Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Augusta Nursing And Rehabilitation during CMS and state inspections, most recent first.
Inadequate Snack Availability and Missed Bedtime Offerings: Staff failed to provide bedtime and between-meal snacks for multiple residents, including residents with DM, nutritional risk, and cognitive impairment. Surveyors found nourishment rooms with little or no snack stock and a kitchen dry storage area without snack items. Interviews and ADL records showed residents were not consistently offered snacks, and staff stated snacks were mainly prepared for diabetic residents rather than the whole building.
Staff failed to implement care plan interventions for two residents by not consistently providing snacks and not documenting meal intake. One resident had dementia and severe cognitive impairment, while the other had DM, CKD, and GERD and stated that bedtime snacks were not provided despite the care plan directing ordered diet, intake monitoring, and food substitutes.
Failure to document eating assistance and meal intake for a cognitively intact resident. A resident with depression was assessed as needing setup or clean-up assistance for eating, but the ADL record did not show the resident’s level of assistance or the percentage of food consumed in multiple meal opportunities. CNAs stated that this information is documented on the ADL record, and the facility policy required residents’ ADL abilities not to deteriorate unless unavoidable.
Failure to document and provide feeding assistance for two residents. One resident with COPD, dysphagia, and severe cognitive impairment had repeated gaps in ADL documentation for meal assistance and percent consumed, despite staff describing variable need for prompting, minimal help, or total feeding assistance. Another resident with hepatic encephalopathy and dependence for multiple ADLs had numerous missing meal-intake entries, and staff reported confusion about feeder status while the resident was observed without a lunch tray and later documented as refusing meals.
Improper Food Handling by Dietary Manager: The Dietary Manager was observed plating dessert and preparing peanut butter protein drinks for residents without his mustache covered. He later acknowledged that mustache guards are worn to prevent hair from falling into food and stated he should have had his mustache covered. The facility's Staff Attire policy required employees to wear approved attire while performing their duties.
A resident with dementia and a known elopement risk was able to leave the facility unnoticed due to a malfunctioning wander guard system and inadequate supervision. The resident fell into a drainage ditch, resulting in back pain and requiring medical treatment. The facility's wander guard system frequently failed to trigger alarms, and staff did not consistently implement monitoring interventions, leading to the resident's elopement and injury.
The facility failed to uphold residents' voting rights and maintain a dignified environment. Multiple residents expressed a desire to vote but were not informed about the process, and the deadline for registration had passed. Additionally, a loud argument between staff members in a resident's room caused distress to residents, highlighting a lack of policy on staff interactions in care areas.
The facility failed to ensure residents could exercise their voting rights, as multiple residents were not informed about voting opportunities. The social service director and administrator acknowledged the lack of preparation and communication, resulting in missed registration deadlines and confusion about absentee ballots. The facility lacked a formal voting policy, leading to a deficiency in promoting resident autonomy.
The facility failed to uphold residents' voting rights and provide a dignified environment. Multiple residents were uninformed about voting options, and the deadline for registration had passed. Additionally, a loud argument between staff in a resident's room caused distress, highlighting a lack of policy on staff interactions in care areas.
The facility failed to manage its wander management system, allowing residents at risk of elopement to exit unsupervised. Additionally, the administration did not ensure residents' voting rights were upheld, leaving many uninformed about the voting process. A staff argument disrupted residents, with the administrator unaware until informed by surveyors.
Facility staff failed to assess residents for self-administration of medications, leading to medications being left at the bedside without proper authorization. A resident was given sodium bicarbonate tablets without an assessment, another had Vicks vapor rub without a physician's order, and a third had Tums left for self-administration without proper evaluation. The facility's policy requires a physician's order and an interdisciplinary team assessment for self-administration, which was not followed.
The facility failed to implement its abuse policy for two residents, leading to deficiencies in reporting and addressing potential abuse or mistreatment. A resident with multiple sclerosis and other conditions reported feeling unsafe due to a CNA's rough handling, but the incident was not reported to the state agency. Another resident with dementia and other conditions experienced distress when a CNA allegedly pointed a finger in their face, but the incident was reported late. The facility's policy mandates immediate reporting, which was not followed in these cases.
The facility failed to report suspected abuse and mistreatment for two residents. One resident, with multiple health conditions, felt unsafe due to a CNA's rough handling, but the incident was not reported to the state agency. Another resident, with dementia and other conditions, experienced a delay in reporting an incident involving a CNA pointing fingers during a confrontation. The facility's abuse policy requires immediate reporting, but these incidents were not reported timely, leading to deficiencies.
A resident with dementia and identified as an elopement risk managed to leave the facility unsupervised, despite wearing a wander guard. The facility's investigation was inadequate, failing to interview the resident promptly and inaccurately concluding that a receptionist allowed the exit. The wander guard system was known to malfunction, yet this was not considered in the investigation, highlighting deficiencies in managing elopement risks.
A resident identified as an elopement risk due to dementia and smoking habits was not monitored every 30 minutes as required by their care plan. Observations showed no evidence of consistent monitoring, and the facility could not provide documentation of such checks, except for a brief period. The responsible care plan nurse was no longer employed, and another LPN was unaware of the intervention.
A resident, previously assessed as an elopement risk, was found outside the facility by a CNA, indicating a failure to update the care plan. Despite a later assessment showing the resident was no longer at risk, the care plan was not revised until the survey team intervened. The facility's policy mandates timely updates to care plans based on assessments, which was not followed in this instance.
Facility staff failed to follow professional standards during medication administration for two residents. One resident was left with medication unattended, unaware of its purpose, and not permitted to self-administer. Another resident had medication at the bedside without proper physician orders or administration records. Nurses did not ensure medications were consumed, contrary to facility policy.
The facility staff failed to securely store medications for two residents. One resident had Vicks vapor rub unsecured at the bedside, and another had Ketoconazole Shampoo 2% on the bedside table. The facility's policy requires secure storage of all medications, but these were accessible to anyone entering the rooms.
The facility failed to maintain accurate clinical records for two residents. One resident's records were incomplete due to a mix-up with another resident's name, resulting in missing medication documentation. Another resident's assessment was not documented after an elopement and fall, despite being advised to do so. These deficiencies indicate significant oversights in record-keeping.
The facility failed to protect residents from abuse and neglect, resulting in psychosocial harm and immediate jeopardy. A male resident engaged in inappropriate sexual behavior with female residents, including unwanted advances and verbal harassment. Despite reports from residents and staff, the facility administration did not adequately investigate or address these incidents, allowing the behavior to continue. The administration dismissed allegations as rumors, requiring written reports before taking action, contributing to ongoing abuse and harassment.
A resident in an LTC facility engaged in inappropriate sexual behavior and verbal harassment towards multiple residents, causing psychosocial harm. Despite staff awareness, these incidents were not reported to authorities, and the affected residents altered their routines to avoid the perpetrator. The facility failed to assess the cognitive capacity of one resident involved in the incidents, leading to a finding of immediate jeopardy.
A male resident in an LTC facility was reported to have engaged in inappropriate behavior and sexual harassment towards female residents, affecting 59 out of 98 residents. Despite multiple reports and observations of the male resident's actions, the facility staff failed to investigate or document these incidents properly. This led to immediate jeopardy and psychosocial harm for several residents, with no measures taken to protect them or prevent further abuse.
A male resident in a LTC facility engaged in inappropriate sexual behavior and comments towards female residents, causing psychosocial harm and leading them to alter their routines to avoid him. Despite awareness of the situation, the facility staff failed to document or address the incidents adequately, resulting in immediate jeopardy for the residents' safety and well-being.
A resident with dementia and a known elopement risk exited a facility unnoticed due to a malfunctioning wander guard system, resulting in a fall and injury. The system failed to consistently trigger alarms or lock doors, and staff were unclear on supervision protocols. This led to immediate jeopardy, requiring urgent corrective action.
A male resident in the facility engaged in inappropriate sexual behaviors and harassment towards female residents, causing psychosocial harm. Despite being aware of these incidents, the facility's administration and staff failed to implement effective interventions or conduct thorough investigations. The administrator, who is also the abuse coordinator, did not ensure proper documentation or credible evidence collection, leading to immediate jeopardy findings in abuse and quality of life.
The facility failed to uphold residents' rights to vote and maintain a dignified environment. Multiple residents expressed a desire to vote but were not informed about voting procedures. Additionally, a loud argument between staff in a resident's room caused distress, highlighting a lack of policy on staff interactions in care areas. The administration was unaware of the incident until informed by surveyors.
The facility staff failed to assess and determine if four residents were safe to self-administer medications, resulting in medications being stored in residents' rooms without proper authorization or assessment. Observations revealed that residents had various medications at their bedside, and interviews with an LPN confirmed that medications should not be at the bedside. The clinical records lacked evaluations for self-administration, and facility policies require that criteria be met to determine a resident's capability to self-administer medications safely.
The facility failed to ensure residents could exercise their voting rights, as multiple residents were not informed about voting procedures or deadlines. The social service director, new to the position, and the administrator acknowledged the oversight, with no formal voting policy in place. This resulted in residents being unable to participate in the election process, highlighting a deficiency in promoting resident autonomy.
A deficiency was identified due to inadequate nurse staffing on one unit, resulting in delayed responses to resident call bells. Observations showed only two nurses initially present, with four call bells sounding and no immediate assistance available. Interviews confirmed staffing shortages, with only one CNA scheduled during critical hours. The issue was acknowledged by facility leadership.
The facility staff failed to secure medications, leaving them accessible in resident rooms. A resident had medications without orders for bedside storage or self-medication, and no assessments for safe self-administration were found. Another resident had Flonase nasal spray at the bedside, with nurses responsible for administering medications. Unsecured medications, including dermal wound cleanser and antifungal powder, were found in a third resident's room. A fourth resident had saline mist spray and Aquaphor ointment at the bedside, with no orders or assessments for self-medication. Interviews confirmed that medications should be stored in a locked cart or room, not at the bedside.
A resident reported feeling unsafe due to inappropriate interactions with another resident, but the facility failed to document or address the grievance. Despite awareness of the issue by the DON and administrator, there was no evidence of a formal grievance or investigation, and a stop-sign banner meant to prevent unwanted entry was not in place.
The facility failed to implement its abuse policy for two residents, leading to deficiencies in reporting and addressing allegations of mistreatment. One resident reported rough handling by a CNA, which was not reported to the state agency. Another resident's allegation of mistreatment was reported late, missing the required 24-hour window. The facility's abuse policy mandates immediate reporting, but it was not followed in these cases.
A resident's comprehensive care plan was not developed or implemented, failing to address their medical and nursing needs, despite being dependent on oxygen and receiving an anticoagulant. The care plan coordinators confirmed that the care plan was not completed following the resident's admission assessment, and several quarters passed without review, contrary to facility policy.
The facility failed to update care plans for two residents after falls, neglecting to include interventions to prevent recurrence. One resident was sent to the ER after a fall, yet their care plan lacked fall risk information. Another resident's care plan was outdated, missing new interventions despite identified fall factors. Staff confirmed care plans should be revised with any incident, which was not done, leading to deficiencies.
Two residents were involved in medication administration deficiencies where nurses failed to observe them taking their medications. One resident was left with sodium bicarbonate tablets without supervision, and another had Tums left at the bedside without proper documentation or physician orders. The facility's records confirmed neither resident was permitted to self-administer medications.
A resident discharged after a hip replacement did not have an effective discharge plan, resulting in no home health services or timely medication arrangements. The discharge instructions were incomplete, and necessary records were not sent to the home health agency. Staff interviews revealed a lack of coordination, with the NP noting medications were sent late and the SW confirming no records were sent for home health services.
Staff on a nursing unit failed to respond to call bells in a timely manner, with some calls going unanswered for up to 30 minutes despite staff presence. Residents expressed dissatisfaction with the delays, and the facility's policy requires prompt response to call lights. The regional director of clinical services stated that call bells should be answered within 10 to 15 minutes.
Two residents in a facility did not receive timely incontinence care, resulting in unsanitary conditions and strong odors. One resident was found with feces and urine on her bed, while another had wet clothing and a saturated wheelchair. Staff interviews confirmed that incontinence care should occur every two hours, but understaffing was cited as a challenge.
The facility failed to conduct a yearly performance review for a CNA, as required by their policy. The CNA, hired in November 2021, had their last review in July 2022, missing the annual evaluation deadline. Interviews confirmed the oversight, and the issue was discussed with the regional director and a consultant.
The facility staff failed to provide therapeutic diets as ordered for two residents, resulting in deficiencies. A resident did not receive fortified foods and large portions as prescribed, and another resident did not receive large portions. The dietary manager served regular portions despite meal ticket instructions, and interviews revealed a misunderstanding of portion sizes. Clinical records confirmed the orders, and the facility's policy on therapeutic diets was not correctly implemented.
A facility failed to maintain a complete and accurate clinical record for a resident, as required by regulations. The deficiency involved the lack of documentation regarding a mark on a resident's neck, reportedly caused by another resident, and several instances of inappropriate behavior between the two. Despite staff awareness and reports of these incidents, the necessary documentation was missing from the clinical records.
A facility failed to provide QAPI training to six out of eight staff members reviewed, as revealed by personnel file examinations and staff interviews. Only two employees had documented evidence of QAPI training. The regional vice president of operations highlighted the importance of such training for staff to identify and report issues effectively, citing a past instance involving malfunctioning Hoyer lifts. Despite acknowledging the deficiency, no further documentation was provided before the survey exit.
Facility staff failed to follow a physician's order to obtain a stat x-ray for a resident who fell and presented with pain and swelling in the right ribcage. The order was not properly transmitted to the x-ray company, resulting in a delay attributed to the holiday weekend. The resident was later sent to the hospital where a CT scan was performed.
Inadequate Snack Availability and Missed Bedtime Offerings
Penalty
Summary
The facility failed to provide snacks at bedtime and between meals for residents whose care plans and conditions indicated a need for nourishment support. Surveyors found that unit nourishment pantries were inconsistently stocked, with some halls having no snacks at all and others containing only limited items such as peanut butter sandwiches, mighty shakes, vanilla ice cream cups, or chocolate snack cakes. A review of the kitchen dry storage area also found no snack crackers, cookies, or other snack varieties available for residents. Resident #2 was admitted with diagnoses including Alzheimer’s disease, dementia, and rheumatoid arthritis, and the most recent MDS coded the resident as severely cognitively impaired. The resident’s care plan identified nutritional risk related to esophageal ulcer with bleeding, hypothyroidism, hiatal hernia, and protein calorie malnutrition, with interventions to provide ordered supplements and diet and to monitor intake. The resident’s ADL record showed multiple days with no evidence of snacks being provided or meal intake documented, and the resident stated that snacks were only brought once in a while and that there was no snack the previous evening. Resident #5 had diagnoses including diabetes mellitus and pneumonitis due to inhalation of food or vomit, and the MDS showed the resident was cognitively intact and independent in daily function. The care plan identified nutritional risk related to type 2 DM, CKD, and GERD, with interventions to provide the ordered diet, monitor intake, and offer substitutes for foods not eaten. The resident stated that bedtime snacks were not provided and that, despite diabetes, a bedtime snack should be available. Resident #3, who was cognitively intact, stated that snacks were not always offered during the day or evening, and the ADL record documented missed snack opportunities during the overnight period. Resident #4, who was severely cognitively impaired and had swallowing difficulties, also had no evidence of consistent snack provision, and staff interviews confirmed that snacks were not always available for residents who were not diabetic.
Failure to Implement Care Plans for Snacks and Meal Intake Monitoring
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for two residents by not providing snacks and not consistently monitoring and recording meal intake. One resident had diagnoses including Alzheimer's disease, dementia, rheumatoid arthritis, ulcer of the esophagus with bleeding, hypothyroidism, hiatal hernia, and protein calorie malnutrition. The resident's quarterly MDS coded severe cognitive impairment, and the care plan directed staff to provide and serve supplements and diet as ordered and to monitor intake and record every meal. Review of the ADL record for March through May 2026 showed no evidence of snacks being provided or meal intake percentages recorded on multiple days, and the resident stated staff only brought food "once in a while." A second resident had diagnoses including DM, pneumonitis due to inhalation of food or vomit, CKD, and GERD. The resident's quarterly MDS coded the resident as cognitively intact and independent in ADLs, and the care plan directed staff to provide and serve the ordered diet, monitor intake and record every meal, and offer substitutes for foods not eaten. Review of the ADL record for March through May 2026 showed no evidence of snacks being provided or meal intake percentages recorded on multiple days, and the resident stated no snacks were provided and that a bedtime snack was not brought in, despite the resident stating that with diabetes a bedtime snack should be provided. RN #1 stated that if interventions are not followed, the care plan has not been implemented.
Failure to Document Eating Assistance and Meal Intake
Penalty
Summary
Facility staff failed to provide ADL care for one of five residents reviewed, Resident #3, by not documenting the resident’s level of assistance and the percentage of food consumed during meals. Resident #3 was admitted with a diagnosis that included depression, and the most recent comprehensive MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for making daily decisions. Section GG Functional Abilities coded the resident as requiring setup or clean-up assistance for eating, meaning the resident completed the activity after the helper set up or cleaned up. The ADL sheet for May 2026 documented eating at 0900, 1300, and 1800, but review of the record failed to show documentation of the resident’s level of assistance and the percentage of the meal consumed in 9 of 19 opportunities. During interviews, CNA #1, CNA #5, and CNA #6 each stated that the resident’s level of assistance during a meal and the percentage of the meal consumed are documented on the ADL record. The facility’s ADL policy stated that the facility will ensure a resident’s abilities in ADLs do not deteriorate unless deterioration is unavoidable.
Failure to Document and Provide Feeding Assistance
Penalty
Summary
Facility staff failed to provide activities of daily living assistance for dependent residents, including failure to document feeding assistance and meal intake for two residents. One resident had diagnoses including COPD and dysphagia, was severely cognitively impaired on the most recent BIMS, and was coded on the MDS as requiring setup or clean-up assistance for functional abilities. The resident’s ADL records for February, March, and April 2026 repeatedly lacked documentation of the level of assistance provided during meals and the percentage of food consumed across numerous meal opportunities. During interviews, CNA staff and the ADON described that the resident could sometimes feed self with prompting or minimal assistance, sometimes required total assistance, and was independent with finger foods. Staff also stated that family members often came in to feed the resident at lunch and dinner. Despite these descriptions of variable feeding needs and assistance, the ADL records did not consistently show the resident’s level of assistance or meal consumption percentages for many documented meals. A second resident had diagnoses including fracture of the left ulna, neuropathy, and hepatic encephalopathy, and the MDS coded the resident as dependent for multiple ADLs and needing assistance with meals. The care plan directed staff to provide the ordered diet and monitor intake and record every meal. The resident’s ADL record had missing percent-eating documentation on numerous dates from March through May 2026. On one occasion, the resident was observed sleeping in bed with no lunch tray present, and staff stated the family had asked not to feed the resident, while another staff member stated the resident refused breakfast and lunch when offered. Interviews also showed staff concern that there was a lack of communication about which residents were feeders and that meal assistance was not clearly documented.
Improper Food Handling by Dietary Manager
Penalty
Summary
Facility staff failed to prepare food in a sanitary manner in the kitchen. During observation on 05/06/2026, the Dietary Manager was seen plating and covering slices of caramel apple cake for resident dessert without having his mustache covered, and later was observed making peanut butter protein drinks for residents without having his mustache covered. When interviewed the same day, the Dietary Manager stated that hair, beard, and mustache guards are worn to prevent hair from falling into food and acknowledged that he should have had his mustache covered. The facility's Staff Attire policy stated that all employees wear approved attire for the performance of their duties. The Executive Director and Director of Clinical Services were informed of the findings on 05/07/2026, and no further information was provided prior to exit.
Inadequate Supervision and Malfunctioning Wander Guard System Lead to Resident Elopement
Penalty
Summary
The facility staff failed to provide an environment free from accident hazards and adequate supervision to prevent an avoidable accident for a resident identified as an elopement risk. The resident, who had a history of dementia and was known to wander, was wearing a wander guard device. Despite this, the resident was able to exit the facility without staff knowledge, leading to an incident where the resident fell into a drainage ditch and was unable to get up, resulting in back pain and the need for medical treatment. The wander guard system at the facility was found to be inconsistently functioning, which contributed to the resident's ability to leave the premises unnoticed. Staff interviews revealed that the wander guard system frequently failed to trigger alarms or lock doors as intended. On multiple occasions, the system did not function properly, allowing residents to exit the facility without setting off alarms. This lack of a reliable wander guard system, combined with inadequate supervision, allowed the resident to elope and suffer harm. The resident's care plan had identified them as an elopement risk, and interventions were in place to monitor their location. However, the facility failed to consistently implement these interventions, as evidenced by the lack of documentation for required checks. The facility's inability to maintain a functioning wander guard system and ensure adequate supervision directly led to the resident's elopement and subsequent injury.
Failure to Uphold Resident Voting Rights and Maintain Dignity
Penalty
Summary
The facility staff failed to uphold the residents' rights to vote, affecting multiple residents across two units. During the survey, several residents expressed their desire to vote and reported that no one from the facility had discussed voting with them. The social service director, who had recently assumed her position, acknowledged the lack of posted voting information and had not contacted the registrar's office until prompted by the surveyor. The administrator admitted that preparations for voting should have begun in September, but due to a vacancy in the social services department, this was not done. Consequently, the deadline for non-registered voters to register had passed, and residents registered in other counties faced uncertainty about submitting absentee ballots. Additionally, the facility staff failed to provide an environment that promotes dignity on one of the units. An incident occurred where a unit manager and a certified nursing assistant engaged in a loud argument in a resident's room, causing distress to the residents present. One resident reported feeling anxious and agitated due to the yelling, while another resident expressed discomfort and a desire for the argument to be taken elsewhere. The altercation was witnessed by other staff members, who confirmed the loud and disruptive nature of the incident. The facility lacked a specific policy regarding staff interactions in resident care areas, although they provided documents outlining professional courtesy and resident rights. The facility's administrator and regional director of clinical services were unaware of the staff argument until informed by the surveyors. They later suspended the employees involved and reported the incident as an allegation of abuse. However, the facility's failure to address the voting rights and maintain a respectful environment for residents led to deficiencies in upholding resident rights and dignity.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility staff failed to ensure that residents were able to exercise their right to vote, which is an important aspect of resident autonomy and self-determination. During an initial tour, two residents expressed their desire to vote and mentioned that no one from the facility had discussed voting with them. The social service director, who had recently assumed her position, acknowledged the lack of posted voting information and committed to addressing it. However, the administrator admitted that preparations for voting should have started earlier, and there was no voting policy in place. Further interviews revealed that multiple residents were not informed about voting opportunities. Some residents were registered to vote in different counties and were unsure about the absentee ballot process. Others were not registered and missed the registration deadline. The social services director confirmed that the deadline for non-registered voters had passed, and absentee ballots needed to be mailed by a specific date. Despite posting signs about voting, residents who did not leave their rooms were not informed, and the facility lacked a comprehensive plan to ensure all residents could exercise their voting rights. The facility's failure to facilitate voting for residents was compounded by the absence of a formal voting policy. The administrator provided a CMS guidance document that emphasized the importance of supporting residents' right to vote, but no specific policy was in place. The lack of proactive measures and communication with residents about voting opportunities resulted in a deficiency in promoting and facilitating resident self-determination through support of resident choice.
Failure to Uphold Voting Rights and Promote Dignity
Penalty
Summary
The facility staff failed to uphold the residents' right to vote, affecting multiple residents across two units. During the survey, several residents expressed their desire to vote and reported that no one from the facility had discussed voting with them. The social service director, who had recently assumed her position, acknowledged the oversight and stated that preparations for voting should have begun in September. The administrator confirmed that the facility lacked a voting policy and relied on a CMS document that emphasized the importance of supporting residents' voting rights. Despite posting notices in common areas, many residents remained uninformed about their voting options, and the deadline for voter registration had already passed. Additionally, the facility staff failed to provide an environment that promoted dignity for residents on one of the units. An incident occurred where a unit manager and a certified nursing assistant engaged in a loud argument in a resident's room, causing distress to the residents present. Resident #104 reported feeling anxious and agitated due to the yelling, while Resident #122 expressed discomfort and wished the argument had taken place elsewhere. The facility's director of nursing and regional director of clinical services were unaware of the incident until informed by the surveyors. The facility lacked a specific policy regarding staff interactions in resident care areas, although their Employee Guidebook and Code of Ethics emphasized professional courtesy and a non-hostile work environment. The facility's failure to address these issues in a timely manner resulted in a deficiency in maintaining residents' rights and dignity, as well as a lack of communication and preparation for voting.
Facility Management Failures in Wander Management, Voting Rights, and Staff Conduct
Penalty
Summary
The facility staff failed to effectively manage the wander management system, leading to residents with known elopement risks being able to exit the facility unsupervised. Multiple staff interviews revealed that the administration was aware of the malfunctioning wander guard system, yet residents identified as wandering risks were permitted to exit the facility. One resident, R113, was able to leave the facility multiple times unsupervised, resulting in an incident where she fell into a drainage ditch and was found by a staff member. Despite the known issues with the wander guard system, the facility administration did not ensure adequate supervision or address the malfunctioning system. The facility administration also failed to uphold residents' rights to vote, with several residents expressing their desire to vote but not receiving any guidance or information from the facility. The social service director, who had only been in the position for a short time, was unaware of the voting process and had not contacted the registrar's office. The administrator acknowledged that preparation for voting should have begun earlier, but due to the absence of a social services staff member, the process was delayed. As a result, residents were not informed about their voting rights or assisted in registering to vote before the deadline. Additionally, the facility administrator was unaware of a disruptive staff argument that occurred on the nursing unit and continued into the room of two residents. The argument involved raised voices that awoke one resident and caused distress to both. The administrator only became aware of the incident after being informed by the survey team. The staff involved in the argument were suspended, and an investigation was initiated. However, the administrator initially failed to recognize the involvement of one of the residents, who was cognitively intact and able to communicate about the incident.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility staff failed to ensure that residents were clinically assessed and deemed appropriate to self-administer medications before allowing them to do so. For Resident #111, a nurse left two sodium bicarbonate tablets at the bedside for the resident to self-administer without an assessment or physician's order permitting self-administration. The resident was unaware of the medication's purpose, and the nurse admitted to not following the accepted practice of observing the resident take the medication. Resident #114 was found with Vicks vapor rub at the bedside, which the resident used without a physician's order or an assessment to determine if self-administration was appropriate. The registered nurse confirmed that no medications should be left at the bedside and removed the vapor rub upon discovery. The unit manager acknowledged the need for an assessment to determine if the resident could self-administer the vapor rub safely. For Resident #121, medications were left at the bedside without an assessment or physician's order for self-administration. The resident identified the medication as Tums, which had been left for him to take. The registered nurse was unaware of the situation, and the unit manager confirmed issues with the resident's physician orders. The Director of Nursing emphasized the importance of following the facility's policy, which requires a physician's order and an interdisciplinary team assessment before allowing self-administration of medications.
Failure to Implement Abuse Policy for Two Residents
Penalty
Summary
The facility failed to implement its abuse policy for two residents, leading to deficiencies in reporting and addressing potential abuse or mistreatment. For Resident #203, who has multiple sclerosis, quadriplegia, pulmonary embolism, and depression, an incident occurred where a CNA was reported to have been rough and rude during care. The resident expressed feeling unsafe, although they did not believe the CNA intended harm. Despite the resident's concerns being reported to the DON and administrator, the incident was not reported to the state agency as required by the facility's abuse policy. The administrator and DON conducted an investigation but concluded it was a customer service issue rather than abuse, and the CNA was suspended pending further investigation. For Resident #207, who has dementia, diabetes, hemiplegia, and anxiety, an incident was reported where a CNA allegedly pointed a finger in the resident's face, causing distress. The incident was documented by a social worker, but there was a delay in reporting it to the appropriate authorities. The regional administrator was not informed until three days after the incident, which violated the facility's policy requiring timely reporting of such allegations. The CNA involved was terminated for unrelated reasons, and the incident was still under investigation at the time of the report. The facility's abuse policy mandates immediate reporting of any abuse allegations, but in both cases, the policy was not followed. The DON and administrator acknowledged the reporting failures, and the facility's documentation indicated that the incidents should have been reported within the specified time frames. The lack of timely reporting and proper implementation of the abuse policy resulted in deficiencies noted by the surveyors.
Failure to Report Abuse and Mistreatment Timely
Penalty
Summary
The facility failed to report suspicion of physical abuse or mistreatment for two residents, leading to deficiencies in their care. For one resident, diagnosed with multiple sclerosis, quadriplegia, pulmonary embolism, and depression, the facility did not report an incident where a CNA was perceived as rude and rough during care. The resident expressed feeling unsafe during the interaction, although they did not believe the CNA intended harm. Despite the resident's cognitive intactness and the incident being reported to the wound nurse, the facility's investigation concluded it was a customer service issue rather than abuse, and the incident was not reported to the state agency. In another case, the facility delayed reporting an incident involving a resident with dementia, diabetes, hemiplegia, and anxiety. The resident accused a CNA of pointing fingers in their face during a confrontation about missing items. Although the resident felt safe and acknowledged the CNA's habit of talking with her hands, the incident was not reported to the state agency within the required timeframe. The social worker initially reported the incident to the regional administrator, but there was confusion about whether it was communicated effectively, leading to a delay in filing the Facility Reported Incident. The facility's abuse policy mandates immediate reporting of any abuse allegations, but in these cases, the policy was not followed. The DON and administrator were involved in the investigations, but the lack of timely reporting to the state agency constituted a deficiency. The facility's failure to adhere to reporting protocols highlights a gap in their handling of potential abuse or mistreatment cases.
Inadequate Investigation of Resident Elopement Incident
Penalty
Summary
The facility staff failed to conduct a thorough and accurate investigation of a serious elopement incident involving a resident, identified as Resident #113, who was part of a survey sample of 29 residents. The incident occurred when the resident, who had a history of dementia and was identified as an elopement risk due to her smoking habit, managed to leave the facility unsupervised. The resident was found outside the facility, covered in mud, after having fallen and crawled out of a muddy area. Interviews with the resident revealed that she was able to exit the facility without any alarm sounding, despite wearing a wander guard. The investigation into the incident was inadequate, as the facility staff did not interview the resident about the incident until much later, and there was confusion about who allowed the resident to exit the building. The facility's synopsis of the incident inaccurately concluded that a receptionist allowed the resident to leave, despite conflicting statements from staff and the absence of a receptionist on the day of the incident. Additionally, the wander guard system was known to malfunction, and tests conducted by the facility staff confirmed its inconsistency, yet this was not considered a causative factor in the facility's investigation. The facility's documentation and policies were not effectively followed, as the resident was able to leave without signing out, and the wander guard system failed to prevent her exit. The facility's policy required residents to sign out before leaving, and the wander guard system was intended to prevent unsupervised exits. However, the system's failure and the lack of proper staff oversight allowed the resident to elope, highlighting significant deficiencies in the facility's management of elopement risks.
Failure to Implement Resident Monitoring Interventions
Penalty
Summary
The facility staff failed to implement the comprehensive care plan interventions for a resident identified as an elopement risk and wanderer due to dementia and smoking habits. The care plan required staff to monitor the resident's location every 30 minutes and as needed, but observations on multiple occasions showed no evidence of such monitoring. The care plan initially included monitoring every two hours, which was later updated to every 30 minutes, but this intervention was not followed. During the survey, the facility was unable to provide evidence of consistent monitoring, except for a brief period on one day. The care plan nurse responsible for entering the interventions was no longer employed at the facility, and another LPN was unaware of the current intervention. The care plan was eventually resolved by the regional director of clinical services, but the deficiency was noted due to the lack of implementation of the required safety checks.
Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility staff failed to review and revise the care plan for a resident, identified as no longer being an elopement risk, in a timely manner. The resident, who had been previously assessed as an elopement risk due to dementia and a smoking habit, was found outside the facility by a CNA, lying on the ground off the property. The CNA assisted the resident back to the facility, noting that the resident was wet and muddy, and there was no audible alarm indicating the resident's absence. Despite a subsequent assessment determining the resident was no longer an elopement risk, the care plan was not updated to reflect this change. The care plan, initially indicating the resident as an elopement risk, was not revised until after the survey team brought the issue to the facility's attention. The facility's policy requires care plans to be reviewed and updated based on changing needs and assessments, which was not adhered to in this case. The oversight was acknowledged by the facility's regional director of clinical services, who resolved the care plan issue only after the survey team highlighted the deficiency.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility staff failed to adhere to professional standards of care during medication administration for two residents. For one resident, a nurse left a cup containing two white tablets on the over bed table without observing the resident take the medication. The resident was unaware of the medication's purpose, and a visitor had to inform her that it was her morning medication. The nurse admitted to leaving the medication to retrieve insulin, acknowledging that the accepted practice is to ensure the resident takes the medication. The resident did not have an order permitting self-administration of medication, as confirmed by the facility's records. In another instance, a resident was found with a medication cup containing two large tablets on the over bed table. The resident identified the medication as Tums given for an ulcer, but there were no physician orders or records of medication administration in the resident's clinical record. The nurse responsible for the resident could not recall the medication administration, and the unit manager confirmed issues with the resident's physician orders. The Director of Nursing stated that nurses should follow the five rights of medication administration and ensure medications are consumed before leaving the resident. The facility's policy requires documentation of observations and education provided to the resident or family regarding medication.
Medication Storage Deficiency
Penalty
Summary
The facility staff failed to ensure medications were stored securely for two residents. For one resident, Vicks vapor rub was found unsecured at the bedside. The resident mentioned using it nightly to prevent nasal congestion. A registered nurse confirmed that no medications should be left at the bedside and removed the Vicks vapor rub upon observation. The facility's policy requires all medications to be stored securely, and there was no physician order for the use of Vicks vapor rub in the resident's clinical record. For another resident, a bottle of Ketoconazole Shampoo 2% with a pharmacy label was observed on the bedside table. The facility administration confirmed that the medication should not be stored at the bedside, as it was accessible to anyone entering the room. The facility's policy on medication storage emphasizes secure storage, including proper temperature, light, and humidity controls. The director of nursing reiterated that all medications should be stored securely in the medication cart.
Deficiencies in Clinical Record Maintenance for Two Residents
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for two residents, leading to deficiencies in their care. For one resident, who had been readmitted to the facility following hospitalization for a bleeding esophageal ulcer, the staff did not enter the resident's physician orders, nursing assessment, and documentation of medication administration into the correct clinical record. This resulted in an incomplete record, with no evidence of medication administration, including the antibiotic Zosyn, since the resident's readmission. The issue was compounded by a mix-up with another resident of a similar name, which was identified by the Director of Nursing. Another resident experienced a failure in documentation following an elopement and fall. The resident, who was wearing a wander guard, was found off the facility property by a CNA, who assisted the resident back to the facility. Despite the incident, there was no documentation of a nursing assessment in the clinical record, other than a fall risk evaluation. The regional director of clinical services had advised a nurse to complete an assessment upon the resident's return, but this was not documented in the clinical record. These deficiencies highlight the facility's failure to adhere to its policy on maintaining complete and accurate clinical records. The lack of proper documentation and record-keeping for both residents indicates a significant oversight in ensuring that all necessary medical information is accurately recorded and accessible, which is crucial for providing appropriate care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility staff failed to protect several residents from abuse and neglect, resulting in psychosocial harm and immediate jeopardy. The report highlights multiple incidents involving a male resident who engaged in inappropriate sexual behavior with female residents. This behavior included unwanted sexual advances, inappropriate touching, and verbal harassment. Despite numerous reports from residents and staff, the facility administration did not adequately investigate or address these incidents, allowing the behavior to continue. One resident, known to have delusions, was involved in a relationship with the male resident, who was reported to have engaged in sexual activities with her. The facility staff did not assess her capacity to consent to sexual relations, and there was no documentation of these interactions in her clinical records. Other residents reported feeling uncomfortable and altering their daily routines to avoid the male resident due to his inappropriate behavior. Despite these reports, the facility administration and nursing staff failed to take appropriate action to protect the residents. The facility's director of nursing and administrator were aware of the allegations but dismissed them as rumors and gossip, requiring written reports before taking action. This lack of response and failure to investigate the allegations contributed to the ongoing abuse and harassment of residents. The facility's inadequate handling of the situation and failure to protect residents from abuse and neglect resulted in the identification of immediate jeopardy by the survey team.
Failure to Report Abuse and Harassment by Resident
Penalty
Summary
The facility staff failed to report allegations of abuse and sexual harassment involving a resident, identified as R10, affecting multiple residents. The incidents included inappropriate sexual behavior and verbal harassment by R10 towards other residents, which were not reported to the appropriate authorities. This failure resulted in psychosocial harm to the affected residents, as they experienced distress and altered their daily routines to avoid interactions with R10. Resident #9 was involved in a situation where her ability to consent to sexual activity was questionable due to cognitive impairments. Despite multiple staff members being aware of inappropriate interactions between R9 and R10, including sexual activity, these incidents were not documented or reported. Interviews with staff and residents revealed that R9 had delusions and was not fully aware of her actions, yet the facility did not assess her capacity to consent or report the incidents to regulatory agencies. Other residents, including R7, R8, R12, and R13, also experienced harassment and inappropriate behavior from R10. These residents reported feeling uncomfortable and altered their routines to avoid R10. Despite being aware of these issues, the facility staff did not take appropriate action to report the allegations or protect the residents. The facility's policy required immediate reporting of such incidents, but this was not followed, leading to a finding of immediate jeopardy.
Failure to Investigate Allegations of Abuse and Sexual Harassment
Penalty
Summary
The facility staff failed to investigate allegations of abuse and sexual harassment by a male resident who was targeting female residents, affecting 59 female residents out of 98 in the facility. This failure resulted in immediate jeopardy and psychosocial harm for six residents. The staff did not take measures to protect the residents or prevent further potential abuse. Interviews with residents and staff revealed multiple instances of inappropriate behavior by the male resident, including sexual activity and harassment, which were not properly documented or investigated by the facility. For one resident, the facility staff did not take measures to protect her from further potential abuse or conduct an investigation to determine her capacity to consent to sexual activity. Despite reports of inappropriate behavior, including the male resident being seen at her bedside and engaging in sexual activity, there was no documentation of these interactions in her clinical record. The resident's cognitive skills were noted to be moderately impaired, yet no assessment of her ability to consent to sexual contact was documented. Another resident reported an incident involving the male resident that made her uncomfortable, leading her to self-isolate and change her daily routine to avoid him. Despite her daughter reporting the incident to social services, there was no documentation of the incident or any measures taken to protect her. The facility's grievance log did not contain any record of the incident, and observations revealed that a stop-sign banner meant to deter the male resident was not consistently in place. The facility administrator and director of nursing were aware of the incidents but failed to conduct thorough investigations or report them to regulatory agencies.
Failure to Protect Residents from Sexual Harassment
Penalty
Summary
The facility staff failed to provide care and services to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being, resulting in psychosocial harm for several residents. A known aggressor, identified as a male resident, was targeting female residents with inappropriate sexual comments and behaviors. This behavior led to multiple female residents feeling uncomfortable, scared, and altering their daily routines to avoid interactions with him. The facility did not document or address these incidents adequately, as evidenced by the lack of documentation in the grievance log and care plans. One resident reported self-isolating due to the aggressor's behavior, which included entering her room uninvited and making inappropriate comments. Despite the resident's daughter reporting the incident to social services, there was no documentation of the incident or any interventions implemented to address the resident's concerns. Another resident expressed anxiety and discomfort due to the aggressor's behavior, which included unwanted physical contact and inappropriate comments. This resident also altered her routine to avoid the aggressor, indicating a significant impact on her psychosocial well-being. Additional residents reported similar experiences, with one resident crying and expressing fear due to the aggressor's pressure for sexual activity. Another resident witnessed inappropriate sexual activity between the aggressor and her roommate, which affected her psychosocial well-being. The facility's administration and staff were aware of these issues but failed to take appropriate action to protect the residents and address the aggressor's behavior, resulting in immediate jeopardy for the residents' safety and well-being.
Inadequate Supervision and Malfunctioning Wander Guard System Lead to Resident Elopement and Injury
Penalty
Summary
The facility staff failed to provide an environment free from accident hazards and adequate supervision to prevent an avoidable accident for a resident identified as an elopement risk. The resident, who had a history of dementia and was known to wander, was wearing a wander guard device. Despite this, the resident was able to exit the facility without staff knowledge, resulting in a fall into a drainage ditch. The resident was found by a staff member driving to work, who assisted her back to the facility. The resident complained of back pain following the incident, which required medical attention and new physician orders for x-rays. The wander guard system at the facility was found to be inconsistently functioning, which contributed to the resident's ability to elope. Staff interviews revealed that the system did not always trigger alarms or lock doors as intended. On multiple occasions, the system failed to sound an alarm or lock the door when tested by staff and surveyors. Additionally, there was confusion among staff regarding the supervision and monitoring of residents with wander guards, as evidenced by inconsistent documentation of safety checks and unclear protocols for allowing residents outside. The facility's failure to maintain a consistently functioning wander guard system and provide adequate supervision for residents at risk of elopement resulted in immediate jeopardy. The lack of proper monitoring and functioning safety systems allowed the resident to leave the facility unnoticed, leading to a fall and subsequent harm. The survey team identified these deficiencies during their investigation, highlighting the need for immediate corrective action to ensure resident safety.
Failure to Protect Residents from Sexual Harassment and Abuse
Penalty
Summary
The facility staff failed to administer the facility in a manner that ensured residents' highest practicable psychosocial well-being and protection from sexual harassment and abuse. A male resident, identified as R10, was reported to have displayed inappropriate sexual behaviors and sexually harassed multiple female residents and staff. This behavior was known to the facility administrator and staff, yet appropriate interventions were not implemented to stop the abuse and harassment, resulting in psychosocial harm to several residents. Interviews with residents revealed that R10 engaged in inappropriate sexual conversations and actions, making female residents uncomfortable and scared. Resident R7 reported feeling uncomfortable and scared after R10 entered her room at night and made inappropriate comments. Other residents, such as R9 and R12, were also involved in incidents where R10's behavior was inappropriate, including unwanted touching and sexual comments. Despite these reports, the facility staff, including the administrator and DON, failed to take adequate action to address the situation. The facility's administration was aware of the allegations and incidents involving R10 but did not conduct thorough investigations or implement effective measures to protect the residents. The administrator, who is also the abuse coordinator, relied on the DON to handle investigations but did not ensure that proper documentation or credible evidence was collected. The facility's failure to act on these reports and protect residents from R10's behavior led to the identification of immediate jeopardy in the areas of abuse and quality of life by the survey team.
Failure to Uphold Resident Rights and Maintain Dignity
Penalty
Summary
The facility staff failed to uphold the residents' rights to vote, affecting multiple residents across two units. During the survey, several residents expressed their desire to vote and reported that no one from the facility had discussed voting with them. The social service director, who had only been in the position for a short time, acknowledged the lack of posted voting information and had not contacted the registrar's office until prompted by the surveyor. The administrator admitted that preparations for voting should have started earlier and that there was no voting policy in place, relying instead on a CMS document that affirmed residents' rights to vote. Additionally, the facility staff failed to provide an environment that promotes dignity on one of the units. An incident occurred where a unit manager and a certified nursing assistant engaged in a loud argument in a resident's room, causing distress to the residents present. One resident reported feeling anxious and agitated due to the yelling, while another resident expressed discomfort and a desire for the argument to be taken elsewhere. The altercation was not immediately addressed by the facility's administration, and the residents involved were not promptly interviewed about the incident. The facility lacked a specific policy regarding staff interactions in resident care areas, although they provided documents outlining professional courtesy and resident rights. The administration was unaware of the staff argument until informed by the surveyors, and the incident was later reported as an allegation of abuse. The facility's failure to ensure residents' rights to vote and to maintain a respectful environment contributed to the deficiencies identified during the survey.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility staff failed to assess and determine if four residents were safe to self-administer medications. During a tour of the facility, it was observed that several residents had medications stored in their rooms without proper authorization or assessment. Resident 16 had nose spray and eye drops on the overbed table, and the care plan indicated that nurses were to administer medications, with no orders for self-administration or bedside storage. Similarly, Resident 17 had Flonase nasal spray at the bedside, with no orders or evaluations for self-administration. Resident 18's room contained dermal wound cleanser, zinc oxide paste, and antifungal powder, all unsecured and without proper orders or evaluations for self-administration. Resident 19 had saline mist nasal spray and Aquaphor ointment at the bedside, with no orders for self-administration or bedside storage. Interviews with the unit manager confirmed that medications should not be at the bedside and should be removed if found. The clinical records for these residents lacked evaluations for self-administration of medications. Facility documentation and policies were reviewed, indicating that criteria must be met to determine if a resident is capable of self-administering medication. The interdisciplinary care planning team, along with the attending physician, must determine a resident's capacity to self-administer medications safely. The facility staff's failure to adhere to these policies and procedures resulted in the deficiency, as they did not assess the residents' ability to self-administer medications or ensure proper storage and documentation.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility staff failed to ensure that residents had the opportunity to exercise their autonomy regarding voting interests and preferences. During an initial tour, two residents expressed their desire to vote and mentioned that no one from the facility had discussed voting with them. The social service director, who had recently assumed her position, acknowledged the lack of posted voting information and committed to addressing it. The administrator admitted that voting preparations should have started earlier and that the absence of a social services staff member for a month contributed to the oversight. Further interviews with residents revealed that several individuals were not informed about voting procedures, despite expressing interest in participating in the election. Some residents were registered to vote in different counties and were unsure how to proceed, while others were not registered at all. The facility had not provided guidance or assistance in these matters, and the deadline for voter registration had already passed by the time the issue was addressed. The facility lacked a formal voting policy, as confirmed by the administrator, who provided a CMS guidance document that emphasized the importance of supporting residents' right to vote. The facility's failure to have a plan in place to facilitate residents' voting rights resulted in multiple residents being unable to participate in the election process, highlighting a significant deficiency in promoting resident self-determination and choice.
Inadequate Nurse Staffing on Unit Leads to Delayed Resident Care
Penalty
Summary
The facility staff failed to maintain adequate nurse staffing on one of the two nursing units, leading to a deficiency in providing necessary care to residents. On the observed date, the surveyor noted that only two nurses were present at the nurse's station, and they were the only staff visible on the unit. During this time, four call bells were sounding, indicating residents' need for assistance, but no staff were available to respond. A family member seeking help was also unable to find assistance until the regional traveling director of nursing intervened. The call bells continued to sound for an extended period, with some being answered only after 25 to 30 minutes. Interviews with staff revealed that the unit was inadequately staffed, with only one CNA present at the time of observation. The CNA confirmed she was alone on the unit, and the supply clerk had to step in to help. The regional director of clinical services and the director of nursing acknowledged the staffing shortage, noting that only one aide was scheduled from 3:00 p.m. to 7:00 p.m. The scheduling staff member was unaware of the whereabouts of another aide who was supposed to be on duty. The deficiency was discussed in an end-of-day meeting with the administrator and corporate staff.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility staff failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for four residents in a survey sample of 28. Resident R16 had medications stored in their room without any orders for bedside storage or self-medication, and no assessment of their ability to self-administer medications safely was found. Similarly, Resident R17 had Flonase nasal spray at the bedside, with no orders or assessments for self-medication. The care plan indicated that nurses were responsible for administering medications. Resident R18's room contained unsecured medications, including dermal wound cleanser and antifungal powder, without any orders for bedside storage or self-medication. Resident R19 had saline mist spray and Aquaphor ointment at the bedside, with no orders or assessments for self-medication. Interviews with the unit manager confirmed that medications should be stored in a locked medication cart or room, and no medications should be at the bedside. The facility's policy on medication storage was not adhered to, as evidenced by the unsecured medications found in residents' rooms.
Failure to Address Resident Grievance and Ensure Safety
Penalty
Summary
The facility staff failed to respond to a grievance from a resident who felt unsafe due to unwanted interactions with another resident. The resident reported an incident where another resident made inappropriate comments and entered her room uninvited, which made her feel uncomfortable and led her to stay in her room more often. Despite the resident's daughter communicating the issue to social services, there was no documentation of the grievance or any measures taken to address the resident's concerns in the clinical records or grievance log. Observations revealed that a stop-sign banner, which was supposed to be placed across the resident's door to prevent unwanted entry, was not in place. Interviews with the Director of Nursing and the facility administrator confirmed awareness of the incident, but there was no evidence of a formal grievance or investigation being conducted. The facility's policy on grievances was not followed, as there was no record of the grievance being logged or resolved, and the resident was not informed of any progress towards resolution.
Failure to Implement Abuse Policy for Two Residents
Penalty
Summary
The facility failed to implement its abuse policy for two residents, leading to deficiencies in reporting and addressing allegations of mistreatment. For Resident #203, who has multiple sclerosis, quadriplegia, pulmonary embolism, and depression, an incident occurred where a CNA was reported to have been rough and rude during care. Despite the resident expressing feelings of unsafety and the incident being reported to the DON and administrator, it was not reported to the state agency as required. The facility's investigation concluded that the actions were not intentional, and the issue was considered a customer service concern rather than abuse. For Resident #207, who has dementia, diabetes, hemiplegia, and anxiety, an allegation of mistreatment was reported late. The resident accused a CNA of pointing fingers in their face, which was perceived as threatening. Although the incident was documented by the social worker, it was not reported to the regional administrator until three days later, missing the required 24-hour reporting window. The regional administrator only became aware of the incident during a review of progress notes and reports. The facility's abuse policy mandates immediate reporting of any abuse allegations, but in both cases, the policy was not followed. The DON and administrator acknowledged the reporting failures, and the CNAs involved were either suspended or terminated for unrelated reasons. The facility's failure to adhere to its abuse policy resulted in deficiencies in handling and reporting these incidents appropriately.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility staff failed to develop and implement a comprehensive resident-centered care plan for a resident, identified as R10, who was part of a survey sample of 28 residents. R10 was admitted to the facility in January and remained an active resident at the time of the survey. Despite being dependent on oxygen and receiving an anticoagulant, R10's care plan did not address his medical and nursing needs. The care plan only included focus areas such as activities, refusal of care, discharge plan, mood problem/depression, nutritional risk, psychosocial well-being, and code status, but omitted essential medical and nursing care components. Interviews with the care plan coordinators, an LPN and an RN, revealed that the comprehensive care plans are supposed to be developed following the resident's admission assessment and reviewed every 92 days or with any significant changes. However, the nurse responsible for R10's admission assessment did not complete the care plan, and several quarters passed without the care plan being reviewed. The facility's policy mandates the development of a comprehensive plan of care for each resident, including measurable objectives and timetables to meet their needs, which was not adhered to in R10's case.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility staff failed to review and revise the care plan for two residents following significant events, leading to deficiencies in care. For one resident, who experienced a fall and was subsequently sent to the emergency department, the care plan did not address the fall or include interventions to prevent recurrence. Despite the resident's fall being documented in progress notes, the care plan coordinators confirmed that the care plan lacked any information regarding fall risk or interventions. The facility's policy mandates that care plans be updated based on changing needs and significant events, which was not adhered to in this case. Another resident also experienced a fall, yet the care plan was not updated to reflect new interventions to prevent future incidents. The fall incident report identified poor lighting and gait imbalance as contributing factors, and the resident was wearing normal socks instead of non-skid socks. Despite these findings, the care plan had not been revised since the previous year, and no new interventions were documented following the fall. Interviews with facility staff confirmed that care plans should be revised with any change in condition or incident, which did not occur in this instance. The facility's failure to update care plans following significant events was discussed in meetings with administrative staff, including the Director of Nursing and the Regional Director of Clinical Services. The facility's policy on care plans emphasizes the need for updates in response to changing resident needs and conditions, which was not followed, resulting in deficiencies in the care provided to the residents.
Medication Administration Deficiency
Penalty
Summary
The facility staff failed to adhere to professional standards of care during medication administration for two residents. For one resident, a nurse left a cup containing two white tablets on the over bed table without observing the resident take the medication. The resident was unaware of the medication's purpose, and a visitor had to inform her that it was her morning medication. The nurse admitted to leaving the medication to retrieve insulin, acknowledging that the accepted practice is to ensure the resident takes the medication. The resident did not have an order permitting self-administration of medication, as confirmed by the facility's records. In another instance, a resident was found with a medication cup containing two large tablets on the over bed table, which the resident identified as Tums given for an ulcer. The nurse responsible for the resident could not recall the medication administration, and a review of the clinical record showed no physician orders or records of medication administration for the resident. The unit manager confirmed issues with the resident's physician orders and denied administering the observed medication. The Director of Nursing stated that nurses are expected to follow the five rights of medication administration and ensure medications are consumed before leaving the resident.
Failure in Discharge Planning for Resident Post-Hip Replacement
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who had undergone a left hip replacement. The resident was discharged home without arrangements for home health services or medication management. The discharge plan and instructions were incomplete, lacking essential contact information and details about the overseeing physician. Although the discharge note indicated that the resident was to receive home health and physical therapy, there was no evidence that the necessary clinical records were sent to the home health agency or that medications were arranged prior to discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's discharge. The social worker, who was assisting from a sister facility, confirmed that there was no evidence of records being sent to arrange for home health services. The nurse practitioner, who had been on vacation, noted that the medications were sent to the pharmacy late on the day of discharge. The resident's spouse expressed concerns about the lack of home health services and the delay in receiving medications. The facility's policy on discharge planning was not followed, as outside services were not contacted in a timely manner.
Delayed Response to Call Bells in Nursing Unit
Penalty
Summary
The facility staff failed to respond to call bells in a timely manner on one of the nursing units, as observed by a surveyor. On the morning of the observation, several call lights were illuminated, indicating that residents were requesting assistance. Despite the presence of staff, including housekeepers, a CNA, and a nurse, the call bells were not answered promptly. The first call bell was answered 25 minutes after it was activated, and the last one was answered 30 minutes later. Interviews with staff revealed that while anyone could answer the call bells, only CNAs could provide direct care. The facility's policy stated that all call lights should be answered promptly by all staff, regardless of assignment. Interviews with residents revealed dissatisfaction with the response times. One resident reported waiting a long time for assistance, while another resident stated that it often took over 30 minutes for their call bell to be answered. The unit manager confirmed that all staff could answer call bells, but only nursing staff could provide direct care. The regional director of clinical services stated that call bells should be answered within 10 to 15 minutes. The facility administrator and corporate staff were informed of these findings, but no additional information was provided regarding corrective actions or follow-up measures.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility staff failed to provide timely incontinence care for two residents, leading to unsanitary conditions and discomfort. For Resident #20, an observation on August 2, 2024, revealed feces and urine on the bed sheets and incontinent pad, with a strong odor of ammonia. The resident's brief was saturated, and the incontinence had leaked onto the bed. The CNAs present did not respond when asked about the last time incontinence care was provided. Interviews with the unit manager and a CNA confirmed that incontinence care should be performed every two hours and as needed. A clinical record review indicated that Resident #20 required assistance with all activities of daily living and needed two-person assistance for daily care. Similarly, Resident #21 was observed with wet pants and a puddle of liquid under her wheelchair during lunch on the same day. The ammonia odor was so strong that a visitor in the room sprayed Lysol. The unit manager and a CNA assisted the resident to the shower room, noting the saturated and odorous condition of the wheelchair seat. Interviews with the CNAs on duty revealed that they had not attended to Resident #21 since her shower that morning, citing understaffing as a challenge. The clinical record review showed that Resident #21 also required assistance with all activities of daily living and needed two-person assistance for transfers. The facility's policy on activities of daily living was reviewed, emphasizing the need for oversight and assistance with hygiene and toileting.
Failure to Conduct Annual Performance Review for CNA
Penalty
Summary
The facility staff failed to conduct a yearly performance review for a certified nursing assistant (CNA15). A review of CNA15's personnel record revealed that the last performance review was conducted on 7/21/22, despite the requirement for annual evaluations. CNA15 was hired on 11/16/21, and according to the facility's policy, performance evaluations are to be conducted annually on the anniversary of the start date unless a job change has occurred. Interviews with the Human Resource Coordinator confirmed that performance evaluations are typically scheduled around the anniversary date of employment. However, CNA15 did not receive a performance review within the expected timeframe. The facility's policy and employee guidebook both emphasize the importance of conducting these evaluations annually, yet this was not adhered to in the case of CNA15. The issue was discussed in a meeting with the regional director of clinical services and a facility consultant, but no additional information was provided regarding corrective actions.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility staff failed to provide therapeutic diets as ordered for two residents, resulting in deficiencies during a survey. Resident #1 was observed not receiving fortified foods and large portions as prescribed. The dietary manager, responsible for plating the meals, served regular portions without the fortified foods, despite the meal ticket indicating otherwise. The clinical record review confirmed that Resident #1 had orders for fortified foods and large portions, which were not adhered to during the meal service. Interviews with the dietary manager and regional dietary consultant revealed a misunderstanding of the portion sizes required, contributing to the failure in providing the correct diet. Similarly, Resident #2 did not receive large portions as ordered. The dietary manager served regular portions, contrary to the meal ticket instructions. The clinical record review showed that Resident #2 was supposed to receive large portions, which was not followed. Interviews with the dietary manager and regional dietary consultant highlighted a discrepancy in understanding the portion sizes, leading to the deficiency. The facility's policy on therapeutic diets was reviewed, emphasizing the need to adjust nutrient levels in residents' diets, which was not implemented correctly in these cases.
Failure to Document Resident Interactions and Incidents
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, identified as Resident #9 (R9), in a survey sample of 28 residents. The deficiency was identified through resident and staff interviews, as well as a clinical record review. The issue centered around the lack of documentation regarding a mark on R9's neck, which was reportedly caused by another resident, identified as Resident #10 (R10). Multiple staff members, including CNAs and LPNs, were aware of the mark and the interactions between R9 and R10, but these were not documented in R9's clinical record. Interviews with various staff members revealed that there were several instances of inappropriate behavior between R9 and R10, including R10 putting a mark on R9's neck and engaging in sexual activities. Despite these occurrences being reported by staff, such as CNAs and LPNs, there was no documentation in R9's clinical record to reflect these interactions or the mark on her neck. The facility's Director of Nursing (DON) and other staff were aware of the situation, but the necessary documentation was missing from the clinical records. The facility's corporate staff and consultant confirmed that they would have expected documentation of the interactions between R9 and R10, as well as the mark on R9's neck, to be part of the clinical record. However, the surveyor and the DON were unable to locate any such documentation. This lack of documentation represents a failure to maintain a complete and accurate clinical record in accordance with accepted professional standards, as required by regulations.
Deficiency in QAPI Training for Facility Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to six out of eight employees whose personnel files were reviewed during a survey. The personnel files of eight staff members, including registered nurses, licensed practical nurses, and certified nursing assistants, were examined, and it was found that only two employees had documented evidence of having received QAPI training. This deficiency was identified through staff interviews and a review of facility documentation, which included an orientation checklist that should have contained evidence of QAPI training. Interviews with the facility consultant, regional director of clinical services, and the regional vice president of operations revealed that the lack of training documentation was acknowledged, and there was an understanding of the importance of QAPI training for staff. The regional vice president of operations emphasized that staff needed to be educated on the QAPI plan to effectively identify and report issues on the floor, as demonstrated by a previous instance where an aide reported malfunctioning Hoyer lifts. Despite these acknowledgments, no additional information or documentation was provided before the survey exit.
Failure to Obtain Stat X-ray for Resident
Penalty
Summary
Facility staff failed to follow a physician's order to obtain a stat x-ray for Resident #3 (R3), who was admitted with multiple diagnoses including a fracture of the first lumbar vertebrae, lower back pain, and muscle weakness. On 12/30/23, R3 fell while trying to get out of bed, and a stat x-ray of the ribs was ordered on 12/31/23 due to pain and swelling in the right ribcage. However, the x-ray was not completed, and the delay was attributed to the holiday weekend. Interviews with the Director of Nursing (DON) and the Medical Director (MD) revealed that the expectation for a stat x-ray is generally within 48 hours, but it may take longer during holidays. The MD noted that the delay did not change the course of treatment, as R3 was later sent to the hospital where a CT scan was performed, revealing that the L1 fracture compression was deemed inoperable due to pre-existing scoliosis. Further investigation revealed that the order for the stat x-ray was not properly transmitted to the x-ray company. Licensed Practical Nurse (LPN #2) explained the process of ordering an x-ray, stating that the order is entered into the computer and then confirmed with the x-ray company. However, the x-ray company staff confirmed that no order for R3 was received on 12/31/23. The DON demonstrated that the nurse who entered the order left areas blank on the form, resulting in the incomplete order not being transmitted. The administrator expressed concern about the delay and was reviewing the issue. A meeting was held to discuss these findings with the Administrator, DON, and the Regional Nurse Consultant.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fishersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shenandoah Nursing Home | 1.1 mi | ★★★★★ | 0 | 0 |
| Augusta Medical Ctr Skilled Ca | 1.3 mi | ★★★★★ | 0 | 0 |
| River Edge Rehabilitation And Nursing | 2.7 mi | ★★★★★ | 4 | 2 |
| Summit Square | 3.9 mi | ★★★★★ | 5 | 0 |
| Staunton Post Acute & Rehabilitation | 7 mi | ★★★★★ | 6 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.