Augusta Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fishersville, Virginia.
- Location
- 83 Crossroad Lane, Fishersville, Virginia 22939
- CMS Provider Number
- 495336
- Inspections on file
- 15
- Latest survey
- October 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Augusta Nursing And Rehabilitation during CMS and state inspections, most recent first.
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 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.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
