Bayside Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Virginia Beach, Virginia.
- Location
- 1004 Independence Blvd, Virginia Beach, Virginia 23455
- CMS Provider Number
- 495213
- Inspections on file
- 17
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bayside Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was found living in a room with significant damage to the wall, a cracked light fixture, and a large, dirty area on the floor. These issues were observed by surveyors and reported by the resident's family. Facility staff confirmed the unacceptable conditions, citing limited housekeeping resources and acknowledging the need for repairs.
A resident with severe cognitive impairment and a history of brain malignancy and seizure disorder was not given prescribed Keppra and Dexamethasone upon admission due to unavailability in the medication dispensing system. An LPN reported the medication was placed on hold and administered the following day, but there was no documentation explaining the delay or the hold in the clinical record.
A resident with a history of diabetes and immobility developed multiple unstageable pressure wounds that were not identified by the facility. The wounds were discovered during an outside appointment, and treatment was delayed. The facility failed to implement preventive measures, complete necessary assessments, and document the wounds, leading to harm.
Two residents in an LTC facility did not receive appropriate wound care, leading to significant deficiencies. One resident's non-pressure wounds worsened due to delayed transcription of treatment orders, resulting in infection and hospitalization. Another resident missed several scheduled treatments for pressure ulcers and venous and arterial ulcers. Interviews with staff revealed a lack of awareness and communication regarding the missed treatments.
The facility failed to ensure the activities program was directed by a qualified professional, resulting in substandard care. A CNA volunteered to provide activities after the previous Director of Recreation left, and was later promoted without completing the required certification. Despite being aware of the qualifications needed, the Administrator did not follow through on the certification process, leading to the deficiency.
Two residents in an LTC facility experienced deficiencies in care, impacting their dignity. One resident was left soiled for extended periods without timely incontinence care, despite being cognitively aware and communicative. Another resident's indwelling urinary catheter was not managed with privacy, as the catheter bag was visible and improperly maintained. The facility lacked policies for ADL care and catheter covers, contributing to these deficiencies.
The facility failed to administer and document medications and treatments as ordered for three residents. One resident missed multiple doses of critical medications, another did not receive prescribed eye drops, and a third missed necessary wound care treatments. Interviews with staff revealed expectations for proper administration, but discrepancies in medication handling and documentation persisted.
The facility failed to provide a resident-centered activities program for four residents, as required by their comprehensive assessments and care plans. A resident with dementia was not engaged in activities despite having interests noted in their assessment. Another resident with afib and pressure ulcers was observed lying in bed without participating in activities. A third resident with depression was not engaged in activities despite having intact cognitive abilities. Lastly, a resident with major depressive disorder reported not participating in activities due to lack of staff assistance. The Activities Director was uncertified, and the facility did not address this issue.
The facility failed to ensure a safe environment by leaving a chemical bottle accessible in the dining room and not supervising a resident who smoked. Staff were unaware of the chemical's presence and lacked proper documentation. Additionally, a resident with a history of respiratory issues was observed smoking unsupervised without a safety assessment or agreement in place.
Two residents in a facility experienced deficiencies in nutrition and hydration. A resident with malnutrition and dementia lost significant weight due to an inappropriate diet and ill-fitting dentures, while another resident struggled to access ice water due to an unreachable call bell. The facility staff failed to address these issues promptly, leading to inadequate care.
The facility staff failed to provide appropriate respiratory care for three residents, leading to deficiencies in their treatment. A resident with chronic respiratory failure was not consistently provided with his prescribed Bi-Pap therapy, and refusals were not documented. Another resident did not have his oxygen tubing changed as per physician orders, with observations showing a lack of proper documentation. A third resident's oxygen humidification tubing was not changed weekly, as confirmed by the resident and family. These findings highlight a pattern of non-compliance with respiratory care protocols.
The facility failed to maintain adequate CNA staffing levels to ensure resident safety and meet their needs. Staffing shortages were confirmed by the HR Director, who stated that agency staff were being used to supplement the shortfall. The Administrator was informed of these concerns during a meeting.
The facility did not ensure that licensed nursing staff completed the necessary competency training to care for residents. A review showed that nine out of 19 staff members lacked required training. The HR Director could not provide evidence of completed training, and the Administrator was informed of the issue.
The facility failed to ensure RN coverage for at least 8 consecutive hours daily, 7 days a week, as required. A review of work schedules revealed a lack of documentation confirming RN presence during specific periods. The HR Director acknowledged the staffing shortage and reliance on agency staff. The Administrator was informed of the issue, but no additional information was provided before the survey's exit.
The facility failed to conduct annual performance reviews and ensure nurse aides completed 12 hours of in-service education. Despite the HR Director's assertion that records were up to date, documentation showed not all aides met these requirements. The Administrator was informed, but no further information was provided before the survey's exit.
A long-term care facility failed to administer medications as ordered for two residents, leading to deficiencies in pharmaceutical services. One resident did not receive prescribed doses of Lovenox and Keflex, while another missed doses of Eliquis. The facility's medication administration records showed missing doses without documentation or physician notification. Interviews with staff revealed a lack of awareness about the omissions, and the care plans were not updated to reflect the necessary treatments.
The facility failed to ensure that pharmacy recommendations from monthly drug regimen reviews were communicated and acted upon for four residents. A resident with severe cognitive impairment did not have pharmacy recommendations communicated to their physician. Another resident was discharged without addressing time-sensitive recommendations. Two other residents' pharmacy reports were not accessed or acted upon for three months, with no documentation of physician response.
The facility failed to maintain proper systems and implement necessary action plans through the QAPI committee. During a QAPI meeting, the facility lacked a qualified professional for the activities program, and the DON or a designee did not participate. Repeated deficiencies were noted in areas such as professional standards, ADL care, activities, pharmacy services, and food handling.
The facility failed to maintain an effective training program for all new and existing staff, as none of the 19 staff transcripts reviewed had completed all mandatory training. Despite the HR Director's claim that files were up to date, the survey findings indicated otherwise. The Administrator was informed of these concerns, but no further information was provided before the survey exit.
The facility did not ensure all direct care staff completed mandatory Effective Communication training. A review of training transcripts showed incomplete documentation, despite the HR Director's assertion that records were up to date. The Administrator was informed of the issue, but no additional information was provided before the survey exit.
The facility failed to ensure all direct care staff completed mandatory Resident Rights training, as revealed by a review of training transcripts and staff education files. Despite the HR Director's assertion that records were up to date, the survey found discrepancies. The Administrator was informed of these concerns, but no further information was provided before the survey exit.
The facility did not ensure that all staff completed mandatory training on Abuse, Neglect, and Exploitation. A review of training transcripts showed that not all direct care staff had documented completion of this training. The HR Director claimed records were up to date, but survey findings indicated otherwise. The Administrator was informed of these issues, but no further information was provided before the survey exit.
The facility failed to ensure all staff received mandatory infection control training, as required by its infection prevention and control program. A review of training records revealed that the DON and several other staff members lacked this essential training. These findings were communicated to the facility's administration and corporate nursing staff.
The facility did not ensure that all staff completed mandatory Ethics and Compliance Training, as 19 direct care staff lacked documentation of completion. Despite the HR Director's assertion that training records were up to date, the survey revealed discrepancies, which were communicated to the Administrator.
The facility did not ensure nurse aides completed the required 12 hours of in-service training within a year, including education on dementia care and abuse prevention. A review of training records showed incomplete training, despite the HR Director's assertion that records were up to date. The Administrator was informed of these issues.
The facility did not ensure all staff completed mandatory Behavioral Health Training, as six out of 19 staff members reviewed had not completed it. The HR Director claimed training records were up to date, but discrepancies were found. The Administrator was informed of the issue.
A resident with glaucoma was found to have prescription eye drops at her bedside without a self-administration assessment or order. The resident kept the drops due to staff misplacing them, but there was no documentation of administration on two occasions. Facility staff confirmed that medications should not be left at the bedside without proper assessment and order.
A resident in an LTC facility, who was cognitively intact and required assistance with daily activities, often did not receive additional coffee as requested after breakfast. Despite having no dietary restrictions, the resident expressed difficulty in obtaining more coffee. The DON confirmed that coffee was available, but the resident needed assistance to pour it into her personal cup, which was eventually provided by a CNA. During a group interview, other residents reported similar issues.
The facility failed to provide two residents with the opportunity to formulate an advance directive. Both residents, admitted after hospital stays with intact cognitive abilities, lacked written advance directives in their clinical records. The Admissions Director confirmed that the absence of signed Business Contracts indicated the residents were not given the chance to develop advance directives.
A resident with glaucoma did not receive prescribed ophthalmic drops due to misappropriation of medication. The resident reported not receiving the drops since admission, and the medication was documented as 'waiting for pharmacy.' An LPN discarded the hospital-sent drops, and the facility could not locate the delivered medication. A hold order was placed as the family provided supplies, but the facility staff could not account for the missing medication.
The facility staff failed to update care plans for several residents, leading to deficiencies in care. A resident's care plan was not revised to include anticoagulant therapy after a pulmonary embolus diagnosis, and another resident's care plan lacked interventions after a fall. Additionally, a resident's ADL needs were not addressed, a pressure ulcer was not documented in a care plan, and TED hose application was omitted for a resident with edema. Staff and administrators were unaware of these oversights.
A resident was discharged from a facility without complete orders for continued IV therapy, resulting in a six-day delay in treatment. The resident, with end-stage renal disease and an infection, was supposed to continue IV Zosyn therapy at home. However, the Home Health Agency only received a referral for rehab and wound care. The resident had to contact her doctor to initiate the therapy, which began six days post-discharge. Interviews revealed that the facility's usual procedure for discharge scripts was not followed, leading to the oversight.
The facility staff failed to provide adequate ADL care, including timely incontinence care, personal hygiene, and grooming, to several residents. A resident was left in a soiled brief for hours, while another missed scheduled showers and hair washes. Other residents experienced inadequate hygiene and bathing care, leading to potential skin breakdown. Staff interviews revealed a lack of adherence to care schedules and proper documentation.
A resident with multiple diagnoses, including anxiety and insomnia, was prescribed several psychotropic medications without documented attempts at gradual dose reduction (GDR). The DON confirmed that the MDS indicated no GDR was done, and there was no documentation to suggest GDR was contraindicated. The issue was raised with the Administrator, but no additional information was provided before the survey exit.
The facility staff failed to administer medications as prescribed for several residents, leading to significant medication errors. A resident did not receive the full course of Eliquis for a pulmonary embolus, while another missed doses of Lovenox and Keflex. Additional residents experienced similar issues with anti-coagulant, anti-hypertensive, and antibiotic medications. The facility lacked documentation and communication with physicians regarding these omissions, and the administration was unaware of the issues until the survey.
The facility failed to ensure proper storage and labeling of medications, with expired COVID-19 vaccines and improperly stored Latanoprost drops found. A resident with glaucoma kept eye drops at the bedside due to staff misplacing them, without an assessment for self-administration. The DON and Corporate Nurse Consultant acknowledged the issue, but no further information was provided.
A resident with multiple health conditions, including Type 2 Diabetes and Chronic Kidney Disease, did not receive necessary dental care despite complaints of tooth pain and a documented order for a dental appointment. The facility's policy required nursing staff to coordinate dental services, but there was no evidence of these actions being taken, and the resident's care plan did not include a referral to a dentist.
A resident with gluten intolerance did not receive meals according to their dietary needs and preferences over three days. Despite having a documented gluten allergy, the resident was served meals containing gluten, and the dining services director admitted to errors in meal preparation. The resident, who required extensive assistance and had a complex medical history, expressed dissatisfaction with the meals provided. The facility's director of nursing and administrator were informed of these findings.
A resident with gluten intolerance was repeatedly served meals containing gluten over several days, despite clear documentation of their dietary restrictions. The resident, who required significant assistance and had moderate cognitive impairment, did not receive meals according to the planned menu or their therapeutic diet. The dining services director acknowledged the error, and the facility's administration was informed of the deficiency.
The facility failed to provide bedtime snacks to residents who desired them. Three residents reported not being offered snacks at bedtime, with one stating that residents had to buy snacks from the General Store. A CNA confirmed that snacks were not consistently available, and not all residents received them due to other CNAs not distributing them.
The facility staff failed to follow food safety standards, with an employee repeatedly not wearing a beard guard in the kitchen and improper storage of teriyaki sauce. The Dietary Manager confirmed the policy requiring beard guards and misinterpreted the storage guidelines for the sauce, which should be used within one month of opening.
The facility failed to secure agreements for dental and optometry services, as confirmed by staff interviews. The Corporate Nurse Consultant and Administrator acknowledged the absence of agreements for these services. It was noted that no local dentist was available for residents needing stretcher transport, and the facility depended on the VA Hospital for residents requiring glasses.
The facility failed to secure a transfer agreement with a hospital, as confirmed by the Corporate Nurse Consultant and the Regional President of Operations. Despite attempts, no hospital was willing to sign a contract with the facility. During a follow-up interview, the Administrator and Corporate Nursing Consultants had no additional comments or concerns.
The facility failed to develop comprehensive care plans for two residents, leading to inadequate wound care and the development of pressure sores. One resident's care plan lacked specific details for treating wounds from a car accident, while another resident developed pressure sores due to insufficient preventive measures and delayed treatment. Interviews revealed that nursing staff did not complete wound assessments, and the facility's policies on skin assessments and wound care were not followed.
A resident with multiple diagnoses, including a fracture and osteoarthritis, did not receive consistent pain management as ordered by the physician. The facility staff failed to perform regular pain assessments and missed administering prescribed doses of Acetaminophen and Lidocaine patches. Interviews with the DON highlighted the expectation for medication administration and notification procedures, which were not followed in this case.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Facility staff failed to maintain a clean, comfortable, and homelike environment for one resident with severe cognitive impairment. Upon observation, the resident's room had large and deep gouges in the drywall behind the bed headboard, a cracked light fixture cover, and a large, dirty black area on the floor between the beds. These conditions were directly observed during a facility tour and were also reported by the resident's family member, who expressed concern about the cleanliness and state of disrepair in the room. Interviews with facility staff confirmed the deficiencies. The Housekeeping Director acknowledged that the floor's condition was unacceptable and attributed the lack of cleaning to having only one housekeeper on duty, who may have been diverted to other tasks. The Maintenance Director also agreed that the wall and light fixture should not be in their current state and indicated awareness of the need for repairs. During a final interview, facility leadership was given an opportunity to provide additional information but had no further comments or concerns regarding the findings.
Failure to Administer Admission Medications as Ordered
Penalty
Summary
Facility staff failed to administer significant medications as ordered upon admission for one resident following transfer from an acute care hospital. The resident, who had diagnoses including malignant neoplasm of the brain and a convulsion disorder, was admitted with physician orders for Keppra (levetiracetam) and Dexamethasone. The resident's Minimum Data Set assessment indicated severely impaired cognitive abilities and a high level of dependence for daily activities. The care plan identified a risk for complications related to the convulsive disorder, with interventions to administer medications as ordered and notify the physician as needed. Upon review, it was found that the Keppra and Dexamethasone were not administered as ordered on the day of admission. The Medication Administration Record showed the Keppra was placed on hold, but there was no documentation in the progress or order notes explaining the reason for this action. An LPN reported that the medication was not available in the Omnicell dispensing system and that a STAT order would typically take 4-6 hours, with the medication ultimately administered the following day. No additional information was provided by facility staff to clarify the delay or the decision to hold the medications.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility staff failed to prevent, identify, assess, and treat pressure sores for a resident, resulting in harm. The resident, who was admitted with no pressure wounds, developed multiple unstageable pressure wounds that were not identified by the facility. These wounds were only discovered during an outside orthopedic appointment, and treatment was delayed until three days later when a wound nurse practitioner assessed the resident. The facility's failure to document and address these wounds in a timely manner contributed to the deficiency. The resident had a history of diabetes type 2, an acute hip fracture with surgical repair, and was immobile, increasing the risk for skin impairment. Despite being coded as needing extensive assistance with personal care and being frequently incontinent, the facility did not implement adequate preventive measures. The resident's care plan only mentioned potential skin impairment related to immobility and catheter use, with no specific interventions for pressure ulcer prevention or treatment. Additionally, the facility failed to complete a Braden scale skin assessment upon admission or during the resident's stay. The facility's documentation and communication were inadequate, as evidenced by incomplete weekly skin evaluations and the absence of a care plan for the pressure ulcers. Nursing staff interviews revealed that wound assessments were not conducted by the facility's nurses, who relied on an external wound care practice. The Director of Nursing's expectations for incontinence rounds and skin breakdown assessments were not met, as evidenced by the lack of timely hygiene care and the omission of wound care treatments as per physician's orders.
Failure to Provide Wound Care Leads to Hospitalization
Penalty
Summary
The facility staff failed to provide appropriate treatment and care for two residents, leading to significant deficiencies. For Resident #172, the staff did not administer wound care treatments for non-pressure wounds, which were not transcribed to the Treatment Administration Record (TAR) until two days after the orders were obtained. This delay in treatment resulted in the worsening of the resident's wounds, leading to an infection and subsequent hospitalization. The resident was admitted with multiple wounds and a history of diabetes and hereditary lymphedema, conditions that increased the risk of wound complications. Resident #27 also experienced a failure in receiving necessary wound care treatments as per physician orders. The resident, who had a history of pressure ulcers and peripheral vascular disease, missed several scheduled treatments for pressure ulcers and venous and arterial ulcers. Despite being at risk for skin breakdown, the facility staff did not ensure the resident received the prescribed wound care, as evidenced by multiple missed treatments documented in the Medication Administration Record (MAR). Interviews with facility staff, including the Director of Nursing (DON) and the Wound Care Nurse Practitioner (WCNP), revealed a lack of awareness and communication regarding the missed treatments. The DON expected nurses to perform skin assessments and carry out wound care treatments, but the facility failed to meet these expectations. The deficiencies were brought to the attention of the facility's administration, but no additional information or corrective actions were provided at the time of the survey.
Unqualified Director of Recreation Leads to Deficiency
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, resulting in substandard quality of care. During a recertification survey, it was discovered that the previous Director of Recreation had left the facility, and a Certified Nursing Assistant (CNA) with an interest in activities had volunteered to provide activities for the residents. This CNA was later promoted to the role of Director of Recreation without completing the necessary certification program. The CNA had received some training from a Director of Recreation at a sister facility but had not completed a certification program, which is a requirement according to the facility's job description for the Director of Recreation. Interviews with the unqualified Director of Recreation, the Administrator, and the Corporate Consultant revealed that the Administrator was aware of the requirement for the Activities Professional/Director of Recreation to be a qualified professional. Despite this, the Administrator had not followed through on the certification process for the CNA, who had registered for the program but was told to wait by the Administrator. The facility's job description for the Director of Recreation requires a Bachelor's or Associate Degree and specific qualifications, which the current Director of Recreation did not possess. The Administrator provided a document indicating a deposit was made for the certification program, but the certification was not completed, leading to the deficiency noted in the survey.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility staff failed to maintain the dignity and self-esteem of two residents, leading to deficiencies in their care. For one resident, the staff did not provide timely incontinence care, leaving the resident soiled for extended periods. Despite the resident's cognitive awareness and ability to communicate, the staff neglected to address the resident's needs, resulting in a foul-smelling room and visible stains on the bed linens. The resident expressed discomfort and the need for care, but staff did not respond promptly, as observed by surveyors and confirmed by the Corporate Nurse Consultant. Another resident experienced a lack of dignity related to the care of an indwelling urinary catheter. The resident was observed in a wheelchair with the catheter bag visible and containing a dark amber substance, with the tubing hanging near the floor. The facility staff failed to provide a leg bag, bag anchor, and cover for privacy, as expected by the Director of Nursing and Administrator. The absence of a policy related to catheter covers further contributed to the deficiency in maintaining the resident's dignity. Interviews with staff and reviews of clinical records revealed that the facility lacked policies and consistent practices for providing timely and dignified care. The Corporate Nurse Consultant acknowledged the absence of policies for ADL care and catheter covers, which contributed to the deficiencies observed. The facility's failure to adhere to expected care standards resulted in a lack of dignity and respect for the residents involved.
Medication and Treatment Administration Failures
Penalty
Summary
The facility staff failed to administer and document medications and treatments as ordered by the physician for three residents. For one resident, several medications, including those for hypertension, diabetes, and insomnia, were not administered on multiple occasions in May 2024. The facility's policy required medications to be administered in a safe and timely manner, yet there was no documentation of the omissions or notifications to the physician. Interviews with nursing staff confirmed the expectation to administer medications as ordered, but the failures persisted. Another resident did not receive prescribed ophthalmic medications for glaucoma since admission. The resident reported not receiving eye drops, and the medication administration record indicated delays due to waiting for pharmacy delivery. However, the medications were found in the facility, unused, and the staff could not account for the missing medications. Interviews with nursing staff and the pharmacist revealed discrepancies in medication handling and documentation. A third resident did not receive necessary wound care treatments as ordered. The resident, who was at risk for pressure ulcers, missed several wound care treatments in May and June 2024. The facility's care plan emphasized the importance of regular wound care, yet treatments were not consistently administered. Interviews with the Director of Nursing and the Wound Care Nurse Practitioner indicated a lack of awareness of the missed treatments, highlighting a failure in communication and adherence to care protocols.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility staff failed to provide an ongoing program to support residents in their choice of activities based on comprehensive assessments and care plans. This deficiency was observed in four residents. Resident #1, who has dementia with behavioral disturbances, was noted to stay in bed most of the day and roam the hallways in the afternoons. Despite having an activity assessment indicating interests in reading newspapers, watching the news, and car races, there was no activities care plan in place. The Activities Director, who was uncertified, stated that Resident #1 does not participate in activities and does not stay long if he happens to join. Resident #170, diagnosed with afib, congestive heart failure, and advanced stage pressure ulcers, was observed lying in bed for several days and lacked engagement in activities. Although her activity assessment indicated interests in animals, news, gardening, sewing, and socializing, there was no activities care plan developed. The Activities Director confirmed that Resident #170 had not participated in group activities or received one-on-one activities. Similarly, Resident #9, with diagnoses of depression and venous ulcers, was observed in bed and not engaged in activities despite having intact cognitive abilities and interests in painting, cards, reading, and socializing. Resident #26, with diagnoses including hyperlipidemia and major depressive disorder, reported rarely participating in activities due to a lack of staff engagement and assistance with transportation to activities. An activity admission assessment was not completed for this resident. The facility's policy stated that the recreation department would provide an ongoing program based on comprehensive assessments and care plans, but this was not implemented for the residents mentioned. The Activities Director had not completed a certification program, and the facility administration did not address this issue when it was brought to their attention.
Failure to Ensure Safety from Chemical Hazards and Smoking Risks
Penalty
Summary
The facility staff failed to maintain a safe environment free from accident hazards, as evidenced by the presence of a half-full spray bottle of wallpaper remover left unattended on a table in the dining room. This chemical was accessible to residents, posing a risk of accidental ingestion or contact. Interviews with staff, including the maintenance director and the administrator, revealed that they were unaware of the chemical's presence and its potential dangers. The maintenance director confirmed that he did not have a Material Safety Data Sheet (MSDS) for the chemical, indicating a lack of proper documentation and oversight. Additionally, the facility staff did not ensure the safety of a resident who smoked, as there was no smoking safety assessment or agreement in place for the resident. The resident, who had a history of acute respiratory failure, COPD, and tobacco use, was observed smoking unsupervised in various areas of the facility. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the lack of supervision and safety measures posed a risk to the resident and others. Interviews with the administrator and the Director of Nursing revealed a lack of awareness of smoking residents and the necessary safety protocols.
Deficiencies in Nutrition and Hydration for Residents
Penalty
Summary
The facility staff failed to provide adequate nutrition and hydration to two residents, leading to deficiencies in their care. Resident #258, who was admitted with diagnoses including malnutrition and dementia, was observed to consume only soft foods like pudding and applesauce due to having no teeth and ill-fitting dentures. Despite being on a regular diet with regular texture and thin liquids, the resident experienced a significant weight loss of 5.07% within 16 days of admission. The nutritionist was unaware of the resident's edentulous status and had not evaluated him until after the weight loss was noted. The resident's diet was later downgraded to Dysphagia Advanced, and a referral for a speech-language pathology evaluation was made. Resident #13 experienced issues with hydration, as she was unable to access ice water due to the call bell being out of reach. Despite expressing her preference for iced water and the difficulty in reaching the call bell, the staff continued to wrap the call bell cord around the bed rail, making it inaccessible. Observations confirmed that the resident's water cup was often empty, and the call bell was consistently out of reach. A CNA acknowledged the issue and rectified it by adjusting the call bell and providing iced water. The administrator was informed of these concerns, but no further information was provided.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for three residents, leading to deficiencies in their treatment. Resident #23, who was admitted with multiple diagnoses including chronic respiratory failure, was not consistently provided with his prescribed Bi-Pap therapy. Observations revealed that the Bi-Pap machine was not in use, and the resident reported that staff no longer applied it. The Treatment Administration Record indicated multiple instances where the Bi-Pap was not applied, and refusals were not documented or communicated to the physician. Resident #258, diagnosed with severe cognitive impairment and other conditions, did not have his oxygen tubing changed as per physician orders. Observations showed that the tubing was not labeled with a date, and staff confirmed that the tubing should be dated when changed. Despite the facility's policy requiring weekly changes, the tubing lacked proper documentation, indicating a lapse in adherence to the prescribed care routine. Resident #31, who required supplemental oxygen due to acute respiratory failure, also experienced a deficiency in care. The oxygen humidification tubing was not changed weekly as required, with observations showing outdated tubing. Interviews with the resident and family confirmed the tubing was not changed regularly, and staff acknowledged the expectation to follow physician orders for respiratory equipment maintenance. These findings highlight a pattern of non-compliance with respiratory care protocols for multiple residents.
Insufficient Nursing Staff
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure the safety and meet the needs of residents. This deficiency was identified through staff interviews and facility documentation, which revealed inadequate Certified Nursing Assistant (CNA) staffing levels during specific periods, including 5/11/2024-5/13/2024, 5/24/2024-5/31/2024, and 6/4/2024-6/24/2024. The Human Resources Director confirmed the staffing shortages and mentioned that the facility was supplementing with agency staff. The issue was brought to the attention of the Administrator during an end-of-day meeting on 6/13/24.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that licensed nursing staff completed the required competencies necessary to care for residents' needs. A review of the training transcripts for 19 licensed staff members revealed that nine of them did not complete the required training courses. During an interview, the Human Resource Director was unable to provide evidence that these nine staff members had completed the necessary competency training. The Administrator was informed of these concerns during the end-of-day meeting on June 13, 2024.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours within a 24-hour period, 7 days a week. This deficiency was identified through a review of the facility's work schedules for specific periods, including 5/11/24-5/13/24, 5/24/24-5/31/24, and 6/4/24-6/24/24, which showed a lack of documentation confirming RN coverage as required. During an interview on 6/11/24, the Human Resources Director acknowledged the requirement for RN coverage and admitted that the facility was experiencing staffing shortages, leading to reliance on agency staff. The issue was brought to the attention of the Administrator during an end-of-day meeting on 6/13/24, but no further information was provided before the survey's conclusion.
Deficiency in Nurse Aide Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that nurse aides received performance reviews every 12 months and completed at least 12 hours of in-service education as part of their annual performance review. This deficiency was identified through staff interviews and a review of facility documentation, which revealed that not all nurse aides had completed the mandatory in-service education. During an interview, the HR Director claimed that the employee files, including performance reviews and in-service records, were correct and up to date, but was unable to provide additional records for those aides who lacked the required reviews and training hours. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided before the survey's exit.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by a physician for two residents, leading to deficiencies in pharmaceutical services. For one resident, the facility staff did not administer Lovenox, an anticoagulant, and Keflex, an antibiotic, as prescribed. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with multiple diagnoses, including a stage 4 sacral pressure sore and aspiration pneumonia. The medication administration records showed missing doses and lacked documentation explaining the omissions or notifying the physician of the missed doses. Another resident, who had moderate cognitive impairment and required extensive assistance, did not receive the prescribed doses of Eliquis, an anticoagulant, following a hospitalization for bilateral pulmonary embolus and pneumonia with sepsis. The medication administration records indicated several missed doses, and there was no documentation of the reasons for these omissions or communication with the physician. The resident's care plan was not updated to reflect the anticoagulant therapy for the pulmonary embolus. Interviews with nursing staff revealed a consensus that medications should be administered as ordered and that missing doses could have serious health implications. The Director of Nursing and the Administrator were unaware of the medication omissions and the lack of communication with the physician and family. The report highlights the facility's failure to ensure medication administration per physician's orders, as evidenced by the missing doses and lack of documentation.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility staff failed to ensure that a licensed pharmacist's monthly drug regimen reviews were properly communicated and acted upon for four residents. For Resident #11, the facility did not have documentation that the physician or designee received the pharmacy recommendations from the review conducted on 4/20/24. Despite the resident's severe cognitive impairment and multiple diagnoses, including type 2 diabetes and dementia, the facility could not provide evidence that the recommendations were communicated to the necessary parties. Resident #172's clinical record showed that pharmacy recommendations made in May were not documented as reviewed or acted upon. The resident, who had multiple health issues including diabetes and a non-pressure wound, was discharged without the time-sensitive recommendations being addressed. The Regional Nurse Consultant indicated that the recommendations were not in the record and had to be retrieved from a website, but they were not addressed during the resident's stay. For Residents #4 and #25, the facility staff did not respond to pharmacy consultant recommendations identified in monthly medication reviews. Both residents were cognitively impaired and dependent on staff for daily activities. The reports containing the recommendations could not be located, and it was revealed that the Director of Nursing and Administrator had not accessed or acted upon these reports for approximately three months. The Medical Director did not have access to the reports, and there was no documentation of the physician's response to the recommendations.
Deficiencies in QAPI Committee Participation and Repeated Deficient Practices
Penalty
Summary
The facility staff failed to maintain proper functioning systems and implement necessary action plans to ensure the quality of life for residents through the Quality Assurance and Performance Improvement (QAPI) committee. During a QAPI meeting on 7/23/24, the facility did not have a qualified professional directing the activities program, and the Director of Nursing (DON) or a designee did not participate in the meeting. The Administrator confirmed that all deficient citations from the Plan of Corrections survey ending 6/13/24 were discussed, along with related audits. The facility repeated deficient practices in several areas, including services provided meeting professional standards, ADL care for dependent residents, activities meeting the interests and needs of each resident, qualifications of the activity professional, pharmacy services, labeling and storing drugs and biologicals, frequency of meals and snacks at bedtime, food procurement, storage, preparation, and serving in a sanitary manner, use of outside resources, and use of transfer agreements. The absence of the DON or a designated representative at the QAPI meeting was confirmed by the review of the sign-in sheet, which did not list the DON or a designee as a participant.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members, as evidenced by a review of staff training transcripts and education files. None of the 19 staff transcripts reviewed had completed all the mandatory training. Despite the Human Resources Director's assertion that the education and training files were up to date, the survey findings indicated otherwise. The Administrator was informed of these concerns during the end-of-day meeting on 6/13/2024, but no further information was provided before the survey exit.
Failure to Complete Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that all direct care staff completed mandatory Effective Communication training. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of this required training. During an interview with the Human Resource (HR) Director, it was stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. However, the survey findings indicated otherwise, as not all staff had completed the mandatory training. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided before the survey exit.
Deficiency in Staff Education on Resident Rights
Penalty
Summary
The facility failed to ensure that all employees were educated on resident rights and the responsibilities of the facility. This deficiency was identified through a review of staff training transcripts and education files, which revealed that not all direct care staff had documented completion of the mandatory Resident Rights training. An interview with the Human Resources Director confirmed that training and education records were maintained in a computer-based platform and were believed to be up to date. However, the survey findings indicated otherwise, as not all staff had completed the required training. The Administrator was informed of these concerns during the end-of-day meeting on 6/13/24, but no further information was provided before the survey exit.
Failure to Complete Mandatory Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to ensure that all staff members completed the mandatory training on Abuse, Neglect, and Exploitation. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of this essential training. During an interview, the Human Resources Director stated that training and education records were maintained in their computer-based training platform and were up to date. However, the survey findings indicated otherwise, as not all staff had completed the required training. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided before the survey exit.
Infection Control Training Deficiency
Penalty
Summary
The facility staff failed to ensure that all staff received mandatory infection control training as part of its infection prevention and control program. During a review of staff training records, it was found that several staff members, including the Director of Nursing (DON) and multiple other staff members, did not have the required infection control training. These findings were shared with the Administrator and corporate nursing staff, but no further information was provided before the conclusion of the survey.
Failure to Complete Mandatory Ethics and Compliance Training
Penalty
Summary
The facility failed to ensure that all staff members completed the mandatory Ethics and Compliance Training. A review of the staff's Training Transcripts and Staff Education files revealed that 19 direct care staff had not documented completion of this required training. During an interview, the HR Director stated that the training and education records were maintained in their computer-based training platform and were up to date. However, the survey findings indicated otherwise, and the Administrator was informed of these concerns during the end-of-day meeting.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that nurse aides received a minimum of 12 hours of in-service training within a 12-month period, which is necessary to meet the needs of the residents. This deficiency was identified through a review of the staff's Training Transcripts and Staff Education files, which revealed that not all nurse aides completed the mandatory training. The training was supposed to include education on dementia care, abuse prevention, facility assessments, and the special needs of the residents. An interview with the Human Resources Director confirmed that training and education records were maintained in a computer-based platform and were believed to be correct and up to date. However, the survey findings indicated otherwise, and the Administrator was informed of these concerns during the end-of-day meeting on 6/13/2024.
Failure to Complete Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to ensure that all staff members completed the mandatory Behavioral Health Training as required by the facility assessment. A review of the staff training transcripts and education files for 19 staff members revealed that six staff members had not completed the required training. During an interview, the HR Director stated that the training and education records were maintained in a computer-based platform and were up to date. However, the discrepancy in training completion was identified, and the Administrator was informed of the issue during the end-of-day meeting on 6/13/24. No further information was provided before the survey exit.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility staff failed to ensure that a resident was clinically assessed and deemed appropriate to self-administer medications. Specifically, prescription eye drops were found at the resident's bedside without an order or self-administration assessment. The resident, who was diagnosed with glaucoma, kept the eye drops at her bedside because staff members frequently misplaced them. She expressed concern about not receiving the medication on time and stated that she would give the eye drops to the nurses when it was time for administration. However, there was no documentation of the eye drops being administered on two specific occasions, and no orders were found for the medication to be left at the bedside. During interviews, the Director of Nursing and Corporate Nurse Consultant confirmed that medications should not be kept at the bedside without a proper assessment and order. They acknowledged the risks associated with leaving medications at the bedside, such as other residents accessing them or the resident administering them outside the scheduled times. The clinical record review revealed no care plan documentation for self-administration or bedside storage of medications. The facility staff was unaware of any issues with the availability of the eye drops for administration by nurses.
Failure to Provide Additional Coffee to Resident
Penalty
Summary
The facility staff failed to honor a resident's right to self-determination by not providing additional coffee as requested. The resident, who was cognitively intact and required extensive assistance with daily activities, expressed a desire for more coffee after breakfast. Despite having no dietary restrictions on coffee consumption, the resident often did not receive additional coffee in a timely manner. During the survey, the resident mentioned the difficulty in obtaining more coffee, and it was observed that the beverage cart with coffee was available but not actively offered to residents. The Director of Nursing confirmed that residents could receive more coffee and identified available coffee on the cart. However, the resident needed assistance to pour the coffee into her personal cup, which was eventually provided by a CNA. The resident expressed happiness upon receiving the extra coffee. During a group interview, several residents reported similar issues with obtaining additional coffee. The facility's Corporate Nurse acknowledged the delay in providing extra coffee, but no further information was provided before the survey exit.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility staff failed to inform and provide written information to formulate an advance directive for two residents. Resident #3 was admitted to the facility after an acute hospital stay with diagnoses including metabolic encephalopathy, difficulty in walking, type 2 diabetes mellitus, muscle weakness, and chronic obstructive pulmonary disease. The resident's cognitive abilities for daily decision-making were intact, as indicated by a BIMS score of 14 out of 15. However, a review of the clinical records revealed no written advance directive, and the Admissions Director confirmed that the opportunity to develop one was not provided, as the resident did not have a signed Business Contract. Similarly, Resident #21, admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, type 2 diabetes with hyperglycemia, and depression, also had intact cognitive abilities with a BIMS score of 15 out of 15. The clinical records for this resident also lacked a written advance directive. The Admissions Director stated that the advance directive is typically received from the hospital chart, and residents are asked if they desire further information. However, since Resident #21 did not have a signed Business Contract, the opportunity to develop an advance directive was not provided. The facility staff, including the Administrator and Corporate Nursing Consultants, did not provide additional information or express concerns during the final interview.
Misappropriation of Resident's Ophthalmic Medication
Penalty
Summary
The facility staff failed to ensure that a resident was free from misappropriation of personal property, specifically ophthalmic medication, for one resident in the survey sample. The resident, who was admitted to the facility after a hospital stay, had a diagnosis of alcohol abuse and glaucoma. Upon admission, the resident was oriented to person and place. During an interview, the resident reported not receiving his prescribed eye drops since admission, which were previously administered by his sister at home. The resident expressed concern about when he would receive the medication, as he had not experienced any symptoms like blurred vision or itching since the drops were not administered. The medication administration record indicated that the ophthalmic drops were documented as 'waiting for pharmacy' on several occasions. During a medication storage task, the drops were not found on the medication cart. An LPN stated she had administered the drops that morning and discarded the bottle, which was sent from the hospital. However, the pharmacist confirmed that the drops were delivered to the facility and signed for by an RN, but their location was undetermined. A nurse's note later indicated a hold order for the medication, as the family was providing the supplies, and the resident was his own responsible party. The facility's staff, including the administrator and corporate nurse consultants, could not provide new information regarding the missing medication.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to review and revise the care plans for several residents, leading to deficiencies in their care. For Resident #45, the care plan was not updated to include anticoagulant therapy after a diagnosis of bilateral pulmonary embolus. Despite physician orders for Eliquis, the care plan lacked revisions to address anticoagulant use and assessments for potential bleeding. Interviews with nursing staff revealed a lack of awareness about the need for care plan revisions, and the Director of Nursing and Administrator were unaware of the oversight. Resident #359 experienced a fall shortly after admission, but the care plan was not updated to include interventions to prevent future falls. The fall was not documented initially, and it was only after an investigation that the oversight was discovered. Similarly, Resident #36's care plan did not address Activities of Daily Living (ADLs) despite the resident's need for assistance due to neuropathy and previous falls. The resident reported receiving minimal ADL care, primarily from occupational therapy, and the care plan lacked any mention of ADL care. For Resident #161, the care plan was not revised after the development of a stage 2 pressure ulcer. The care plan only mentioned the risk of skin impairment without specific interventions for the new wound. Additionally, Resident #50's care plan failed to include the application of TED hose for bilateral lower extremity edema, despite physician orders. The resident struggled to apply the TED hose independently and reported difficulty in getting staff assistance. Interviews with staff and administrators highlighted a lack of awareness and documentation regarding these care plan deficiencies.
Failure to Ensure Complete Discharge Orders for IV Therapy
Penalty
Summary
The facility staff failed to ensure a complete list of orders was sent to the Home Health Agency upon the discharge of a resident, leading to a delay in the continuation of necessary IV therapy. The resident, who was admitted to the facility with end-stage renal disease and an infection of osteomyelitis in the left foot, was discharged after an acute care hospital stay. The resident's cognitive abilities were intact, and she was independent in eating but required assistance with toileting hygiene and bathing. The care plan included administering medications and treatments as ordered, specifically IV Zosyn for a urinary tract infection. Upon discharge, the resident was supposed to continue IV Zosyn therapy at home. However, the facility failed to arrange for this continued therapy, resulting in a six-day delay before the resident could resume treatment. The discharge instructions included a medication list with the IV therapy details, but the Home Health Agency only received a referral for rehab and wound care, not for IV therapy. The resident had to contact her infectious disease doctor to initiate the therapy, which began six days after her discharge. Interviews with facility staff revealed that the normal procedure was to print off all scripts and review them with the resident, with the Physician Assistant calling in the scripts to a pharmacy. However, in this case, the discharge summary did not indicate that the resident received scripts for IV therapy. The Home Health Agency confirmed they only received a referral for wound care, and the resident's IV therapy was initiated after the resident contacted her doctor. The facility's failure to provide complete discharge instructions led to a significant delay in the resident's treatment.
Deficiencies in ADL Care and Hygiene in LTC Facility
Penalty
Summary
The facility staff failed to provide adequate Activities of Daily Living (ADL) care to several residents, resulting in deficiencies in personal hygiene, incontinence care, and grooming. For Resident #13, the staff did not provide timely incontinence care, leaving the resident in a visibly soiled brief with a strong odor of urine and feces in the room. Despite multiple observations and inquiries, the resident remained unattended for several hours, and the facility lacked a specific policy on ADL care. Resident #161 did not receive scheduled showers or documented refusals, and the facility failed to provide daily bed baths as an alternative. The clinical record showed multiple missed shower dates, and interviews with staff revealed a lack of proper documentation and follow-up on resident refusals. Similarly, Resident #258 was observed with long, unkempt nails and had only received one of the four scheduled showers since admission, indicating a lack of routine personal care. Other residents, such as Resident #7, #5, and #165, also experienced inadequate ADL care. Resident #7 missed several scheduled showers and hair washes, despite having a physician's order for specific shampoo use. Resident #5 was left in soiled linens for extended periods, with a strong odor of urine and feces in the room, and Resident #165 did not receive timely hygiene and bathing care, leading to potential skin breakdown. The facility's failure to provide consistent and timely ADL care was evident across multiple cases, with staff interviews confirming the lack of adherence to expected care schedules.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility staff failed to ensure that a resident who was using psychotropic medications received a gradual dose reduction (GDR) and was free from unnecessary psychotropic medications. The resident, who was part of a survey sample of 62 residents, had multiple diagnoses including anxiety disorder, insomnia, major depressive disorder, and others. The clinical record review on the morning of June 10, 2024, revealed that the resident was prescribed several psychotropic medications, including Duloxetine, Zolpidem, Buspirone, and Trazodone, with no documented attempts at GDR. During an interview with the Director of Nursing (DON), it was revealed that the GDR should have been documented in the Minimum Data Set (MDS). However, the MDS for the resident showed no attempts at GDR for the quarterly assessments conducted on February 8, 2024, and May 10, 2024. The DON confirmed that the symbol in the MDS indicated that GDR was not done. Additionally, there was no documentation found in the clinical record to indicate that a GDR was contraindicated for the resident. The issue was brought to the attention of the Administrator during the end-of-day meeting, but no further information was provided before the survey exit.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to prevent significant medication errors for multiple residents, as identified during a survey. For Resident #45, the staff did not administer the prescribed anticoagulant medication, Eliquis, as ordered by the physician following a diagnosis of bilateral lung pulmonary embolus. The medication was only partially administered over several days, with multiple doses omitted, and there was no documentation or notification to the physician regarding these omissions. Additionally, the resident's care plan was not updated to reflect the anticoagulant therapy, and there were no assessments for potential bleeding. Resident #49 also experienced medication administration failures, with the staff failing to administer Lovenox and Keflex as prescribed. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, did not receive several doses of these medications. The facility's records lacked documentation explaining the omissions, and there was no evidence that the physician was informed. The care plan for this resident was not revised to include antibiotic use for a urinary tract infection. Other residents, including Resident #23, Resident #166, and Resident #358, also faced similar issues with medication administration. Resident #23 had blood pressure medications held without physician orders or notification, while Resident #166 did not receive prescribed anti-coagulant and anti-hypertensive medications on several occasions. Resident #358 missed doses of vancomycin due to lack of access or availability. In all cases, there was a lack of documentation and communication with physicians regarding the missed doses, and the facility's administration was unaware of these issues until informed during the survey.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility staff failed to ensure proper storage and labeling of medications, as observed during a survey. In the medication room refrigerator, an opened vial of purified protein derivative (PPD) lacked an opening date, and four single-dose COVID-19 vaccines were found with expiration dates of April 2024. Additionally, on a medication cart servicing Hall #3, three opened bottles of Latanoprost ophthalmic drops were found, with the oldest bottle dated 4/23/24, which should have been discarded by 6/4/24 according to the six-week usage guideline. The facility staff, including an LPN and an RN, were involved in these observations, and during a final interview, the Administrator and Corporate Nurse Consultants did not express concerns about these findings. For Resident #5, the facility staff failed to store eye drops properly, allowing the resident to keep them at the bedside without an assessment for self-administration. The resident, who had multiple diagnoses including glaucoma, expressed concern about not receiving the eye drops on time due to staff misplacing them. The clinical record review revealed missed documentation of eye drop administration on specific dates, and there were no physician orders permitting the medication to be kept at the bedside. During an interview, the Director of Nursing and Corporate Nurse Consultant acknowledged that medications should not be kept at the bedside without proper assessment. The Administrator and Corporate Nurse Consultant were informed of these findings, but no additional information was provided regarding the unavailability of the medication for administration.
Failure to Provide Dental Care for Resident
Penalty
Summary
The facility staff failed to ensure that a resident received necessary routine and emergency dental care. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes, Chronic Kidney Disease, and depression, was observed with noticeable dental caries and complained of tooth pain. Despite a documented order for a dental appointment on 4/25/2024, there was no evidence in the clinical record that an appointment was scheduled or attended. The resident's care plan included monitoring for oral health issues but did not mention referring the resident to a dentist. The facility's policy required nursing staff to initiate and coordinate dental care, including notifying providers and collaborating with the Social Services Department. However, there was no documentation of these actions being taken for the resident. The Administrator and Corporate Nurse Consultant were informed of the resident's complaints and the lack of follow-up, but no further information or documentation of dental appointments was provided. The facility's policy outlined procedures for securing dental services and assisting with transportation and payment, but these were not implemented for the resident.
Failure to Follow Dietary Restrictions and Preferences
Penalty
Summary
The facility staff failed to adhere to the dietary needs and preferences of a resident with gluten intolerance, as observed during a survey. Over the course of three days, the resident did not receive meals according to the menu or their dietary restrictions. On multiple occasions, the resident was served meals containing gluten, despite having a documented gluten intolerance. The dining services director acknowledged the errors, attributing them to mistakes in meal ticket printing and preparation. The resident, who had moderate cognitive impairment and required extensive assistance with daily activities, expressed dissatisfaction with the meals provided. The resident's medical history included conditions such as hypothyroidism, atrial fibrillation, and protein-calorie malnutrition, which necessitated careful dietary management. Despite these needs, the facility repeatedly failed to provide appropriate meals, as evidenced by the discrepancies between the meal tickets and the actual food served. The director of nursing and the administrator were informed of these findings, acknowledging the need for adherence to dietary plans and proper meal provision.
Failure to Provide Gluten-Free Diet to Resident
Penalty
Summary
The facility staff failed to adhere to the prescribed therapeutic diet for a resident with gluten intolerance, as observed during a survey. The resident, who had a history of hypothyroidism, ileus, atrial fibrillation, weakness, falls, gluten intolerance, and obesity, was served meals containing gluten on multiple occasions. Specifically, on three consecutive days, the resident received meals that included gluten-containing items such as oatmeal, crackers, pasta, fried rice, and peach cobbler, despite the meal tickets clearly indicating a gluten allergy. The dining services director acknowledged the error, attributing it to a mistake. The resident, who was moderately cognitively impaired and required extensive assistance with daily activities, expressed dissatisfaction with the meals provided, noting that they did not receive breakfast or lunch on one occasion. The meals served did not align with the planned menu or the resident's dietary requirements, and there was a lack of adequate beverages on the trays. The director of nursing and the administrator were informed of these findings, and the administrator confirmed that the menu should be followed and that each tray should contain at least two drinks.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility staff failed to provide bedtime snacks to residents who desired them, as observed during a survey. Three residents, identified as Resident #21, Resident #2, and Resident #37, reported during a Resident Council Meeting that they were not offered snacks at bedtime. Resident #21 expressed a desire for a bedtime snack if it were available, while Resident #2 mentioned that residents had to purchase snacks from the General Store if they wanted them. Resident #37 stated that she was never offered snacks at bedtime or between meals, despite her desire for them. Interviews with facility staff, including a Certified Nursing Assistant (CNA), revealed that snacks were not consistently available to residents between meals or upon request. CNA #1 admitted that not all residents received snacks due to other CNAs not distributing them. During a final interview with the Administrator and Corporate Nursing Consultants, no additional information or concerns were provided by the facility staff regarding the deficiency.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards for food safety, as observed during a survey. Specifically, an employee was seen in the kitchen without a beard guard on two separate occasions, despite acknowledging the requirement to wear one. The Dietary Manager confirmed that it is the facility's policy for all staff to wear appropriate hair nets and beard guards while in the kitchen, as outlined in their Staff Attire policy. This policy mandates that all Dining Services employees must have their hair off the shoulders and facial hair properly restrained. Additionally, the facility did not properly store teriyaki sauce according to the manufacturer's guidelines. A large, half-empty bottle of teriyaki sauce was found in the refrigerator with a date indicating it was opened several months prior. The Dietary Manager initially believed the sauce was good for one year in the refrigerator, but upon reviewing the food vendor's sheet, it was revealed that the sauce should only be stored for one month after opening. This discrepancy was further confirmed by the manufacturer's website, which recommends using the sauce within one month of opening for the freshest taste.
Lack of Agreements for Dental and Optometry Services
Penalty
Summary
The facility staff failed to obtain agreements for necessary dental and optometry services, as revealed during staff interviews. On June 12, 2024, the Corporate Nurse Consultant and the Administrator confirmed that the facility lacked agreements with outside resources for these services. Further interviews on June 13, 2024, revealed that there was no local dentist available to accommodate residents requiring stretcher transport. Additionally, the facility relied on the VA Hospital for residents needing glasses. Despite being given an opportunity to provide additional information, the facility staff had no further comments or concerns regarding these deficiencies.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility staff failed to secure a transfer agreement with a hospital to ensure residents could be transferred when medically necessary. During an interview on June 12, 2024, the Corporate Nurse Consultant and the Regional President of Operations confirmed that the facility lacked such an agreement. They also mentioned that no hospital was willing to sign a contract with the facility. A subsequent interview on June 13, 2024, with the Administrator and two Corporate Nursing Consultants, provided an opportunity for the facility staff to present additional information, but they had no further comments or concerns regarding the issue.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For one resident, the facility did not provide a comprehensive care plan for wounds sustained from a car accident, including a lymphatic wound ulcer. Although a wound specialist assessed the wounds and prescribed treatments, the care plan only vaguely mentioned 'skin impairment' without specific details on the nature of the wounds or tailored interventions. This lack of specificity in the care plan was acknowledged by a Licensed Practical Nurse (LPN) during an interview, who stated that care plans should be individualized and updated as residents' needs change. Another resident was admitted with no pressure wounds but developed multiple pressure sores during their stay. The facility staff failed to implement preventive measures despite the resident's high risk for skin breakdown due to immobility and other factors. The resident's care plan did not address the potential for pressure ulcers, and the facility did not conduct timely skin assessments or document the development of pressure sores. The wounds were only identified during an external orthopedic appointment, and treatment was delayed until a wound specialist was consulted three days later. The facility's failure to provide timely hygiene and incontinence care further contributed to the development of pressure sores. Interviews with nursing staff revealed that they did not complete wound assessments, relying instead on an external wound doctor's practice. The Director of Nursing (DON) stated that skin breakdown should be assessed during incontinence rounds, but this was not consistently done. The facility's policies on skin assessments and wound care were not followed, and the necessary documentation and care planning for the resident's pressure ulcers were lacking. The deficiencies were brought to the attention of the facility's Administrator and Regional Nurse Consultant, who acknowledged the issues but did not provide additional information.
Failure in Pain Management for a Resident
Penalty
Summary
The facility staff failed to provide safe and appropriate pain management for a resident, identified as Resident #166, who required such services. The resident was admitted with multiple diagnoses, including a fracture of the right scapula, osteoporosis, and osteoarthritis, among others. The resident's care plan included physician orders for regular pain assessments using a 0-10 scale or non-verbal scoring tool every shift, as well as administration of Acetaminophen and Lidocaine patches for pain management. However, the facility staff did not consistently perform the required pain assessments or administer the prescribed medications. Specific dates and shifts were identified where pain assessments were not documented, and doses of Acetaminophen and Lidocaine patches were missed. Interviews with the Director of Nursing (DON) revealed that the facility's expectation was for residents to receive all medications as ordered by the physician. The DON stated that if a medication dose is missed, the nurse should notify the physician and the resident or their responsible party. Despite these expectations, the facility failed to adhere to the prescribed pain management plan for Resident #166, as evidenced by the missing documentation and unadministered medications. The facility administrator was informed of these concerns during the survey, but no further information was provided before the survey's exit.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
