. Staff interviews confirmed that care should be provided and refusals documented, but the absence of records made it impossible to determine if care was given.
Failure to Provide and Document Resident Activities
Penalty
Summary
Facility staff failed to provide activities to meet the needs and preferences of five residents over a period of several months. For one resident with no cognitive impairment, there was no evidence of activities being provided according to their stated preferences, which included listening to music, keeping up with the news, group activities, favorite pastimes, and going outside for fresh air. The facility lacked documentation of activities for this resident and others between February and June, and the executive director confirmed that there was no activities director during much of this time, resulting in gaps in activity provision and documentation. Several other residents, including those with severe cognitive impairment and dementia, also did not receive documented activities during the same period. These residents had care plans and MDS assessments indicating the importance of activities such as music, religious services, group events, going outside, and reading materials. Staff interviews revealed that, due to staffing challenges and the absence of an activities director, activities were not consistently offered, especially in the memory care unit. Some CNAs attempted to provide informal activities, but these were not regular or documented, and there was no structured program in place until a new activities director was hired at the end of June. The facility's own policy required group activities to be scheduled and documented to enhance residents' well-being and self-esteem, with participation recorded in the electronic health record and summaries provided at least quarterly. However, administrative and clinical staff acknowledged the lack of evidence for activity participation during the cited period. The deficiency was identified through resident and staff interviews, review of facility documents, and clinical records, all of which confirmed the absence of required activities and documentation for multiple residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Insufficient Dietary Staffing Led to Delayed Meal Service
Penalty
Summary
Facility staff failed to provide sufficient personnel in the kitchen to ensure timely meal service to residents. On one occasion, the last food cart for lunch arrived on a unit at 3:50 p.m., and the last lunch tray was served at 4:10 p.m., which was significantly later than the scheduled meal times. Staff interviews confirmed that the kitchen was understaffed on that day, resulting in delayed meal delivery. The account manager for dietary acknowledged that the observed delays were not acceptable and that residents should not have to wait for their meals. The facility's policy requires that at least three daily meals be provided at regular times comparable to normal community mealtimes. However, observations and staff interviews indicated that the kitchen did not have enough staff to meet this requirement, leading to delays in meal service. Administrative staff were made aware of these findings, and no additional information was provided prior to the survey exit.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
Facility staff failed to serve palatable food at a safe and appetizing temperature on one of three units, Unit One. On the specified date, a test tray containing chicken stir-fry, chopped spinach, and enhanced potatoes was sent from the kitchen to Unit One. The tray was followed by surveyors and a dietary district manager. Upon arrival, the last lunch tray was served to a resident, and the cover was removed from the test tray. Food temperatures were measured: chopped spinach at 118°F, stir-fry at 111°F, and potatoes at 115°F. These temperatures were observed by two surveyors and the dietary district manager, who described the food as lukewarm after tasting it. When asked if the food was palatable, the dietary district manager did not provide an answer. In a subsequent interview, the dietary account manager confirmed that food temperatures should have been 140°F or greater and acknowledged that food at the measured temperatures would not taste good because it was cold and the temperature had dropped too much. The facility's policy requires food to be prepared and served in a manner that conserves nutritive value, flavor, and appearance, and specifies that food should be palatable, attractive, and served at a safe and appetizing temperature. The deficiency was communicated to the executive director and director of clinical services, with no further information provided prior to exit.
Delayed Lunch Service Due to Dietary Staffing Shortage
Penalty
Summary
Facility staff failed to serve lunch in a timely manner on one of three units, specifically Unit One. On the observed date, the last food cart for lunch arrived on Unit One at 3:50 p.m., and the last lunch tray was served at 4:10 p.m. This was significantly later than the scheduled meal times, as the first lunch food carts are typically sent to the floor at 11:45 a.m. Staff interviews confirmed that there was insufficient dietary staff available on the day in question, which contributed to the delay in meal service. The account manager for dietary acknowledged that the observed delay was not acceptable for residents and that residents should not have to wait for their meals. The facility's policy requires that at least three daily meals be provided at regular times comparable to normal mealtimes in the community, and that meal and snack times be coordinated with residents and relevant administrative staff. Despite this policy, the observed delay in meal service on Unit One was attributed to staffing shortages in the kitchen, as confirmed by staff interviews. No additional information or explanation was provided by facility administration prior to the survey exit.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
Facility staff failed to invite residents and/or their representatives to participate in care plan meetings for two residents. For one resident, who was cognitively intact as indicated by a high BIMS score on the most recent MDS assessment, neither the resident nor their representative received invitations to care plan meetings throughout the year. Both the resident and their representative confirmed in interviews that they had not been invited to attend these meetings. Staff interviews revealed that the process for sending invitations had lapsed after the departure of the former MDS coordinator, with the last invitation letter sent several months prior. For another resident, who had documented short- and long-term memory difficulties, there was no evidence in the clinical record that the responsible party was invited to care plan meetings, nor was there documentation of their attendance. A note in the record referenced a meeting set up to address a room change, but this was not identified as a care plan meeting. Staff interviews confirmed that the system for generating and sending care plan invitations had not been maintained, resulting in a lack of invitations for residents and their representatives.
Failure to Promote Resident Dignity in Personal Hygiene and Dining Environment
Penalty
Summary
Facility staff failed to promote dignity for one resident by not maintaining trimmed facial hair on a female resident with severe cognitive impairment and significant ADL self-care deficits. Despite the resident requiring substantial to maximal assistance with personal hygiene and being assessed as sometimes resistant to care, there was no documentation in the clinical record or ADL logs of refusals or attempts to address the facial hair. Multiple observations over several days confirmed the presence of long, curled white hairs on the resident’s chin and upper lip, and staff interviews indicated that personal hygiene, including shaving, should be performed daily and refusals reported and documented, which was not done in this case. Additionally, observations in the dining area revealed that food tray domes containing trash were placed in the center of tables where residents were eating. This practice was observed on multiple occasions and was acknowledged by a nurse as not being a dignified manner for residents to eat. Facility policy requires that all non-edible items be removed from dining tables to maintain a relaxed and social dining environment, but this was not followed during the observed meal times. Both deficiencies were brought to the attention of facility administrative and clinical leadership. No further information or documentation was provided prior to the survey exit regarding these findings.
Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party of a significant change in condition when the resident exhibited aggressive behaviors, refused medication, and was subsequently transferred to the emergency room for further evaluation. Clinical record review showed documentation of the resident's behavioral changes and hospital transfer, but there was no evidence that the responsible party was informed of these events. Staff interviews confirmed that the expected protocol is to notify the representative when a resident is transferred to the hospital, and facility policy requires family notification of any resident changes. Despite these requirements, no documentation or evidence of notification was found for this incident.
Failure to Maintain Clean, Homelike Environment and Control Odors
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment for a resident with a history of stroke and severe cognitive impairment. Multiple observations over two days revealed that the resident's room contained unopened condiment packages, food wrappers, dust, and a fall mat that was sticky and covered with food debris. Despite the facility's policy requiring daily cleaning and immediate attention to visibly soiled surfaces, these conditions persisted across several observations. The director of housekeeping confirmed that the room and fall mat were not clean during a walkthrough. Additionally, staff failed to provide a homelike environment free of lingering urine odors on one of the facility's units. Repeated observations in the memory care unit detected strong, stale urine odors in specific hallways over two consecutive days. The director of housekeeping described the cleaning protocols, which included daily cleaning, weekly floor scrubbing, and deep cleaning of two rooms per day, but acknowledged that lingering urine odors were present and not homelike. The odors were attributed to bathrooms, and efforts were made to assign dedicated housekeeping staff to the unit. Interviews with staff confirmed awareness of the cleaning routines and the presence of odors, with the activities assistant noting that minimizing odors depended on both resident care and housekeeping efforts. The executive director and director of nursing were informed of the findings, and no additional information was provided before the survey exit.
Failure to Timely Report Alleged Abuse and Incomplete Investigation Documentation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner involving one resident who was witnessed hitting another resident in the face. The incident occurred on 12/27/24, but the report to the state agency was not made until 12/30/24, exceeding the facility's policy requirement to report such allegations within two hours if abuse or serious bodily injury is involved. Documentation in the facility's event synopsis and the final report to the state agency confirmed the delay in reporting. The incident resulted in one resident sustaining discoloration to the side of the face, and both the medical doctor and responsible party were updated. Upon review of the facility's investigation file, there was no evidence of a completed investigation, as the only documents present were clinical records for the residents involved. There were no witness statements, staff or resident interviews, or assessments of the residents involved or any other residents. Interviews with administrative staff confirmed awareness of the reporting requirements, but the deficiency was identified due to the lack of timely reporting and insufficient documentation of the investigation process.
Failure to Provide Written Transfer and Bed Hold Notices During Hospital Transfers
Penalty
Summary
Facility staff failed to provide required written notices of transfer and bed hold policies to residents and/or their representatives during hospital transfers for two residents. In the first instance, a resident was transferred to the emergency room due to medication refusal, aggressive behaviors, and psychosis. Although forms documenting the resident's and responsible party's names and the date were completed, there was no evidence that these notices were actually provided to the resident or their representative. The director of social services stated that notices are typically mailed and kept in her office, but could not provide proof that the notices were sent or received in this case. In the second instance, another resident was transferred to the hospital after exhibiting a high temperature and low blood pressure, with the transfer initiated at the request of the resident's spouse. The clinical record did not contain documentation that the required written notice and bed hold policy were sent to the responsible party. The social worker confirmed that while copies of the notices existed, there was no evidence they were actually sent. Facility policy requires notification of bed hold policies at admission and at the time of transfer, but documentation supporting compliance was not available for these two cases.
Failure to Provide Foot Care and Document Refusals
Penalty
Summary
Facility staff failed to provide appropriate foot care for one resident, resulting in long, untrimmed toenails that were observed to be uneven and approximately 1/8 inch from the nailbed. The resident, who was assessed as severely impaired in decision-making and required substantial to maximal assistance with personal hygiene and bathing, was seen walking barefoot in the hallway. The care plan documented that the resident had a self-care deficit related to dementia, lack of coordination, and hemiplegia, and also noted a history of refusing care, including foot care and podiatry services. However, there was no documentation in the nursing progress notes of refusals or attempts to trim the toenails after the last podiatry visit, which occurred several months prior to the observation. Staff interviews revealed that while the resident sometimes refused care, the expectation was that refusals should be documented and reported to the physician and responsible party. The facility's policies required daily grooming activities, including nail care, and documentation of care provided or refusals. Despite these requirements, the clinical record did not show evidence of toenail care or documentation of refusals after the last podiatry visit, indicating a lapse in following facility policy and in providing necessary foot care for the resident.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate daily nursing staff coverage and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
Facility staff failed to complete an annual performance evaluation for one of five certified nursing assistants (CNA) whose records were reviewed. Specifically, there was no evidence that the required annual performance evaluation for CNA #5 had been conducted within the past 12 months. When the survey team requested the most recent performance evaluation for this CNA, administrative staff members, including the executive director and the director of clinical services, indicated that they might not be able to provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not explain why the evaluation had not been completed in a timely manner.
Failure to Assess and Address Psychosocial Needs After Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to provide medically-related social services to a resident who experienced physical abuse from another resident. According to the clinical record, a nurse documented that the resident was found being hit in the face by another resident, resulting in a small skin tear on the nose, facial swelling, and bruising. The nurse assessed the resident's physical condition, notified the nurse practitioner, obtained an x-ray order, and informed the resident's power of attorney. However, there was no documentation that the resident's psychosocial status was assessed or that any psychosocial interventions were implemented following the incident. Interviews with the social services coordinator revealed that the facility's protocol requires social services staff to interview residents involved in such incidents, complete a psychosocial assessment, and monitor the resident's coping status weekly for at least four weeks, with all actions documented in the clinical record. Review of the resident's record did not show evidence that these steps were taken. The facility's policy also mandates that social services complete progress reviews with significant changes or as needed, but no such documentation was found for this incident.
Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for two residents. For one resident with a history of stroke and severe cognitive impairment, the facility's shower schedule and shower sheets indicated that showers were provided every Monday and Thursday. However, the activities of daily living (ADL) tracking sheets did not document that these showers occurred as scheduled. The director of clinical services confirmed that the shower sheets were kept in a separate binder and were not considered part of the clinical record, resulting in incomplete and inaccurate documentation for this resident. In a separate incident, staff failed to document in the clinical record an event where one resident touched another resident's breast. Although the incident was reported to the state agency and staff intervened immediately, there was no documentation of the event in the affected resident's clinical record. The director of clinical services acknowledged that this incident should have been documented. Both deficiencies were confirmed by administrative staff during interviews.
Failure to Ensure Communication and Documentation with Hospice Provider
Penalty
Summary
Facility staff failed to provide evidence of communication between the hospice company and the facility for one resident who had been admitted to hospice care. The physician order documented the resident's admission to hospice, and a request was made for records of communication between the facility and the hospice provider. Documentation from the hospice company, including visit notes, was only faxed to the facility on a later date, despite hospice visits occurring earlier. When questioned, the director of clinical services explained that received hospice information is given to the medical records department and uploaded into the electronic medical record system, but could not specify the expected timeframe for this information to be available in the record. Further investigation revealed there was no hospice communication book on the unit, and while nursing staff reported verbal communication with hospice staff, there was no system in place to ensure this information was accessible to all staff, including physicians. Facility policy requires coordination and communication with hospice representatives and the attending physician, as well as the collection of specific hospice documentation. However, the facility was unable to demonstrate that these requirements were met for the resident in question.
Failure to Provide Required Communications Training for CNA
Penalty
Summary
Facility staff failed to provide required communications training for one of ten certified nursing assistants (CNA #5) as evidenced by staff interviews and document review. When the education records for CNA #5 were requested, administrative staff indicated they might not be able to provide the information due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not account for why the required training had not been completed in the past. A review of the facility's in-service training policy indicated that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. Despite this policy, the facility was unable to provide documentation that CNA #5 had received the necessary communications training, and no further information was provided prior to the survey exit.
Failure to Provide Required Resident Rights Training to Staff
Penalty
Summary
Facility staff failed to provide required resident rights training to two staff members, specifically a registered nurse and an operations staff member. During a review of education records, administrative staff indicated that they could not provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to her role, confirmed she was unaware of why the required trainings had not been completed in the past. She acknowledged that tracking and maintaining staff training is necessary to meet residents' needs and that managers are responsible for ensuring staff are properly trained. A review of the facility's policy on in-service training revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also states that each center is responsible for ensuring compliance with federal, state, and local regulations regarding staff education. No further information or documentation regarding the missing training was provided prior to the survey team's exit.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to RN
Penalty
Summary
Facility staff failed to provide required training in the prevention of resident abuse, neglect, and exploitation for one of ten staff records reviewed, specifically for a registered nurse. During the survey, the education records for this nurse were requested, but administrative staff indicated they might not be able to provide the information due to a recent sale of the facility and lack of access to old personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not speak to why the required trainings were not completed in the past. A review of the facility's policy on in-service training revealed that employees are to be provided training on required topics annually, with additional training as needed based on regulatory requirements and facility assessments. However, for the registered nurse in question, there was no documentation or evidence provided to show that the required training on abuse, neglect, and exploitation prevention had been completed, as required by federal, state, and local regulations.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
Facility staff failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to two staff members, a registered nurse and a dietary staff member, as identified through staff interviews and review of facility documents. When education records for these staff members were requested, administrative staff indicated that the facility's recent change in ownership and lack of access to previous personnel records prevented them from providing the required documentation. The assistant director of clinical services, who was new to the role, was unable to explain why the required trainings had not been completed in the past. A review of the facility's policy on in-service training revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also states that each center is responsible for ensuring compliance with federal, state, and local training regulations. No further information or documentation regarding the missing QAPI training was provided to the survey team prior to their exit.
Failure to Provide Required Infection Control Training to RN
Penalty
Summary
Facility staff failed to provide required infection control training for one of ten staff members reviewed, specifically a registered nurse. During the survey, the education records for this nurse were requested, but facility administrative staff indicated they could not provide the information due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she was unaware of why the required trainings had not been completed in the past. A review of the facility's in-service training policy revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. Despite this policy, the facility was unable to demonstrate that the required infection control training had been provided to the registered nurse in question, and no further documentation was made available to the survey team prior to their exit.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
Facility staff failed to provide required compliance and ethics training for one of ten staff members reviewed, specifically a registered nurse. During the survey, the nurse's education records were requested, but administrative staff indicated they might not be able to provide the information due to a recent sale of the facility and lack of access to old personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not speak to why the required trainings were not completed in the past. She stated that she would be responsible for staff training moving forward and acknowledged the importance of training in meeting residents' needs. A review of the facility's policy on in-service training indicated that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also stated that each center is responsible for ensuring compliance with federal, state, and local regulations regarding staff training. No further information or documentation regarding the missing training was provided prior to the survey exit.
Failure to Provide Required Annual Education for CNAs
Penalty
Summary
The facility failed to provide at least 12 hours of annual education to two certified nurse aides (CNAs) over the past 12 months, as required. When surveyors requested the education records for these CNAs, administrative staff, including the executive director and director of clinical services, indicated that they might not be able to provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not account for the missing education hours in the past. No further information or documentation was provided to the survey team prior to the exit interview.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
Facility staff failed to provide required behavioral health training for two staff members, a registered nurse and a dietary staff member, as identified through staff interviews and review of facility documents. When education records for these staff were requested, administrative staff indicated that the facility's recent change in ownership and lack of access to previous personnel records prevented them from providing the necessary documentation. The assistant director of clinical services, who was new to the role, acknowledged that she could not account for why the required trainings had not been completed in the past. The facility's policy on in-service training specifies that employees are to receive training on required topics annually, with additional training as determined by the facility assessment and regulatory requirements. Despite this policy, the facility was unable to demonstrate that the required behavioral health training had been provided to the identified staff members. No further information or documentation was provided to address the deficiency prior to the survey exit.
Unqualified Activities Director
Penalty
Summary
The facility staff failed to ensure that the activities program was directed by a qualified professional, potentially affecting all residents in the facility. The director of activities, who was hired on October 12, 2023, did not meet the qualifications required for the position at the time of hire. The employee record review revealed that the director, previously employed as a CNA and supply/transportation coordinator, only completed an activity management certification class from January 15, 2024, through January 19, 2024, and was not certified prior to this period. The job description for the director of activities required a Bachelor's Degree in therapeutic recreation or equivalent training/experience, NCCAP certification, and a minimum of two years of experience in therapeutic recreation. The facility's executive director and director of nursing were informed of the concern, but they could not provide evidence that the director of activities was qualified from the time of hire until the completion of the certification class. The facility policy outlined various responsibilities for the Community Life Director, including the management and coordination of recreational activities, but the director did not meet the qualifications during the initial period of employment.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility staff failed to investigate an allegation of abuse and report the findings to the State Agency for two residents involved in a physical altercation. The incident occurred on 7/28/23 between two residents, one of whom was cognitively impaired and the other cognitively intact. The facility submitted an initial report to the state agency but did not follow through with an investigation or provide a follow-up report. Nurse's notes documented the altercation and the residents' conditions, but no further investigation was conducted. During the survey, it was discovered that the investigation was not completed, and no documentation was available. The facility's policy required the Director of Nursing or designee to investigate all reported events, but this process was not followed. The Administrator acknowledged the oversight, attributing it to a transition period when a former Director of Nursing left, and admitted that the reporting process was not adhered to. The facility's policy on abuse, neglect, exploitation, and misappropriation was reviewed, highlighting the requirement for thorough investigation and reporting of such incidents.
Deficiency in Hospital Transfer Documentation
Penalty
Summary
The facility staff failed to provide adequate documentation during hospital transfers for three residents, leading to deficiencies in the transition of care. For one resident, there was no evidence of documentation provided to the receiving facility during a hospital transfer for a suspected stroke. Additionally, during a subsequent transfer due to a fall, the comprehensive care plan goals were not sent. Interviews with staff revealed that only face sheets and orders were typically sent, and if not documented in the progress notes, there was no evidence of what was sent. Another resident experienced a similar issue, with no documentation provided during a hospital transfer for severe chest pain. During a later transfer due to vomiting and refusal of IV fluids, the comprehensive care plan goals were again not sent. The facility's policy requires specific information to be sent to ensure a safe transition, but staff interviews confirmed that only limited documentation was typically sent, and there was no evidence if it was not recorded in the progress notes. A third resident was transferred to the hospital due to a critical potassium level, but there was no evidence of any transfer form or clinical documents being sent. Interviews with staff indicated that while certain documents were supposed to be sent, there was no evidence if they were not documented in the progress notes. The facility's policy mandates comprehensive documentation for transfers, but the lack of evidence suggests this was not consistently followed.
Failure to Provide Bed Hold Notices Upon Hospital Transfers
Penalty
Summary
The facility staff failed to provide written bed hold notices to the resident representatives upon hospital transfers for three residents. For Resident #21, there was no evidence of a written bed hold notice provided during hospital transfers on two occasions. The clinical records for these transfers, which were due to a suspected stroke and a fall with increased pain, did not include any documentation of a bed hold notice. Interviews with the Director of Social Services and an LPN revealed a lack of clarity regarding the responsibility for issuing these notices, and the facility's policy did not address the requirement for such notices. Similarly, for Resident #61, the facility did not provide a written bed hold notice upon the resident's request to be sent to the emergency department. The clinical record lacked evidence of the notice, and staff interviews indicated confusion about the process. For Resident #160, who was transferred to the hospital due to a critical potassium level, there was also no evidence of a bed hold notice being provided. Interviews with staff members, including the Director of Social Services and an LPN, highlighted inconsistencies in understanding who was responsible for issuing the notices. The facility's policy did not include a requirement for providing written bed hold notices upon hospital transfers.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility staff failed to provide adequate respiratory care and services for six residents, leading to deficiencies in their care. For one resident, the staff did not store the nebulizer mouthpiece in a sanitary manner, leaving it uncovered on the bedside table. This resident had a severe cognitive impairment, making it difficult for them to make daily decisions. The physician's order required the use of a nebulizer with specific medication for shortness of breath, but the improper storage of the mouthpiece posed a risk of infection. Another resident was not administered oxygen according to the physician's order, and their BiPAP mask was left uncovered. This resident was cognitively intact and had a history of respiratory failure and sleep apnea. The oxygen flow rate was set higher than prescribed, and the BiPAP mask was not stored in a sanitary manner, contrary to the facility's infection control procedures. The staff's failure to adhere to the physician's orders and proper storage protocols compromised the resident's respiratory care. Additional deficiencies were noted for other residents, including incorrect oxygen flow rates and improper storage of respiratory equipment. One resident's oxygen concentrator was set at a rate different from the physician's order, and there was no documentation of any changes to the order. Another resident's nebulizer mask was left uncovered, and the facility's policy for storing nebulizer equipment was not followed. These failures in providing respiratory care and adhering to physician orders highlight significant lapses in the facility's infection control and respiratory therapy practices.
Failure to Implement Complete Pain Management Program
Penalty
Summary
The facility staff failed to implement a complete pain management program for a resident, identified as Resident #3, who was admitted with chronic pain. Despite having a comprehensive care plan that included non-pharmacological interventions for pain management, the staff did not attempt these interventions before administering prn pain medications such as Oxycodone-Acetaminophen and Oxycodone. The resident was cognitively intact and reported occasional pain levels ranging from four to nine on a scale of ten. However, the electronic medication administration records (eMAR) for December 2023 and January 2024 showed multiple instances where the resident received pain medication without any documented attempts of non-pharmacological interventions. Interviews with the resident and a licensed practical nurse (LPN) revealed that non-pharmacological methods were not attempted before administering pain medication. The facility's policy on pain management required the development of patient-centered interventions, both pharmacological and non-pharmacological, and monitoring of the resident's response. However, the facility's progress notes and Pain Flow Record for the relevant dates lacked documentation of any non-pharmacological interventions. The deficiency was communicated to the facility's executive director, director of nursing, regional director of clinical services, and vice president of risk management, but no further information was provided before the survey exit.
RN Coverage Deficiency
Penalty
Summary
The facility failed to meet the registered nurse (RN) requirements for two out of thirty days during a review of RN coverage. Specifically, the Director of Nursing (DON) served as the RN charge nurse on two consecutive days, despite the facility's census being 158 and 157 on those days. This occurred on a Saturday and Sunday, when the DON worked the day shift as the charge nurse. An interview with the DON revealed that due to insufficient staffing, he occasionally worked on the floor as a charge nurse during weekends or evenings, in addition to his full-time role as the DON. The facility's staffing policy did not address this issue.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility staff failed to complete an annual performance review for five certified nursing assistants (CNAs), identified as CNA #11, CNA #12, CNA #13, CNA #14, and CNA #15. These CNAs were hired on various dates ranging from 1976 to 2022. During an interview, the director of human resources, who had been employed at the facility since January 2024, acknowledged that it was her responsibility to ensure performance reviews were conducted. She explained her process of printing out due performance reviews at the beginning of each month and distributing them to supervisors for completion, followed by tracking their progress. However, she was unable to provide the required annual performance reviews for the CNAs in question. The facility's policy mandates continual and annual evaluations of employee performance, which were not adhered to in these cases.
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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