Blue Ridge Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisonburg, Virginia.
- Location
- 94 South Avenue, Harrisonburg, Virginia 22801
- CMS Provider Number
- 495146
- Inspections on file
- 22
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Blue Ridge Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses, including Alzheimer's disease and malnutrition, was admitted without a completed admission assessment or a baseline care plan addressing ADL needs such as bed mobility, dressing, eating, and transfers. Staff interviews confirmed that required documentation and care planning were not completed within the expected timeframe.
Facility staff did not inform a resident's family when the resident was sent to the ER from dialysis. The facility learned of the transfer from a transport company but did not notify the resident's son, who only found out the next day. Documentation confirmed the facility's policy requires prompt notification of such changes.
Facility staff did not follow physician orders for oxygen administration for two residents, with oxygen concentrators set at incorrect flow rates. In both cases, the settings did not match the prescribed liters per minute, and staff had to adjust the equipment after the discrepancies were identified during the survey.
Facility staff did not honor the documented food dislikes of two residents, serving them vegetables listed as dislikes on their meal tickets. Both residents confirmed receiving unwanted foods, and the dietary manager acknowledged that such preferences should have been respected and substitutions provided, as outlined in facility policy.
The facility failed to provide written notice for room changes to several residents, violating their rights. Residents experienced room changes without prior written notification, despite the facility's policy requiring it. The lack of communication led to confusion and dissatisfaction among residents, highlighting a significant oversight in adhering to established protocols.
Several residents in the facility experienced inadequate assistance with activities of daily living (ADL) and delayed responses to call bells. A resident was left waiting for toileting assistance, resulting in an accident, while another resident's request for grooming was not prioritized. Additionally, a resident was left unattended on the toilet, and another had their call bell out of reach, preventing them from calling for help. These incidents reflect a failure to adhere to care plans and facility policies.
Two residents in a LTC facility experienced significant medication errors due to unavailability of prescribed medications. One resident missed several doses of vancomycin for osteomyelitis and c-diff, while another missed multiple insulin doses for diabetes. Staff interviews revealed inadequate processes for handling unavailable medications, and the facility's policy was not followed, leading to a lack of physician notification and alternative measures.
The facility staff failed to maintain accurate clinical records for residents, including incorrect documentation of oxygen and nebulizer tubing changes, missing dermatologist treatment notes, incomplete dialysis communication, and inconsistent wound treatment records. Additionally, there was a discrepancy in documenting a resident's code status, with conflicting information between the nurse practitioner's notes and the care plan.
The facility failed to meet the shower preferences of three residents, leading to a deficiency in personal care. A resident received only one shower in a month, despite being cognitively intact and preferring evening tub baths. Another resident, able to communicate effectively, filed a grievance about not receiving showers twice weekly, as preferred. A third resident, with multiple health conditions, reported going ten days without a shower. Despite adequate staffing, the facility did not uphold the residents' preferences, and the DON acknowledged the ongoing issue.
The facility failed to follow its abuse prevention policies regarding pre-employment screening and background checks for a significant number of employees. Out of twenty-five records reviewed, eighteen lacked reference checks, two had unverified licenses, and six did not include a sworn statement regarding criminal history. The human resource manager acknowledged the disorganization of records, which hindered compliance with the facility's policy.
The facility failed to update care plans for four residents, leading to deficiencies in care. A resident's care plan was outdated, indicating the use of a communication board despite verbal communication abilities. Another resident experienced a fall, but the care plan was not updated to prevent future falls. A third resident had a fall requiring a hospital visit, yet the care plan was not revised. Lastly, a resident experienced significant weight loss, but the care plan was not updated to address this change. Facility policies did not adequately address care plan revisions following significant events.
The facility staff failed to follow physician orders for three residents, leading to deficiencies in care. A resident did not receive a prescribed nutritional supplement due to stock issues, another did not have sutures removed or a dermatology follow-up scheduled, and a third did not receive consistent wound care or the application of a multi-podus boot. Staff interviews revealed issues with ordering processes, documentation, and adherence to care plans.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions for a resident with a feeding tube, and did not follow transmission-based precautions for a resident with scabies. Additionally, the facility did not respond appropriately to a COVID-19 outbreak, failing to conduct contact tracing or broad-based testing. The presence of Legionella bacteria in the water system was not adequately addressed, indicating significant gaps in infection control practices.
The facility failed to provide education and offer flu and pneumonia immunizations to three residents, as revealed during a review of immunization protocols. Clinical records lacked documentation of education, offers, or consent for the vaccines. The infection preventionist confirmed these deficiencies, noting that floor nurses are responsible for offering immunizations upon admission. Despite the facility's policies requiring documentation of education and consent, these were not followed, and no additional information was provided by the facility's leadership.
The facility failed to educate and offer the COVID-19 vaccine to four residents and one staff member. Clinical records showed no evidence of education or offering of the 2023-2024 spike vaccine. The infection preventionist confirmed the lack of documentation, and the human resources manager could not find immunization information for a staff member. The facility's policy on vaccination planning was not followed.
A resident's personal property was moved to another room without prior notice or consent while the resident was at a medical appointment. The move was due to conflicts with a roommate, but staff failed to communicate or involve the resident in the process. The resident, who was cognitively intact, expressed dissatisfaction with the lack of communication and handling of personal items.
The facility failed to maintain adequate funds on-site, denying two residents timely access to their personal funds, potentially affecting 41 residents with trust accounts. One resident reported multiple instances of being unable to withdraw money for shopping, while another experienced delays in accessing funds for outings. The Business Office Manager cited a recent bank change and insufficient petty cash as reasons for the issue, with only $5 available at the time of the survey. The facility's policy did not address residents' access to funds, and there was no visible posting of banking hours.
A resident was found with Bengay cream, antifungal powder, and Tums at her bedside without an assessment for self-administration ability or physician orders. Facility staff, including an LPN and the unit manager, confirmed that medications should be stored in the medication cart unless an order allows self-administration. The unit manager removed the items, and a review of the resident's records showed no assessment for self-administration ability, contrary to facility policy.
A facility failed to develop a complete care plan for a resident with end-stage renal disease receiving dialysis. The resident's care plan lacked blood pressure parameters despite recent increases in blood pressure readings. An LPN noticed the changes but was unsure if they had been reported to the physician. The DON confirmed the absence of these parameters in the care plan.
A resident at high risk for falls experienced a fall after becoming agitated about a room change. The facility staff failed to conduct a post-fall assessment or update the resident's care plan, as required by the facility's Fall Prevention Program policy. Interviews revealed a lack of documentation and follow-up, highlighting a deficiency in the facility's response to the incident.
The facility failed to provide proper catheter care for two residents. One resident's catheter tube was not anchored, risking dislodgement, despite a physician's order to check the placement every shift. Another resident's catheter bag was found on the floor, contrary to the facility's policy and care plan, which required it to be suspended above the floor to prevent infection. Both issues were confirmed by nursing staff.
A facility failed to adhere to infection control measures and professional standards for oxygen therapy. A resident's nebulizer mask and tubing were not changed weekly as required, and the oxygen tubing was not labeled with a date. Staff interviews confirmed the equipment should be changed weekly, but the treatment administration record inaccurately reflected this. The unit manager confirmed the deficiency, and the findings were shared with the facility administrator and DON.
A facility failed to provide meals or snacks for a resident with ESRD and diabetes during offsite dialysis treatments, resulting in the resident missing meals on dialysis days. Staff interviews confirmed no food was sent with the resident, and the dietary manager cited concerns about meals going missing. Additionally, the facility did not maintain effective communication with the dialysis center, as the dialysis communication book was found to be incomplete, contrary to the facility's policy and contract requirements.
A Novolog insulin pen on a medication cart was improperly labeled with a handwritten name instead of a pharmacy label, violating pharmacy standards. The pen was taken from a back-up supply kit, and the facility's policy requiring a usage slip was not followed. The issue was discussed with the facility's administration.
A resident with hand tremors did not receive a two-handled sippy cup as recommended by therapy and documented in her care plan. Despite the resident's cognitive awareness and multiple health conditions, staff were unaware of the requirement, and the dietary department was not notified, leading to the absence of the cup on meal trays.
The facility staff failed to follow food safety standards, with unlabeled and expired food products found in the kitchen, and improper food distribution practices observed on a unit. A CNA mixed clean and soiled trays, raising infection control concerns. The dietary manager and facility leadership were informed of these issues.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan for one resident within 48 hours of admission, as required. The clinical record review revealed that the resident, who had diagnoses including Alzheimer's disease, HIV, anxiety disorder, dementia, and malnutrition, did not have an admission assessment completed. The most recent MDS was a discharge assessment, and the comprehensive care plan lacked interventions for activities of daily living (ADL) such as bed mobility, dressing, eating, and transfers. During staff interviews, the MDS coordinator confirmed that the admission assessment and baseline care plan for ADL care were missing for this resident. This information was presented to the director of nursing and the administrator, with no further information provided before the exit conference. The deficiency was identified through clinical record review and staff interviews, which confirmed the absence of required documentation and care planning for the resident's immediate needs following admission.
Failure to Notify Family of Resident's Emergency Room Transfer
Penalty
Summary
Facility staff failed to notify the family of a resident's change in condition when the resident was sent to the emergency room from dialysis. According to staff interviews, the unit manager (an LPN) stated that the facility became aware of the resident's transfer to the ER only after the transport company informed them. Despite this knowledge, no one from the facility notified the resident's son about the ER transfer. The son only learned of the situation when he arrived at the facility the following day to take the resident to an appointment. A review of the resident's clinical record showed a progress note indicating the resident had been admitted to the hospital, and facility documentation confirmed a policy requiring prompt notification of the resident's representative in such situations. The deficiency was identified for one resident out of a sample of eleven, and the issue was discussed with the facility's administrator and director of nursing during the survey.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Facility staff failed to administer oxygen therapy according to physician orders for two residents. In the first instance, a resident's oxygen concentrator was observed to be set at 3 liters per minute (LPM), while the physician's order specified continuous oxygen at 2 LPM via nasal cannula. The treatment administration record indicated that a registered nurse had documented the resident was receiving oxygen at the correct rate, but direct observation revealed otherwise. Upon being notified, the nurse acknowledged the discrepancy and adjusted the setting to the ordered amount. In the second case, another resident's oxygen concentrator was found set at 2.5 LPM. The physician's order required supplemental oxygen at 2 LPM, with an allowance to increase to 3 LPM only if oxygen saturation dropped below 92%. The nurse confirmed the setting was incorrect and adjusted it to 2 LPM. Facility documentation reviewed stated that oxygen is to be administered under physician orders. These findings were discussed with facility leadership during the survey.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
Facility staff failed to honor the documented food preferences of two residents during meal service. In one instance, a resident was served carrots, broccoli, and cauliflower, all of which were listed as food dislikes on her meal ticket. The resident confirmed during an interview that she often receives food she does not like and simply leaves it uneaten. The dietary manager acknowledged that the purpose of listing food dislikes on the meal ticket is to inform staff of resident preferences and that these items should have been substituted with another vegetable. In a separate instance, another resident was served carrots, which were also listed as a food dislike on her meal ticket. This resident expressed resignation, stating that nothing would be done about the issue. The dietary manager reiterated that food dislikes should be honored and substitutions made as necessary. Facility documentation, including the Food Preparation Guidelines policy, supports the expectation that resident preferences are to be honored regarding food and drinks.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility staff failed to provide written notice prior to room changes for five residents, violating their right to be informed in advance. Resident #53 experienced room changes on two occasions without receiving any written or verbal notice. The facility's social worker confirmed that the room changes were due to roommate conflicts, but no written notices were provided. The facility's policy requires written notification in a language and manner the resident understands, but this was not adhered to. Resident #200 also experienced multiple room changes without written notification. The social worker admitted to verbally informing the resident about one of the changes but acknowledged the absence of written notices for all room changes. The facility's administrator confirmed that residents should be notified ahead of time to allow for planning, yet this protocol was not followed. Other residents, including #57, #12, and #13, also did not receive written notifications for their room changes. Resident #57 was moved for isolation purposes without prior written notice. Resident #12 was moved under the pretext of renovations, which did not occur, and expressed a desire to reunite with a previous roommate. Resident #13 was separated from a preferred roommate without written notice, and the facility failed to address her preference adequately. The facility's policy mandates written notice for room changes, but this was consistently overlooked.
Inadequate ADL Assistance and Delayed Response to Call Bells
Penalty
Summary
The facility staff failed to provide adequate assistance with activities of daily living (ADL) for several residents, leading to multiple deficiencies. Resident #12, who required extensive assistance for toileting, experienced significant delays in staff response to her call bell, resulting in her urinating on the floor. On multiple occasions, the call bell was observed to be engaged for extended periods before staff responded, despite the presence of numerous staff members in the vicinity. The resident, who was cognitively intact, reported frequent delays in receiving assistance, which was corroborated by observations during the survey. Resident #22, who required assistance with personal hygiene, was observed with significant facial hair that she expressed a desire to have removed. Despite her request, the staff failed to provide the necessary grooming assistance in a timely manner. The resident's care plan indicated a need for extensive assistance with grooming, yet the staff did not prioritize her request, citing time constraints and other activities as reasons for the delay. Other residents, such as Resident #57, were left unattended in vulnerable situations, such as being left on the toilet for an extended period without assistance. The facility staff also failed to ensure that Resident #40's toenails were trimmed as required by her care plan, and Resident #49's call bell was repeatedly found out of reach, preventing her from calling for assistance. These incidents highlight a pattern of inadequate response to residents' needs and a failure to adhere to care plans and facility policies regarding timely assistance and call light accessibility.
Medication Errors and Omissions in LTC Facility
Penalty
Summary
The facility staff failed to ensure that two residents were free from significant medication errors. For Resident #32, the staff did not administer the prescribed antibiotic, vancomycin, as ordered by the physician. The resident, who was being treated for osteomyelitis and c-diff, missed several doses of vancomycin due to unavailability. The medication administration record (MAR) indicated missed doses on specific dates, and there was no documentation of the physician being notified about these omissions or any alternative orders being sought. Resident #249, an insulin-dependent diabetic, also experienced medication errors. The facility staff failed to administer multiple doses of insulin, specifically Basaglar and Humalog, as prescribed. The MAR showed missed doses on several occasions, and nursing notes indicated that the medications were not available. However, there was no evidence that the physician was informed about the unavailability of insulin or that any alternative measures were taken to address the situation. Interviews with facility staff, including LPN #6 and RN #1, revealed inconsistencies in the process of handling unavailable medications. The emergency supply of medications was found to be inadequately stocked, lacking essential medications like insulin. The facility's policy on unavailable medications was not followed, as there was no proper documentation or notification to the physician regarding the missed doses. The facility administrator and director of nursing were informed of these findings during a mid-day meeting.
Deficiencies in Clinical Record Maintenance and Documentation
Penalty
Summary
The facility staff failed to maintain accurate clinical records for several residents, leading to deficiencies in care. For one resident, the staff did not properly document the changing of oxygen and nebulizer tubing. The nebulizer mask and tubing were observed to be dated incorrectly, and the treatment administration record (TAR) was signed off inaccurately, indicating changes that did not occur on the documented dates. This discrepancy was confirmed by the unit manager, who acknowledged the incorrect documentation. Another resident, who was being treated for scabies by a dermatologist, had incomplete clinical records as the facility failed to include treatment notes from the dermatologist. Despite multiple entries in the nursing notes referencing the scabies diagnosis and treatment, the dermatologist's information was missing from the resident's chart. The unit manager confirmed the absence of these notes and had to contact the dermatologist to obtain the necessary documentation. Additionally, the facility did not maintain a complete clinical record for a resident undergoing dialysis. The communication book intended for documenting dialysis sessions was found with blank pages, and no information was recorded in the resident's clinical record regarding dialysis treatments, medications, or weights. Furthermore, the facility failed to accurately document another resident's wound treatments, as the bandages were not changed as ordered by the physician, leading to drainage through the bandage. Lastly, there was a discrepancy in documenting a resident's code status, with conflicting information between the nurse practitioner's notes and the care plan, which indicated a DNR status.
Failure to Meet Residents' Shower Preferences
Penalty
Summary
The facility failed to accommodate the shower preferences of three residents, leading to a deficiency in meeting their personal care needs. Resident #71, who was cognitively intact, expressed dissatisfaction with not receiving showers twice a week as scheduled, receiving only one shower between late July and late August. The resident preferred evening tub baths for relaxation, but the facility's records showed a significant gap in providing these services. Interviews with staff, including an LPN and the DON, revealed awareness of the issue, with attempts to address it by assigning a dedicated shower aide, yet the problem persisted. Resident #57 also experienced a failure in receiving showers twice weekly, as preferred. Despite being assessed as able to communicate effectively, the resident's MDS did not document preferences for routine activities. The resident filed a grievance in July about the lack of showers, and the facility's grievance log showed similar complaints from other residents. The facility's shower schedule indicated assigned days, but the resident received only five showers in a month. Staff interviews and observations during the survey did not clarify the reason for the unmet preferences, despite adequate staffing levels. Resident #53, with a history of coronary artery disease, hypertension, diabetes, and depression, did not receive showers twice per week as preferred. The resident, who required moderate assistance, reported going ten days without a shower. The facility's records confirmed only four showers in a month, with no documentation of refusals. Interviews with CNAs and the LPN unit manager did not provide reasons for the missed showers, and the DON acknowledged the issue, noting that audits had been conducted but the problem remained unresolved.
Failure to Conduct Pre-Employment Screening and Background Checks
Penalty
Summary
The facility staff failed to adhere to their abuse prevention policies concerning pre-employment screening and background checks for a significant number of employees. Out of twenty-five employee records reviewed, eighteen lacked reference checks, two had unverified licenses prior to employment, and six did not include a sworn statement regarding any criminal history. This deficiency was identified during a review of employee records, which revealed missing documentation that is required by the facility's policy to ensure the safety and well-being of residents. The human resource manager acknowledged the absence of the necessary information and attributed it to disorganized employee records, making it difficult to locate the required documentation. The facility's policy mandates job reference checks, drug screenings, licensure verifications, and criminal conviction record checks for all new employees. The policy also prohibits the employment of individuals with a history of abuse, neglect, exploitation, or any related disciplinary actions. Despite these requirements, the facility failed to comply, as evidenced by the missing documentation in the employee records reviewed.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plans for four residents, leading to deficiencies in their care. Resident #80's care plan was outdated, indicating the use of a communication board despite the resident's ability to communicate verbally. This oversight persisted for approximately four months, as confirmed by the LPN unit manager, who acknowledged the resident's verbal communication abilities. Resident #57 experienced a fall, but the care plan was not updated to reflect this incident or to implement new interventions to prevent future falls. The resident was identified as high risk for falls, yet the most recent intervention was dated several months prior to the fall. Similarly, Resident #39 had a fall that required a hospital visit, but the care plan was not revised to address the incident or to include new preventive measures, despite recommendations for care plan revision in the post-fall review. Resident #32 experienced a significant weight loss of 22.6 pounds in one month, yet the care plan was not updated to reflect this change or to implement interventions addressing the weight loss. The facility's policies on comprehensive care plans and fall prevention did not adequately address the need for care plan revisions following significant events such as falls or weight changes. Interviews with facility staff, including the DON, confirmed the expectation for care plans to be updated with each change or event, highlighting the deficiencies in the facility's care planning process.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility staff failed to administer the nutritional supplement Pro-stat to Resident #77 as ordered by the physician for over two months. The resident, who was admitted with multiple diagnoses including protein-calorie malnutrition, did not receive the supplement due to it being out of stock and unavailable for administration. The medication administration record documented that the Pro-stat was not administered on several occasions, and staff interviews revealed issues with vendor changes and ordering processes that delayed the supplement's availability. Resident #57 did not have sutures removed or a follow-up dermatology appointment scheduled as ordered by the doctor. The resident, who had a history of scabies, was found with red lesions and dried blood on his body. The clinical record review showed a lack of documentation from the dermatologist, and the unit manager confirmed the absence of this information in the resident's chart. The director of nursing later identified a suture that needed removal and confirmed that the dermatology follow-up had not been scheduled. Resident #32 did not receive wound care and the application of a multi-podus boot as ordered by the physician. The resident reported that bandage changes for a foot ulcer were frequently missed, and the treatment administration record confirmed that the wound care was not consistently performed. During an observation, the resident's wound was found to have drained through the bandage, and the multi-podus boot was not in place. The unit manager acknowledged the ongoing issue of staff not performing the wound care as ordered and noted that the order for the multi-podus boot had not been correctly updated in the clinical record.
Inadequate Infection Control and Response to Outbreaks
Penalty
Summary
The facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. In one instance, staff did not adhere to enhanced barrier precautions for a resident with a feeding tube, as required by the facility's policy. Observations revealed that personal protective equipment (PPE) was not available outside the resident's room, and staff members entered the room without wearing the necessary PPE. Interviews with staff indicated a lack of understanding and communication regarding the enhanced barrier precautions, contributing to the failure to implement appropriate infection control measures. In another case, the facility staff did not follow transmission-based precautions for a resident diagnosed with scabies. Despite the resident's care plan indicating the need for contact isolation, staff members were observed entering the resident's room and providing care without wearing PPE. The facility's infection preventionist was unaware of the need for a line listing and failed to track other symptomatic residents, indicating a lack of proper infection surveillance and monitoring. Additionally, the facility did not respond appropriately to a COVID-19 outbreak. The infection preventionist was unable to provide evidence of contact tracing or broad-based testing, as recommended by the CDC. The facility also failed to maintain a line listing of COVID-19 cases and did not conduct necessary testing for residents and staff. Furthermore, the facility did not adequately address the presence of Legionella bacteria in the water system, as recommended cleaning and follow-up testing were not performed. These deficiencies highlight significant gaps in the facility's infection control practices and response to infectious disease outbreaks.
Failure to Provide Immunization Education and Offers
Penalty
Summary
The facility staff failed to provide education and offer flu and pneumonia immunizations to three residents, as identified during a review of immunization protocols. The clinical records for two residents showed no evidence of education or offers for the flu and pneumonia vaccines since their admission, and there was no documentation of consent or refusal. Another resident's record indicated that while she received the Prevnar 13 vaccine, there was no documentation of being offered the flu vaccine or the pneumococcal 23 vaccine. All three residents had been in the facility for at least eight months and were present during the flu season. During an interview, the facility's infection preventionist confirmed the lack of documentation regarding the immunizations, education, and consents for the three residents. The infection preventionist explained that floor nurses are responsible for offering immunizations upon admission and contacting the responsible party for consent. The facility's policies on influenza and pneumococcal vaccinations require documentation of education and consent, which was not adhered to in these cases. The facility's administrator, director of nursing, and corporate nurse consultant were informed of these findings, but no additional information was provided to address the deficiency.
Failure to Educate and Offer COVID-19 Vaccine
Penalty
Summary
The facility staff failed to provide education and offer the COVID-19 immunization to four out of five residents sampled, as well as to one staff member. During clinical record reviews, it was found that there was no evidence of education or offering of the COVID-19 2023-2024 spike vaccine to the residents. Specifically, Resident #80 had no immunization information noted except for a PPD tuberculin skin test, and Residents #42, #60, and #70 had no information regarding COVID immunization listed. Additionally, there was no documentation indicating that the vaccine was offered, education was provided, or that it was declined or refused. An interview with the facility's infection preventionist confirmed the lack of documentation regarding COVID immunizations for the residents. The infection preventionist stated that floor nurses are responsible for offering immunizations upon admission and contacting the responsible party to determine if they want the immunization. The importance of immunizations was acknowledged to prevent outbreaks. However, the facility's process was not followed, as evidenced by the absence of documentation and education. Furthermore, the facility's human resources manager and administrator were unable to find any COVID immunization information for Other Employee #8 in the employee's file. The employee had to provide a photo of her COVID immunization card, which showed she had received the primary series and one booster dose in October 2022. There was no evidence of the employee being educated on the COVID immunization or being offered subsequent boosters. The facility's policy on Coronavirus Prevention and Response outlines the requirements for vaccination planning, including education and documentation, which were not adhered to in these cases.
Resident's Personal Property Moved Without Notice
Penalty
Summary
The facility staff failed to honor a resident's right to be treated with respect and dignity by moving personal property without prior notice or consent. The incident involved a resident who was cognitively intact and had multiple diagnoses, including congestive heart failure, hip fracture, neurogenic bladder, diabetes, anxiety, and depression. The resident's personal items were moved to another room while the resident was out of the facility for a medical appointment. There was no documentation of verbal or written notice provided to the resident before the room change, and the resident was not given the opportunity to assist or accompany staff during the transfer of personal items. Interviews with facility staff, including the social worker, LPN, CNA, DON, and the administrator, revealed that the room change was made due to conflicts and complaints about the resident's roommate. However, the staff did not recall why the move was conducted on that specific day or why it was done without the resident's supervision. The resident expressed dissatisfaction with the lack of communication and the handling of personal items, particularly the discarding of pretzels. The administrator acknowledged that it was not the facility's expectation for staff to move personal items without the resident's permission or oversight.
Facility Fails to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to maintain adequate funds on-site, denying two residents access to their personal funds, which could potentially affect 41 residents with trust accounts. Resident #226 (R226) reported multiple instances where he was unable to withdraw money from his trust account for shopping. The Business Office Manager (BOM) explained that residents are allowed to withdraw $40 per day, but due to a lack of funds, R226 was unable to access his money. The BOM mentioned that the facility had recently changed banks and was waiting for funds to be replenished, leaving only $5 available at the time. The activity assistant corroborated R226's claims, stating that he often missed out on shopping trips due to insufficient funds. Resident #53 (R53) also experienced delays in accessing her personal funds. Despite having available funds, R53 reported that it sometimes took several days to receive money from her account, especially if she had an outing planned. The BOM, who started working at the facility on August 1, 2024, acknowledged the issue and attributed it to the recent bank switch and insufficient petty cash reserves. At the time of the survey, only $5 was available for residents, highlighting the facility's failure to ensure timely access to personal funds. The facility's policy on resident trust accounts did not address residents' access to funds, focusing only on business office procedures. During the survey, it was noted that there was no visible posting of banking hours for residents, and the BOM confirmed that money was only available Monday through Friday. The administrator attempted to address this by posting a sign indicating banking hours, but the BOM clarified that the receptionist did not have access to the money box, further complicating residents' access to their funds.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility staff failed to ensure that it was clinically appropriate for a resident to self-administer medications. This deficiency was identified for a resident who had Bengay cream, antifungal powder, and Tums at her bedside. The facility staff did not assess the resident's ability to self-administer medications, did not obtain physician orders for these medications, and failed to remove them from the resident's room. During an initial tour, the surveyor observed these medications on the resident's over-bed table and in a bedside drawer. The resident reported using Bengay cream for arthritis pain several times a day. Interviews with facility staff, including an LPN and the unit manager, revealed that medications, including over-the-counter ones, should be stored in the medication cart or room unless there is an order allowing self-administration. The unit manager confirmed that no residents were authorized to self-administer medications and removed the items from the resident's room. A review of the resident's clinical records showed no assessment for self-administration ability, and the facility's policy required such an assessment by the interdisciplinary team. The facility administrator and director of nursing were informed of these findings during an end-of-day meeting.
Incomplete Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to develop a complete care plan for a resident with end-stage renal disease who was receiving dialysis. The resident, who was cognitively intact, had a history of congestive heart failure, pulmonary embolism, and hypertension. A review of the resident's blood pressure readings from late July to late August showed an average systolic pressure in the 140s and diastolic pressure in the 70s, with recent increases to 183/83 and 179/83. Despite these changes, the care plan did not include blood pressure parameters for dialysis, nor were they found in any other focus area of the care plan. An LPN noticed the increase in blood pressure and suggested it could indicate kidney failure but was unsure if it had been reported to the physician. The DON confirmed the absence of blood pressure parameters in the care plan.
Failure to Implement Post-Fall Interventions for Resident
Penalty
Summary
The facility staff failed to implement necessary interventions following a fall incident involving a resident, identified as R57, who was at high risk for falls due to impaired mobility and cognition. On 8/13/24, R57 experienced a fall after becoming anxious and agitated about a room change. Despite the fall being documented in a nursing note, there was no evidence of a post-fall assessment or any interventions to prevent future falls. The resident's care plan, which had not been updated since 3/27/24, did not reflect any new strategies to address the fall risk following the incident. Interviews with the unit manager revealed that the expected protocol, which includes a post-fall review and updating the care plan, was not followed. The unit manager acknowledged the absence of documentation and the importance of these steps in ensuring resident safety. The facility's Fall Prevention Program policy outlines specific actions to be taken after a fall, including assessment, documentation, and care plan review, none of which were completed for R57. The Director of Nursing was aware of the fall but could not provide additional documentation or witness statements to support the incident's circumstances.
Improper Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure proper catheter care for two residents, leading to potential health risks. Resident 41, who has benign prostatic hyperplasia and obstructive uropathy requiring a catheter, did not have the catheter tube anchored to prevent dislodging. Despite having a physician's order to check the placement of the catheter strap every shift, the tubing was observed unanchored during an interview and observation with a registered nurse. The resident did not report any pain or skin concerns, but the lack of anchoring was acknowledged by the nurse. Resident 77, who has multiple diagnoses including congestive heart failure and obstructive uropathy, was found with a catheter bag positioned on the floor, which is unsanitary and poses a risk for infection. The catheter bag was supposed to be suspended below bladder level and above the floor, as per the facility's policy and the resident's care plan. However, observations showed the bag resting on the floor, and both a CNA and an LPN confirmed that this was not the correct positioning. The facility's policy and the resident's care plan both emphasized the importance of maintaining proper catheter positioning to prevent complications.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide oxygen therapy consistent with infection control measures and professional standards of practice for a resident. During an initial tour, it was observed that the resident had a nebulizer mask sitting open to air on the bedside table, and the mask and tubing were dated over a month prior, indicating they had not been changed weekly as required. Additionally, the oxygen tubing was not labeled with a date, and the nasal cannula was found on the floor, which posed a potential infection risk. Interviews with staff revealed that the oxygen and nebulizer tubing should be changed weekly and stored properly to prevent contamination. However, the treatment administration record (TAR) inaccurately indicated that the equipment had been changed on specific dates, despite evidence to the contrary. The facility's policy required weekly changes of nebulizer tubing, but this was not adhered to, as confirmed by the unit manager and the discarded nebulizer mask dated 7/16/24. The findings were shared with the facility administrator and director of nursing, but no additional information was provided to address the deficiency.
Failure to Provide Meals and Ensure Communication for Dialysis Resident
Penalty
Summary
The facility failed to provide meals or snacks for a resident who required dialysis treatment at an offsite location, leading to the resident missing meals on dialysis days. The resident, who had end-stage renal disease, type 2 diabetes, and was dependent on renal dialysis, reported leaving the facility around 10 a.m. and returning around 3 p.m. on dialysis days without receiving any food or drink. Despite being an insulin-dependent diabetic, the resident had to wait until the evening meal to eat, as no food items were sent with him, nor was anything provided upon his return. Interviews with facility staff, including a CNA and the dietary manager, confirmed that no meals or snacks were sent with the resident to the dialysis center. The dietary manager stated that meals were not sent because they often went missing, and there was no established practice of sending packed lunches or snacks. The unit manager was unaware of the need to send meals, assuming the resident would eat at the dialysis center, despite the resident's nutritional issues and dietary needs. Additionally, the facility failed to maintain effective communication with the dialysis center to ensure continuity of care. The resident reported that a folder was sometimes sent with him, but it was not consistently filled out. The dialysis communication book, intended to document the resident's care and treatment at the dialysis center, was found to be full of blank pages. The unit manager acknowledged the lack of follow-up and documentation, which was contrary to the facility's dialysis policy and the contract with the dialysis center, both of which emphasized the importance of communication and coordination between the facility and the dialysis provider.
Improper Labeling of Insulin Pen from Back-up Supply
Penalty
Summary
The facility staff failed to label a Novolog prefilled insulin pen according to pharmacy standards on the B wing unit. During an inspection of the B wing medication cart, it was observed that the insulin pen lacked a pharmacy label indicating the drug name, resident's name, prescribed dose, strength, or administration instructions. Instead, the resident's name and the date opened were handwritten on the pen. A Licensed Practical Nurse (LPN) was unaware of why the pen was labeled in this manner and did not know what happened to the pharmacy-provided bag or label. The Director of Nursing (DON) explained that the insulin pen was taken from a back-up supply kit, and a different LPN had written the resident's name on it. The consultant pharmacist confirmed that nurses are not authorized to label prescription medications and that a form should have been completed and sent to the pharmacy when medications are removed from a back-up supply. The facility's policy required a usage slip to be completed and placed in the drug kit when drugs are removed. This deficiency was discussed with the facility's administration, but no further information was provided before the survey concluded.
Failure to Provide Recommended Eating Equipment
Penalty
Summary
The facility staff failed to provide a two-handled sippy cup for a resident, as recommended by therapy and documented in the resident's plan of care. The resident, who was cognitively intact, had been admitted with multiple diagnoses including atrial fibrillation, hypertension, arthritis, anxiety, depression, hypothyroidism, and a urinary tract infection. The resident was observed eating breakfast without the sippy cup, despite having hand tremors that made it difficult to manage regular cups. The resident confirmed that she had not received the sippy cup for several weeks, although it was initially provided after the recommendation. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's need for the handled cup. The LPN unit manager was unaware of the requirement, and the CNA stated that therapeutic cups were usually listed on meal tickets, but did not recall seeing it on the resident's ticket. The dietary manager confirmed that no notification was sent to the kitchen about the need for the therapeutic cup, resulting in its absence on meal trays. The deficiency was discussed with the facility's administration and clinical services directors, but no additional information was provided before the survey concluded.
Food Safety and Distribution Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards for food safety in the main kitchen and on one of the units, leading to deficiencies in food storage, preparation, and distribution. During an initial kitchen tour, it was observed that multiple open food products, such as syrup, bread, and croissants, were not labeled with an open date. Additionally, expired meat products, sugar, and flour were accessible for distribution. The dietary staff member acknowledged that all opened food products should have an open date, and expired items should have been discarded. The dietary manager was informed of these concerns, and the facility's policy on date marking for food safety was reviewed, which mandates that food be clearly marked with a date for consumption or disposal. On another occasion, the facility staff failed to distribute food in a manner that prevents contamination. During breakfast tray distribution on a unit, a CNA was observed taking a resident's tray back to the cart with other clean trays after the resident had removed some food items. This action mixed clean and soiled trays, which the CNA acknowledged could be an infection control concern. The facility administrator and director of nursing were informed of these findings, but no additional information was provided before the exit conference.
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Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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