Battlefield Park Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Petersburg, Virginia.
- Location
- 250 Flank Road, Petersburg, Virginia 23805
- CMS Provider Number
- 495252
- Inspections on file
- 16
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Battlefield Park Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and an active elopement care plan, including a wanderguard, was reportedly found outside the building by a visitor, inadequately dressed and visibly cold, while an alarm sounded and no staff were present at the entrance. The visitor stated they could not reach staff by phone, contacted 911, and later informed the DON of the incident. Facility leadership initially denied receiving any report of the event, and the DON later described a prior call with a similar-sounding resident name that they could not match to any resident. Despite a written abuse/neglect policy requiring prompt reporting of all alleged neglect to the administrator and regulatory agencies, the allegation that a resident had been outside unsupervised was not reported as required.
Staff failed to thoroughly investigate an allegation that a cognitively impaired, elopement-risk resident with a wanderguard was found outside the building by a visitor, visibly cold and wearing only a short-sleeved shirt and pants. The visitor reported difficulty reaching staff by phone and stated that a staff member eventually returned the resident inside. Facility leadership initially denied receiving a report, then acknowledged a call but believed the name did not match any resident. Witness statements and a body/skin inspection form were produced with dates that did not align with when staff reported actually giving statements, and some staff denied being asked for statements, resulting in inconsistent and unreliable documentation that did not meet the facility’s own abuse/neglect investigation policy requirements.
Facility staff did not update a care plan to reflect a resident's preference for a plant-based diet, despite being aware of this need. The resident, who was cognitively intact and dependent on staff for self-care, experienced ongoing nausea and vomiting due to not receiving preferred meals. The care plan noted risk for malnutrition but did not specify the plant-based diet, and staff initially enforced policies that prevented the resident from storing preferred foods.
A resident with a contracted hand and multiple medical conditions did not receive necessary assistance with fingernail care, resulting in long, rammed fingernails and discomfort. Staff could not provide documentation of refusals or education regarding fingernail care, leading to a deficiency in maintaining personal hygiene.
A resident with advanced cancer and intact cognition did not receive her preferred plant-based diet as agreed upon, resulting in ongoing nausea and vomiting. The facility failed to update the care plan to reflect her dietary preferences, did not provide requested foods, and restricted her ability to store outside food, leading to unmet nutritional needs.
Staff did not ensure that a resident's clinical record included the most recent hospice plan of care and a description of hospice services, despite the resident being admitted under hospice care with multiple serious diagnoses. The required hospice documentation was missing at the time of review, and the only available hospice plan covered a previous period, not the current one.
A resident with advanced cancer and intact cognition was found with a cup containing two Reglan tablets and one Benadryl left on the over-bed table for several hours. The resident was unaware of the pills and did not take them due to ongoing nausea. Nursing staff confirmed the medications were poured earlier but not administered as ordered, and facility leadership acknowledged that medications should not be left at the bedside.
Several residents in the facility were not provided with adequate personal care, affecting their dignity. A resident with severe cognitive impairment was found with unkempt hair and facial hair, while another was in stained clothing. A third resident had an uncovered foley urine drainage bag, and a fourth was dressed in a hospital gown instead of personal clothing. Staff interviews confirmed these were dignity issues, but no immediate corrective actions were documented.
The facility failed to consistently hold unit council meetings for residents and family representatives due to the absence and resignation of the Activities Director. The Activities Assistant, lacking official training, managed the department alone, resulting in missed meetings. The Executive Director confirmed the inconsistency and provided documentation for some meetings, but not for others, violating the residents' rights policy.
The facility did not ensure residents were aware of their rights to contact the Ombudsman or file complaints with the state agency. During a meeting, none of the residents knew how to contact the Ombudsman or file a complaint. Interviews with staff revealed no practice to inform residents of these rights, despite the facility's policy stating residents have the right to make complaints.
Residents reported that their packages were always opened upon receipt, which they felt was an invasion of privacy. The ED was unaware of this issue, despite the facility's policy stating that residents have the right to receive mail and packages unopened. The issue was discussed with the facility's leadership, but no further information was provided.
The facility failed to ensure a clean and homelike environment, with surveyors observing pests, stains, and cluttered shower rooms lacking clean linens. Pest control recommendations were not followed, contributing to ongoing issues. Staff interviews confirmed the deficiencies, and the Administrator was informed without further action.
The facility failed to complete PASARRs prior to admission for three residents, leading to significant delays in required screenings. One resident with major depressive disorder was observed talking to himself, while another with depression and dementia showed confusion and frailty. A third resident with multiple diagnoses, including epilepsy and depression, had their PASARR completed post-admission. These deficiencies were acknowledged by facility staff during interviews.
Two residents with indwelling catheters experienced deficiencies in care at the facility. One resident's catheter was not properly anchored, risking trauma, while another resident missed multiple urology appointments due to scheduling and transportation issues. These failures indicate lapses in adhering to care plans and ensuring necessary medical follow-ups.
A resident with a history of depression expressed increased depressive symptoms, but the facility failed to coordinate necessary mental health services. Despite being cognitively intact, the resident reported symptoms such as fatigue and loss of interest, and the Preadmission Screening did not capture the depression diagnosis. The care plan included antidepressants, but interventions were limited, and psychiatric recommendations to adjust medication were not followed. The Social Services Director was unaware of the resident's condition, leading to a deficiency in mental health service coordination.
The facility failed to remove expired Covid-19 tests, an expired medication, and expired wound dressings from medication storage rooms. Additionally, medications were found opened and undated on a medication cart, contrary to facility policy. Staff interviews confirmed awareness of these issues.
The facility failed to provide regular bedtime snacks to residents, as observed during a survey. Residents reported that snacks were rarely offered and often consisted of sugary items. The Dietary Manager acknowledged the issue and planned to revamp the snack program. The findings were shared with the facility's leadership, but no additional information was provided.
The facility staff failed to maintain sanitary conditions in the kitchen, with issues such as commingled clean silverware and a sponge with dead insects, sticky and debris-covered carts, unrefrigerated mandarin oranges, and unsanitary condiment bins. Mouse feces and a crusted mouse trap were found under shelving units, and the ice machine's drain pipe was improperly placed, leading to mold-like substance and water damage. The Dining Services Manager admitted to a mouse problem and began cleaning.
The facility failed to maintain an effective pest control program, leading to the presence of pests and rodents. Surveyors observed mouse droppings, flies, and gnats throughout the facility. Despite recommendations from the pest control company to address issues like improperly sealed doors and structural concerns, these actions were not completed. The Maintenance Director was unaware of the necessary repairs, and the Administrator was informed of the concerns without further action.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital discharges. The resident, who was cognitively intact and had multiple medical conditions, was transferred to a hospital on two occasions for seizure activity and infections. Documentation provided by the Social Services Director did not include notifications for these discharges, and the administrative team confirmed the absence of additional records.
A resident with a contracture in the left hand and multiple medical conditions did not have a comprehensive care plan addressing the contracture or measures to prevent its worsening. The resident was observed with long fingernails that could cause a wound, and staff interviews revealed a lack of awareness and action regarding protective devices. The DON acknowledged the risk but no immediate actions were taken.
The facility staff failed to provide adequate assistance with ADLs for three residents, leading to deficiencies in personal hygiene and grooming. A resident with severe cognitive impairment was observed with unkempt hair and facial hair, indicating a lack of assistance with bathing. Another resident, dependent on staff for ADLs, had greasy hair due to infrequent bathing. A third resident was found with long, debris-filled fingernails, showing a lack of routine nail care. These issues were reported to the administrator, but no further information was provided.
A resident with multiple diagnoses, including hemiplegia, was found with a contracture in her left hand and long fingernails that could cause injury. The facility staff failed to implement measures such as splints or palm guards to prevent further contracture, and the PT Director and DON acknowledged the risks but did not take immediate action.
Two residents in a facility experienced deficiencies in enteral feeding management. The staff failed to ensure that syringes used for PEG tube maintenance were clean and changed daily, and tube feeding setups were not correctly labeled and dated. Observations revealed undated and improperly maintained feeding equipment, contrary to facility policy. An LPN confirmed the policy was not followed, and the administrator was informed of the issues.
A resident requiring oxygen therapy did not receive appropriate respiratory care as facility staff failed to date and properly store oxygen tubing, and there was no PRN order for oxygen use. The resident's oxygen tubing was found on the floor, undated, and not in a plastic bag, contrary to facility policy. Additionally, there was no 'Oxygen in Use' sign on the door, and the existing oxygen order was discontinued without a replacement.
A resident was administered duplicate antihistamine therapy with Loratadine and Cetirizine for seasonal allergies, despite both medications having the same mechanism of action. This oversight occurred due to separate orders from the Medical Director and an NP. The resident was also on Gabapentin, which could interact with the antihistamines. The ADON confirmed the error, and the NP discontinued one of the medications.
A resident with multiple health conditions was administered Midodrine for over three months without proper blood pressure monitoring or adherence to a 14-day administration limit. The facility staff failed to check blood pressure as required before administering the medication, and neither the nursing staff nor the pharmacy identified the order's time limit. This oversight was discovered during a survey, revealing significant medication management deficiencies.
Failure to Report Allegation of Neglect After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect related to a cognitively impaired resident who was found outside the building. The resident had vascular dementia, diabetes mellitus, and a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment, but was documented as having clear speech. The resident’s care plan and physician’s orders identified him as an elopement risk and required a wander/elopement alarm (wanderguard) to be in place and checked regularly for placement and function. Treatment administration records showed all required checks as completed. A visitor reported that on an evening visit to return laundry, the front door was locked, no one was at the reception desk, and an alarm was sounding inside. The visitor stated they waited about 10 minutes at the door, then saw a resident come around the side of the building wearing pants and a short-sleeved shirt, without a coat, and appearing visibly cold, with a wanderguard on the right wrist. The visitor asked the resident his name, and he responded with his first name, which matched the resident later identified by the surveyor. The visitor reported calling the facility multiple times with no answer, then calling 911; the 911 operator reportedly called the facility twice before staff answered. A female staff member then came to the door, asked the resident how he got out, and took him back inside toward Unit 1. The visitor stated they called the facility the next day and spoke with the DON to ensure the incident of the resident being outside was reported, and the DON said they would investigate. During the survey, the ED and DON initially stated that no one had called them about the resident being found outside. When informed of the visitor’s account, the DON acknowledged receiving a call on a prior date but said the caller gave a similar-sounding name that did not match any resident, and that an investigation had been done but they could not determine whether any resident had been outside. The facility’s Abuse, Neglect, and Exploitation policy defined neglect to include failure to take precautionary measures to protect resident safety, failure to report observed or suspected abuse or neglect, and failure to adequately supervise a resident known to wander from the facility without staff knowledge, and required reporting all alleged violations of abuse or neglect to the administrator and regulatory bodies within specified time frames. The surveyor concluded the facility failed to report an allegation of neglect involving this resident in accordance with its policy and regulatory requirements.
Failure to Thoroughly Investigate Alleged Elopement and Neglect Incident
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of neglect involving a cognitively impaired resident with vascular dementia and diabetes mellitus who was care planned and ordered for elopement precautions, including a wander/elopement alarm (wanderguard) to the right wrist and routine checks of its placement and function. The resident’s MDS showed severe cognitive impairment but clear speech, and the care plan identified the resident as an elopement risk who wandered aimlessly. Physician orders and the treatment administration record documented that wanderguard placement and function checks were completed as ordered. A visitor reported arriving at the facility in the early evening to return laundry and finding the front door locked with no staff at the reception desk, while hearing an alarm sounding inside. After approximately 10 minutes at the door, the visitor observed a resident walking around the outside of the building from the right side, wearing pants and a short-sleeved shirt without a coat and appearing visibly cold, with a wanderguard on the right wrist. The visitor asked the resident his name, and the resident responded with his first name. The visitor stated they repeatedly called the facility with no answer, then called 911; the 911 operator reportedly called the facility twice before someone answered, after which a female staff member brought the resident back inside toward Unit 1. The visitor later called the DON the next day to ensure the incident was reported, and the DON stated they would investigate. When surveyors interviewed staff, multiple CNAs and an RN stated they did not recall the resident being outside on the reported date. The ED and DON initially stated no one had called them about the resident being outside; the DON later acknowledged receiving a call but believed the name given did not match any resident. The DON provided witness statements and a body/skin inspection form dated around the time of the alleged incident, but the unit manager (LPN) reported obtaining the statements on a later date and instructed staff to date them for the day of the incident, resulting in discrepancies between the actual date statements were taken and the dates written on them. Some staff named on the witness list either denied giving a statement or reported giving one on a different date than documented. These inconsistencies, along with the lack of clear documentation of the alleged elopement and the facility’s own abuse/neglect policy requiring immediate, documented investigation with timely, signed, and dated statements, demonstrated that the facility did not complete a thorough investigation of the neglect allegation.
Failure to Address Resident's Plant-Based Diet Preference in Care Plan
Penalty
Summary
Facility staff failed to develop a care plan that addressed a resident's preference for a plant-based diet, despite being aware of this preference. The resident, who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, morbid obesity, and atrial fibrillation, was cognitively intact and dependent on staff for most self-care activities. The resident reported experiencing frequent nausea and vomiting over several days due to not receiving her preferred plant-based meals, which she stated had been agreed upon with the facility. She attempted to supplement her diet by purchasing bean burritos from a local restaurant, but staff disposed of them due to storage policies, and she was initially told she could not have a personal refrigerator in her room. The resident's nutritional care plan identified her risk for malnutrition and included interventions such as identifying food preferences and offering substitutions, but did not specifically address her plant-based diet preference. Staff interviews confirmed awareness of the resident's dietary preference, but the care plan was not updated to reflect this, and facility policies regarding personal refrigerators were not initially clarified. The deficiency was acknowledged by facility leadership during the survey process.
Failure to Provide Necessary Assistance with Personal Hygiene
Penalty
Summary
Facility staff failed to provide necessary assistance with personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who had a history of stroke, diabetes, hypertension, and a contracted right hand with curled fingers, was assessed as dependent in upper and lower body dressing, footwear, and personal hygiene. During an interview, the resident reported pain in his right hand due to long fingernails and could not recall the last time staff had trimmed them. Observation confirmed the presence of long, rammed fingernails, dry skin, and healed scars on the resident's right hand. The resident also reported removing his splint due to discomfort. Review of the care plan indicated interventions for pain management and contracture care, but there was no documentation of the resident refusing fingernail care or of staff providing education regarding this aspect of hygiene. The Unit Manager acknowledged that the resident was care planned as non-compliant with fingernail care but could not provide evidence of refusals or education attempts. The lack of documentation and failure to maintain the resident's fingernail hygiene led to the deficiency cited by surveyors.
Failure to Honor Resident's Plant-Based Dietary Preferences
Penalty
Summary
Facility staff failed to make reasonable efforts to honor and meet the meal choices and preferences of a resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, use of a nephrostomy tube, and bilateral lymphedema. The resident was cognitively intact and dependent on staff for most self-care activities, requiring setup assistance with eating. Despite a care plan identifying her risk for malnutrition and the need to identify food and beverage preferences, the resident reported ongoing nausea and vomiting over several days due to not receiving her preferred plant-based diet, which consisted mainly of beans, fresh vegetables, and fruit. The facility did not provide these preferred foods as previously agreed upon, and the resident's attempts to supplement her diet with outside food were hindered when staff discarded her purchased bean burritos due to storage policies. Additionally, the resident was informed she could not have a personal refrigerator in her room, further limiting her ability to store preferred foods. Interviews with facility leadership confirmed that the resident's person-centered care plan did not reflect her plant-based food preferences, and the dietary department had not consistently accommodated her nutritional needs as outlined in her care plan. The failure to update and follow the care plan and dietary preferences contributed to the resident's ongoing nutritional issues.
Failure to Maintain Current Hospice Plan of Care in Clinical Record
Penalty
Summary
Facility staff failed to ensure that the written plan of care for a resident included both the most recent hospice plan of care and a description of hospice services, as required. The resident, who was admitted under hospice care from another LTC facility, had diagnoses including malignant ovarian and endometrial cancer, a right nephrostomy tube due to hydronephrosis with ureteral stricture, and bilateral lower extremity lymphedema. The resident was cognitively intact but dependent on staff for most self-care activities. Despite a physician's order to admit the resident to hospice care, the clinical record did not contain the hospice agency's plan of care at the time of review. Staff interviews confirmed that the hospice care plan was not present in the clinical record, and the Assistant Director of Nursing indicated it may not have been uploaded by Medical Records. A hospice document was later added to the record, but it only covered a previous benefit period and did not address the current period. The absence of the current hospice plan of care in the resident's clinical record constituted the deficiency identified by surveyors.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
Facility staff failed to administer medications as ordered for one resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, a right nephrostomy tube, and bilateral lower extremity lymphedema. The resident was cognitively intact but dependent on staff for most self-care activities. On the day of the incident, two white pills and one orange pill were observed in a medication cup on the resident's over-the-bed table at 10:35 AM, and the same pills remained there at 1:50 PM. The resident was unaware of the pills' presence, did not know what they were, and stated she was not going to take them due to ongoing nausea and recent vomiting. A registered nurse confirmed that the pills were two Reglan tablets and one Benadryl, which had been poured at 6:00 AM according to the medication administration record. The nurse stated she had not seen or left the pills at the bedside. The unit manager also stated that medications should not be left at the bedside and should be administered in the presence of a nurse. The facility's leadership team reviewed and acknowledged the findings, confirming that the medications were not administered as ordered and were improperly left at the resident's bedside.
Failure to Maintain Resident Dignity in Personal Care
Penalty
Summary
The facility staff failed to ensure the dignity of several residents by neglecting their personal grooming and clothing needs. Resident #5, who has severe cognitive impairment and multiple health issues, was observed with unkempt hair and long facial hair, indicating a lack of assistance with grooming. Despite being coded as independent in the facility's documentation, interviews with staff revealed that Resident #5 required help with bathing and grooming, which was not being provided. Resident #33, also with severe cognitive impairment, was found wearing stained and dirty clothing, which was not addressed by the staff until it was pointed out by the surveyor. The resident was unable to communicate effectively, and the staff acknowledged the need for changing his clothes and cleaning him up, but this was not done in a timely manner. Additionally, Resident #58 was observed with an uncovered foley urine drainage bag, which should have been covered with a dignity bag according to facility policy. Resident #114 was found wearing a hospital gown instead of personal clothing, with no documentation of refusal to wear personal attire. The facility's staff, including the DON and Administrator, acknowledged these issues as dignity concerns, but no immediate corrective actions were documented.
Inconsistent Unit Council Meetings
Penalty
Summary
The facility failed to consistently arrange regular unit council meetings for residents and/or family representatives, as required by the residents' rights policy. The Activities Assistant (AA) reported that since the Activities Director (AD) went on leave in January and subsequently resigned, she had been managing the department alone without official training to set up these meetings. Although the Executive Director (ED) assisted with the most recent meeting, the AA admitted to missing some months without holding meetings. The ED confirmed the inconsistency in holding these meetings and provided documentation for meetings held in July and September, but none for June and August. The facility's policy on Resident's Rights states that residents have the right to form or participate in a resident group to discuss issues and concerns about the facility's policies and operations. However, the facility failed to uphold this policy consistently, as evidenced by the lack of regular meetings. The ED acknowledged the deficiency and noted that the position of Activities Director is currently posted. Despite being given an opportunity to provide additional information during a meeting with facility leadership, no further information was provided.
Failure to Inform Residents of Ombudsman and Complaint Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights to contact the Ombudsman and file complaints with the state certification agency. During a unit council meeting, none of the six residents present were aware of who the Ombudsman was or how to contact them, nor were they aware of their right to file a complaint with the state agency. This lack of awareness was confirmed through interviews with the facility's Activities Assistant and Admissions Coordinator, who both indicated that there was no established practice to ensure residents were informed of these rights. The facility's policy on Resident's Rights states that residents have the right to make complaints, yet this information was not effectively communicated to the residents. The information regarding how to contact the Ombudsman and the state agency was located in the facility's lobby, but it was not adequately highlighted or communicated to the residents. The deficiency was discussed with the facility's leadership team, but no additional information was provided to counter the findings.
Residents' Packages Opened Upon Receipt
Penalty
Summary
The facility's staff failed to ensure that residents' packages were received unopened, which was identified as a deficiency. During a unit council meeting, three out of six residents expressed their frustration, stating that while their mail was received unopened, their packages were always opened upon receipt. This was perceived as an invasion of their privacy. The Executive Director (ED) of the facility was interviewed and stated that she was unaware of this issue, affirming that residents should receive their mail and packages unopened. The facility's policy on Resident's Rights, which was undated, indicated that residents have the right to privacy in sending and receiving mail. The findings were shared with the facility's leadership team, but no additional information was provided by the staff.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for residents, particularly those on the 100's hall and those receiving food from the kitchen. Over a three-day survey period, surveyors observed flies and gnats in the conference room and dead bugs in light fixtures throughout the building. Stains were noted on the hallway floors near specific rooms, and repairs in one room had not been completed as the area above the bed was spackled but not painted. Additionally, an IV pole and floor in another room had a dried brownish substance, likely tube feeding. The shower room was cluttered with various equipment and dirty linens, and lacked necessary clean linens. A nebulizer machine was found unlabeled and undated in the shower room, and several tiles were missing from the baseboard and floor. The facility's pest control service book revealed that from April to August 2024, the pest control company made monthly recommendations to address pest issues, including cleaning drains, repairing door sweeps and drywall, and sealing entry points for mice. These recommendations were not implemented, contributing to the ongoing pest problem. Interviews with staff, including a CNA and the DON, confirmed the cluttered state of the shower room and the lack of clean linens. The DON was unaware of the missing tiles and acknowledged that the nebulizer should not be left in the shower room. The Administrator was informed of these findings during the end-of-day meeting, but no further information was provided.
Failure to Complete PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for three residents. Resident #92 was admitted with diagnoses including major depressive disorder with psychotic symptoms, anxiety disorder, and avoidant restrictive food intake disorder. The resident was observed to be moving quickly around his room, talking to himself, and not responding to the surveyor. A review of his clinical record revealed that the PASARR was completed eight months after admission, indicating a significant delay in the required screening process. Resident #104 was admitted with diagnoses of depression and dementia with agitation. The resident was observed to be frail, underweight, and confused, with erratic movements and poor skin turgor. The clinical record review showed that the PASARR was completed on the day the survey began, rather than prior to admission, as required. This delay in completing the PASARR was acknowledged by the facility staff during interviews. Resident #84 was admitted with multiple diagnoses, including epilepsy, depression, and aphasia following cerebrovascular disease. The resident's clinical record indicated that a PASARR was not completed prior to admission from the acute care hospital. The PASARR was only completed and uploaded into the clinical record after the surveyor's review. The facility's social worker admitted to completing PASARRs post-admission when they were not done beforehand, highlighting a systemic issue in the facility's admission process.
Deficiencies in Catheter Care and Appointment Management
Penalty
Summary
The facility staff failed to provide appropriate care and services for managing indwelling catheters for two residents. Resident #67, who has quadriplegia and stage 4 pressure ulcers, was observed with an unsecured indwelling catheter, which was not anchored as per the care plan. This oversight was noted during wound care observations, and neither the Assistant Director of Nursing (ADON) nor the Licensed Practical Nurse (LPN) recognized the issue. Resident #67 confirmed that he was unaware of the catheter not being anchored and had not refused the procedure. Resident #81, who also has an indwelling catheter due to obstructive uropathy, experienced issues with attending a follow-up urology appointment. Despite being cognitively intact, Resident #81 reported that due to scheduling and transportation problems, he missed multiple appointments with the urologist. The scheduling coordinator and ADON acknowledged the failure in ensuring the resident's transportation to the appointments, which were crucial for his post-surgical follow-up care. These deficiencies highlight the facility's failure to adhere to care plans and ensure necessary medical follow-ups for residents with indwelling catheters. The lack of proper catheter management and failure to facilitate medical appointments could potentially compromise the residents' health and well-being.
Failure to Coordinate Mental Health Services for Resident with Depression
Penalty
Summary
The facility staff failed to coordinate mental health services for a resident diagnosed with depression, who expressed feelings of increased depression. The resident, who was admitted to the facility in April 2022 and readmitted in November 2023, had a history of depression diagnosed in 2015. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident reported experiencing symptoms of depression, such as feeling tired, having trouble sleeping, and losing interest in activities over a two-week period. The resident also expressed concerns about financial constraints and lack of family support, contributing to his depressive state. Additionally, the resident's Preadmission Screening and Resident Review did not capture the depression diagnosis, and there was a lack of follow-up on psychiatric recommendations to adjust medication. The resident's care plan included the use of antidepressants, with goals to avoid complications from medication side effects. However, the interventions were limited to encouraging the resident to voice feelings and discussing coping skills, without ensuring access to mental health services. The Social Services Director was unaware of the resident's depressive symptoms and had not coordinated mental health services. The resident's chart showed only two psychiatric visits in 2022, with a recommendation to increase medication that was not reflected in the physician's orders. This lack of coordination and follow-up on mental health services contributed to the deficiency identified during the survey.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility staff failed to adhere to proper storage and labeling protocols for drugs and biologicals, as evidenced by the presence of expired Covid-19 tests, an expired medication, and expired wound dressings in two medication storage rooms. Specifically, 11 boxes of BinaxNow Covid-19 tests were found expired, and a multi-dose vial of Insulin Lantus was kept beyond the manufacturer's recommended 28-day usage period after opening. Additionally, 10 Collagen Wound Dressings were stored past their expiration date. Interviews with staff, including a Regional Nursing Consultant and a Registered Nurse, confirmed the awareness of these expired items and the inability to use them. Further deficiencies were observed in the medication administration process, where medications were found opened and undated on a medication administration cart. These included a bottle of 81 mg Aspirin, a bottle of Vitamin D 10 mcg, and a bottle of Osmotic Laxative. An LPN acknowledged that per training and competency requirements, all medications should be dated upon opening. The facility's policy mandates the removal and destruction of expired medications, yet this was not adhered to, as evidenced by the findings during the survey.
Failure to Provide Regular Bedtime Snacks
Penalty
Summary
The facility staff failed to offer and provide snacks at bedtime, as observed during a survey conducted from 9/17/24 to 9/19/24. No observations were made of snacks being offered or provided to residents during this period. During a unit council meeting on 9/18/24, six residents complained about not being offered snacks regularly, stating that it was random and rare to receive snacks at bedtime. They also mentioned that when snacks were provided, they were often sugary items like fig bars and cakes. Additionally, residents reported that dietary staff occasionally brought snacks to the unit, but nursing staff left them at the desk, making them accessible only to residents who could reach the desk. An interview with the Dietary Manager on 9/19/24 revealed awareness of the snack issue and plans to revamp the snack program to include healthier options. The Dietary Manager also mentioned collaborating with nursing leadership to ensure snacks are distributed to all residents as required. The facility provided unit council minutes for meetings held on 7/16/24 and 9/16/24, but there were no meetings in June or August. The findings were shared with the facility's leadership team on 9/19/24, but no additional information was provided by the staff.
Unsanitary Food Preparation and Storage Conditions
Penalty
Summary
The facility staff failed to prepare and serve food in a safe and sanitary manner, as observed during an inspection of the kitchen area. The inspection revealed several unsanitary conditions, including a clean silverware tray commingled with a dish sponge that contained dead insects. Additionally, clean glasses were found on a cart covered in a sticky brown substance, along with bread clips, food crumbs, and other debris. A green cart with a segmented tray was observed to have cloudy liquid and food debris in each segment, despite being reportedly clean. In the dry storage area, trays of mandarin oranges were left unrefrigerated, and a cart with encrusted knives and food debris was found. Condiment bins contained rusted paper clips, crumbs, and spilled condiments, and a Styrofoam box with a dried, half-eaten hamburger was discovered. Further inspection revealed mouse feces and a crusted mouse trap under the shelving units, along with sticky floors and a greasy substance that caused slipping. The ice machine's drain pipe was directly on the floor, surrounded by mildew and a black mold-like substance, with water damage noted on the wall. The Dining Services Manager acknowledged the issues, admitting to a mouse problem and stating that cleaning would begin immediately. The Regional Director later confirmed that a deep cleaning had started, and the Dining Services Manager had resigned.
Pest Control Deficiency Due to Inaction on Recommendations
Penalty
Summary
The facility staff failed to maintain an effective pest control program, resulting in the presence of pests and rodents throughout the facility. During a survey conducted from September 17 to September 19, 2024, surveyors observed mouse droppings in the kitchen's dry storage area, small flies in a dishwashing sponge, and flies and gnats in various resident rooms and the conference room. Dead bugs were also found in light fixtures throughout the building. The pest control book revealed multiple service receipts indicating ongoing issues, such as improperly sealed exit doors, rusted fire doors, and the presence of mice in the kitchen. Despite recommendations from the pest control company to install or replace door sweeps and address structural concerns, these actions were not completed. The Maintenance Director admitted to fixing the doors but noted that wheelchairs frequently knocked off the door sweeps. He was unaware of other necessary repairs and recommendations from the pest control company. Observations on September 19, 2024, confirmed that the drywall over the kitchen baseboards had not been repaired, exit doors still had gaps, and floor drains required cleaning. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided.
Failure to Notify Ombudsman of Resident's Hospital Discharges
Penalty
Summary
The facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for a resident, identified as Resident #67, during a survey. Resident #67 was originally admitted to the facility in early 2022 and had been readmitted after an acute care hospital stay. The resident's medical conditions included quadriplegia, stage 4 pressure ulcers, and obstructive uropathy. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) during a quarterly assessment. The deficiency was identified when the Social Services Director (SSD) provided documentation that only included notification of a discharge on a later date, but not for the hospital discharges on two earlier occasions. The resident had been transferred to a hospital due to seizure activity and sepsis on one occasion, and for a urinary tract infection and seizure activity on another. During interviews, the administrative team, including the Regional President of Operations, confirmed that no additional documentation was available to show that the Ombudsman had been notified of these earlier discharges.
Failure to Address Contracture in Nonverbal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with multiple medical conditions, including a contracture in the left hand. The resident, who is nonverbal and unable to express discomfort, was observed with a closed left hand and long fingernails that could potentially cause a wound. The care plan did not address the existing contracture or measures to prevent its worsening. Interviews with facility staff revealed a lack of awareness and action regarding the resident's condition. A CNA was unaware of any protective devices for the resident's hand, and the PT Director mentioned that a splint or palm guard was not used due to the resident's inability to express discomfort. The DON acknowledged the risk posed by the resident's long fingernails and the need for intervention to prevent further contracture. However, no immediate actions were taken to address these issues, and the care plan remained incomplete.
Deficiencies in Personal Hygiene and Grooming for Residents
Penalty
Summary
The facility staff failed to provide adequate assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #5, who has severe cognitive impairment and multiple health conditions, was observed with unkempt hair and facial hair, indicating a lack of assistance with bathing and grooming. Despite being coded as requiring assistance, the facility's documentation inaccurately recorded her as independent, and staff interviews confirmed that she needed help with bathing and grooming. Resident #38, who is dependent on staff for all ADLs except eating, was observed with greasy and unkempt hair. The facility's records showed infrequent bathing, and the care plan did not address any refusal of showers. The facility's policy requires hair to be shampooed at least weekly, but this was not adhered to, as confirmed by staff interviews. Resident #60, with moderate cognitive impairment and multiple health issues, was found with long, debris-filled fingernails, indicating a lack of routine nail care. The facility's policy mandates nail hygiene as part of bathing, but records showed inconsistent bathing schedules, and staff interviews confirmed that nail care was not routinely performed. These deficiencies were brought to the attention of the facility's administrator, but no further information was provided.
Failure to Address Contracture and Nail Care in Nonverbal Resident
Penalty
Summary
The facility staff failed to provide appropriate care for a resident to maintain or improve mobility, specifically regarding the contracture of the resident's left hand. The resident, who was admitted with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with her left hand closed and fingertips pressing into the palm. The CNA noted that the resident's fingernails were too long and could potentially cause a wound by digging into the palm. Despite this, the CNA was unaware of any devices such as splints or palm guards being used to protect the resident's hand. The PT Director confirmed that the resident had been assessed on admission, but due to her nonverbal status, it was decided not to use a splint or palm guard. The PT Director also indicated that using a rolled washcloth as a preventive measure was a nursing responsibility. The DON acknowledged that the resident's nails were too long and posed a risk of creating a pressure wound, and agreed that there should be some intervention to prevent further contracture. However, no immediate actions were taken to address these concerns, and the administrator was informed of the issues without further information being provided.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility staff failed to provide appropriate treatment and services for residents with enteral feeding, leading to deficiencies in care for two residents. For one resident, the staff did not ensure that the 60 ml syringe used for PEG tube maintenance was clean and changed daily. Additionally, the tube feeding was not correctly labeled and dated. An observation revealed an empty, undated bottle of tube feeding hanging, an undated used syringe with curdled feeding, and a water flush bag that was half empty and undated. The clinical record indicated specific orders for enteral feeding, but these were not followed as per facility policy, which requires daily changes and proper labeling of the feeding setup. For another resident, similar deficiencies were observed. The syringe used for PEG tube maintenance was not clean and had dried tube feeding in it, and the tube feeding bottle was incorrectly dated. The tubing for the feeding had no date or time, and the water flush bag was empty and undated. The clinical record showed specific orders for enteral feeding, but the facility staff did not adhere to the policy of changing and labeling the feeding setup daily. Interviews with an LPN confirmed that the facility policy was not followed, and the administrator was informed of these concerns during an end-of-day meeting.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for a resident who required oxygen therapy. The deficiency was identified when the resident was observed with an oxygen concentrator by her bedside, but the oxygen tubing was found on the floor, undated, and not stored in a plastic bag as per facility policy. The resident reported using oxygen only when experiencing shortness of breath or at night, but there was no PRN order for oxygen use documented in her clinical record. The existing order was for oxygen at 2L/min via nasal cannula for chest pain, which was discontinued the following day. Further investigation revealed that the facility's policy required oxygen tubing to be dated when opened and stored properly when not in use. The LPN interviewed confirmed that the tubing should be dated and acknowledged the absence of a PRN order for the resident's oxygen use. Additionally, there was no 'Oxygen in Use' sign on the resident's door, which is part of the facility's procedure for oxygen administration. These oversights indicate a failure to adhere to professional standards of practice for respiratory care.
Duplicate Antihistamine Therapy Administered to Resident
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medications, specifically duplicate drug therapy involving two second-generation antihistamines, Loratadine (Claritin) and Cetirizine (Zyrtec). Both medications were prescribed to the resident for seasonal allergies and were administered simultaneously during the 9:00 a.m. medication pass. The orders for these medications were entered by different healthcare providers, the Medical Director and a Nurse Practitioner, leading to the oversight. These medications have the same mechanism of action and are not typically prescribed together, as doing so constitutes duplicate drug therapy. Additionally, the resident was also on Gabapentin, which has the potential to interact with both antihistamines, increasing the risk of excessive drowsiness and other side effects. The Assistant Director of Nursing (ADON) confirmed that it is not common practice to administer both antihistamines simultaneously, acknowledging the error. The issue was identified during a clinical record review and was later communicated to the Nurse Practitioner, who discontinued the Claritin prescription. The facility's Administrator was informed of the findings during an end-of-day meeting.
Failure to Monitor Blood Pressure Before Administering Midodrine
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Midodrine, a vasopressor medication. The resident, who is nonverbal and has a BIMS score of 99, was diagnosed with multiple conditions including intracranial injury, intraparenchymal hemorrhage, seizures, right hemiplegia, DVT/pulmonary embolism, dysphagia, and is under hospice care. The clinical record indicated an order for Midodrine to be administered via PEG-Tube every 8 hours as needed for hypotension, with specific parameters to hold the medication if the systolic blood pressure (SBP) was above 115. However, the medication was administered for over three months without adhering to the 14-day limit specified in the order, and blood pressure was only checked three times during this period. Interviews with facility staff revealed a lack of awareness and adherence to the order's requirements. An LPN stated there was no order for blood pressures to be taken prior to administering the medication, while the ADON acknowledged the importance of checking blood pressure due to the parameters for holding the medication. The ADON admitted that neither the nursing staff nor the pharmacy identified the 14-day limit on the order, leading to the continued administration of Midodrine without proper monitoring. The deficiency was brought to the attention of the facility's administration during the survey, highlighting a significant oversight in medication management and monitoring protocols.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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