Canterbury Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 1776 Cambridge Drive, Richmond, Virginia 23238
- CMS Provider Number
- 495272
- Inspections on file
- 32
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Canterbury Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with hypotension related to ESRD had a comprehensive care plan directing staff to administer Midodrine as ordered and to monitor vital signs as ordered and as clinically indicated, but staff did not implement the care-planned intervention to give Midodrine per the physician’s orders. An LPN acknowledged that the care plan is meant to guide staff in meeting residents’ individual needs, and facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident.
Staff failed to clarify PRN orders and consistently monitor blood pressure for a resident receiving Midodrine via PEG tube for orthostatic hypotension and Clonidine for HTN, both ordered every eight hours with specific SBP parameters. Clinical record review showed no evidence that blood pressure was taken every eight hours to determine the need for these PRN medications. An LPN stated that blood pressure should be checked before administering such medications, and a regional clinical leader acknowledged that PRN Midodrine had been cited previously and that PRN Clonidine orders were unusual and required clarification.
Staff failed to follow physician-ordered blood pressure parameters for Midodrine administration for a resident with hypotension related to ESRD and dialysis dependence. The order required Midodrine 10 mg via PEG tube every 8 hours only when SBP was under 100 mmHg, but the MAR showed the medication was given multiple times when SBP readings were above 100 mmHg. An LPN confirmed that the medication should have been held based on the documented blood pressures, despite the care plan and facility policy requiring adherence to ordered parameters and monitoring of vital signs.
Staff failed to monitor and document blood sugar checks as ordered for a resident with diabetes, and did not initiate or document required neurological checks after falls resulting in head injuries for two other residents, despite facility policy and physician orders. Interviews and record reviews confirmed these omissions, with administrative staff acknowledging the lack of evidence for the required care.
A resident admitted with diabetes, respiratory failure, and a tracheostomy did not have diabetes or blood sugar monitoring addressed in their baseline care plan upon admission. Although physician orders for blood sugar checks were present, the initial care plan focused only on discharge planning and equipment needs, omitting necessary interventions for diabetes until several days later. Staff confirmed that diabetes management should have been included from the start.
Multiple residents did not receive wound care treatments as recommended by the wound nurse practitioner, with delays and omissions in implementing physician orders and eTAR documentation. Staff were unaware of required treatments, and residents dependent on staff for turning and repositioning were not consistently assisted, leading to worsening pressure injuries. Recommended changes in wound care and infection management were not followed, resulting in harm and deterioration of residents' conditions.
Staff failed to maintain a clean and homelike environment, as strong urine odors persisted in multiple units and hallways despite regular cleaning, and privacy curtains in several rooms were found to be dirty or improperly maintained. Additionally, a resident was left with a bloody pillowcase in contact with his body for an extended period, with both nursing and housekeeping staff acknowledging this did not meet cleanliness standards.
Facility staff did not follow required procedures for reporting and investigating abuse, neglect, and injuries of unknown origin for several residents. In multiple cases, injuries were not reported to the state agency within the mandated timeframe, and documentation of final investigative reports was missing or incomplete. Staff interviews confirmed knowledge of reporting policies, but these were not consistently implemented.
Facility staff did not follow individualized care plans and physician or practitioner recommendations for several residents, resulting in missed or delayed wound care treatments, lack of required repositioning for pressure injury prevention, improper infection control precautions for a resident with shingles, incomplete tracheostomy care documentation, and failure to provide required medication education. These deficiencies were identified through observations, record reviews, and staff interviews.
Facility staff did not provide or document tracheostomy care as ordered for two residents, with multiple missed care instances noted on both day and night shifts. Despite physician orders and facility policy requiring regular tracheostomy care, the absence of documentation on respiratory administration records indicated that care was not consistently given. Nursing staff confirmed that proper care should be recorded, and administrative staff were informed of these deficiencies.
A resident with ESRD requiring hemodialysis did not have complete dialysis communication forms filled out on multiple treatment days, despite physician orders and facility policy mandating this documentation. Review of records showed several instances where pre-dialysis or dialysis communication was missing, and staff confirmed the expected process was not consistently followed.
A resident with end-stage renal disease and on dialysis did not receive Midodrine as ordered prior to dialysis sessions, despite blood pressure readings within the prescribed parameters. Facility staff, including an LPN and physician, confirmed the medication should have been administered, but records showed repeated omissions. The care plan and facility policy required medication administration as ordered, but this was not followed.
Two residents did not receive dignified care when staff failed to answer a call bell promptly for one cognitively intact resident, resulting in a 13-minute wait, and when a sign in the dining room required another resident to retrieve her meal from outside the dining area if arriving late. Both incidents were contrary to facility policies on dignity and timely response.
Facility staff did not inform a cognitively intact resident about new orders for Percocet and Xanax, nor did they provide information on the risks, benefits, or alternatives before administering these medications. Despite care plan requirements and facility policy mandating resident education and involvement in care decisions, there was no evidence that the resident was notified or educated prior to receiving the medications.
A resident's personal clothing and belongings were not relocated to their current room after a room change, leaving items such as clothing and water bottles in a vacant room. Staff confirmed the items belonged to the resident and acknowledged they should have been moved. The resident, who was moderately cognitively impaired, noticed the missing items and expressed a desire to have them returned. This failure violated facility policy regarding respect for resident property.
Two residents were assessed by a nurse practitioner in the dining room while other residents were present, rather than in a private setting as required by facility policy. An LPN confirmed that assessments should be conducted privately except in emergencies, and the nurse practitioner stated that public assessments sometimes occur for timing reasons. Facility leadership was informed of these privacy breaches.
A resident with anxiety and intact cognitive status received Xanax multiple times without evidence that staff attempted or documented alternative interventions prior to administration. Staff interviews confirmed that no alternate interventions were tried before using the psychotropic medication as a chemical restraint.
Facility staff did not report injuries of unknown origin for three residents with severe cognitive impairment within the required timeframe. In each case, bruises were discovered without a known cause, and although internal notifications were made, reporting to the state agency was delayed beyond the facility's policy of two hours. Staff and administrative interviews confirmed the reporting failures and the lack of adherence to established procedures.
Facility staff did not submit required follow-up investigative reports to the state agency for two residents after incidents involving an allegation of neglect and a bruise of unknown origin. Despite staff awareness of reporting procedures and initial incident reporting, documentation confirming submission of the final investigative reports within the required timeframe was not found.
Facility staff did not document required neurological checks after an unwitnessed fall involving a resident at moderate fall risk who was on anticoagulant therapy. Although initial assessments and notifications were made, there was no evidence of ongoing neuro monitoring as required by facility policy, and staff interviews confirmed the lack of documentation.
A resident with paraplegia and an indwelling urinary catheter was repeatedly observed with the catheter collection bag lying on the floor while in bed. Both an LPN and a CNA confirmed this practice was improper due to infection risk, and facility policy required catheter bags to be kept off the floor.
Staff failed to document attempts at non-pharmacological pain interventions before administering prn Percocet to a cognitively intact resident. Despite facility policy and standard nursing procedures requiring such interventions and their documentation, records showed that pain medication was given without evidence that alternatives were tried first.
A resident who was cognitively intact repeatedly refused morning medications before dialysis, believing they would be removed during the procedure. Nursing staff documented the refusals and informed the physician, who acknowledged awareness but did not document any discussion or provide further education to the resident. Facility policy requires physician supervision and documentation of such events, which was not completed in this case.
A resident with a history of pulmonary embolism was prescribed Apixaban and required monitoring for anticoagulant complications as per physician orders and care plan. However, staff did not document any monitoring for adverse effects or complications in the eMAR for an extended period, despite facility policy and staff statements that such monitoring should occur every shift.
Staff failed to adhere to infection control protocols for three residents, including improper glove use and hand hygiene during tracheostomy care, not replacing a blood-soiled pillowcase for a dependent resident, and not implementing required contact precautions for a resident with shingles. Interviews confirmed staff awareness of the lapses, and facility policies and CDC guidelines were not followed.
Facility staff failed to provide adequate ADL care, specifically turning and positioning, for four dependent residents with various medical conditions. Documentation was missing for several dates and shifts, despite care plans requiring repositioning every two hours. Interviews with CNAs confirmed the expected practice, but it was not consistently followed. Administrative staff were informed, but no further information was provided before surveyors' exit.
The facility staff failed to implement comprehensive care plans for three residents, resulting in missed treatments and medication errors. A resident with impaired skin integrity did not receive prescribed treatments, while another received medication despite contraindications and missed doses due to pharmacy issues. A third resident's treatments for pressure ulcers and GERD were not administered as ordered, despite available medications. Interviews confirmed the importance of following care plans, but deficiencies were noted.
Two residents in a facility did not receive medications and treatments as per physician orders, leading to deficiencies. One resident did not receive wound care and medications due to lack of documentation and unavailability, while another received medication against prescribed parameters and had discrepancies in medication administration. These issues highlight significant deficiencies in medication management and adherence to physician orders.
The facility staff failed to provide adequate pressure ulcer care and documentation for three residents. A resident did not receive prescribed treatments for deep tissue injuries, with missing documentation on several dates. Another resident's wound care was compromised by improper glove use, violating infection control protocols. Additionally, there was a lack of documentation for a third resident's pressure injury treatments on a specific date, contrary to physician orders.
A resident did not receive prescribed medications as scheduled, and the facility staff failed to notify the physician and responsible party. Despite the availability of medications in the emergency backup system, they were not administered, and the facility's policy on handling unavailable medications was not followed.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident in an LTC facility. The incident involved inappropriate sexual behavior observed by a CNA, leading to immediate separation and reporting to authorities. Both residents had cognitive impairments, and the male resident was placed under 1:1 supervision.
A resident's clinical record was incomplete due to the failure to document the holding of Metoprolol Tartrate and the lack of notification to the physician or responsible party. The LPN stated that the facility's protocol requires documentation and notification when a medication is unavailable, but this was not followed. The nurse practitioner was informed via text, but this was not recorded in the clinical record, violating the facility's documentation policy.
The facility failed to maintain kitchen utensils in a sanitary manner, with several items found dirty or damaged during an observation. The dietary manager acknowledged the issue and took immediate action to clean and discard the affected utensils. The facility's sanitation policy requires all utensils to be clean and in good repair.
A facility failed to maintain accurate clinical records for three residents, leading to documentation errors. One resident's record inaccurately documented urinary drainage bag changes after catheter removal. Another resident's advanced directives were inconsistently recorded, with conflicting 'Full Code' and 'DNR' statuses. A third resident's dental consult efforts were not documented, despite family refusal for an outside consult. These deficiencies highlight issues in record-keeping and communication among staff.
The facility failed to implement comprehensive care plans for four residents, resulting in deficiencies in urinary catheter care, dialysis care, and respiratory therapy. Documentation was missing for critical care interventions, indicating that the care plans were not fully executed. Interviews with staff confirmed these lapses in care plan adherence.
The facility staff failed to follow physician orders for two residents, leading to deficiencies in care. A resident with severe cognitive impairment did not have daily weights recorded as ordered, despite having a comprehensive care plan addressing multiple health issues. Another resident did not receive ordered wound care treatments for surgical wounds on several occasions, as evidenced by blank spaces on the treatment administration record. Interviews with staff confirmed the lack of compliance with documentation and treatment protocols.
The facility staff failed to provide proper urinary catheter care for three residents, leading to deficiencies in maintaining sanitary conditions and following physician orders. A resident's catheter bag was observed touching the floor, contrary to guidelines. Two residents had missing documentation for catheter care, indicating that care was not provided as ordered. Interviews with staff confirmed these deficiencies, and administrative staff were informed, but no further information was provided before the survey exit.
The facility failed to provide documented respiratory care for three residents with tracheostomies and ventilator needs. Missing documentation in the respiratory administration records indicated that care such as trach care, ventilator settings, and oral care was not consistently provided, as confirmed by interviews with staff.
A resident's dignity was compromised during medication administration via a PEG tube when an LPN left the room door open and did not pull the privacy curtain, exposing the resident to the hallway. The facility's policy lacked guidance on maintaining dignity during such procedures.
An LPN in a facility left a sheet with confidential resident information on a medication cart in the hallway, unattended and out of sight, while she went to the medication room. The sheet contained residents' pictures, names, and medical details like dialysis schedules. This breach of confidentiality was observed by surveyors as a resident and staff member walked past the cart. The LPN admitted to using the sheet as a cheat sheet and acknowledged the mistake.
A resident experienced a choking incident and was transferred to a hospital without notifying the long-term care ombudsman. Despite the facility's policy requiring such notification, staff interviews confirmed that the ombudsman was not informed. The responsible party and physician were notified, but the omission of ombudsman notification was identified as a deficiency.
An LPN on the Tuckahoe unit failed to lock a medication cart while attending to residents, leaving it unattended and out of sight on multiple occasions. Another LPN confirmed the requirement to lock carts when unattended. The facility's policy mandates that medication carts be locked when out of sight.
The facility staff failed to maintain a clean and homelike environment for two residents. One resident had a stained blanket that was not changed for over a day, despite the resident's cognitive impairment and facility policy requiring immediate linen changes. Another resident's bed had food debris on the side rails, which was not addressed until it was brought to the attention of housekeeping. The facility's policy emphasizes a clean environment, but these standards were not met, leading to deficiencies.
The facility staff failed to provide timely ADL assistance and proper documentation for two residents. One resident's call light for incontinence care was not answered for over 30 minutes, despite staff being present at the nurse's station. Another resident, who was severely cognitively impaired and dependent on staff for all ADLs, lacked documented evidence of incontinence care and personal hygiene on multiple occasions. Interviews with staff confirmed the expectation for prompt response to call lights and proper documentation of care.
A resident did not receive physician-ordered colostomy care on multiple occasions, as documented in the treatment administration record. The colostomy bag was not emptied during certain shifts, and the appliance was not removed, skin care was not provided, and the appliance was not reapplied for several days. An LPN confirmed that treatments are evidenced by signing off on the TAR, but this was not done. The facility's policy required documentation of the procedure, which was not followed.
The facility failed to provide adequate dialysis care for two residents with ESRD. Both residents required regular monitoring of their dialysis access sites, but documentation was missing for required checks and communication sheets on several occasions. Interviews with staff confirmed the expected procedures, but records did not consistently reflect adherence to these protocols.
A resident's room in the LTC facility had a heating/air conditioning unit with a missing slat and broken slats with sharp edges, creating a safety hazard. The director of maintenance confirmed the unit needed replacement. The facility's maintenance policy requires equipment to be safe and operable, but this was not adhered to, resulting in the deficiency.
Failure to Implement Care Plan for Midodrine Administration
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plan for one of six sampled residents, Resident #5, related to the administration of the medication Midodrine for hypotension associated with end stage renal disease (ESRD). The comprehensive care plan dated 11/3/2025 identified a focus of hypotension related to ESRD and included interventions to give medications as ordered and to monitor vital signs as ordered and as clinically indicated. Surveyors determined that staff did not follow the care-planned intervention to administer Midodrine per the physician’s orders. In an interview, LPN #4 stated that the care plan is intended to guide staff on how to care for residents and their individual needs. The facility’s written policy on comprehensive, person-centered care plans states that a comprehensive care plan with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs is to be developed and implemented for each resident. Administrative staff, including the administrator, director of nursing, and regional director of operations, were informed of these findings during the survey, and no additional information was provided by the facility prior to survey exit.
Failure to Clarify PRN Blood Pressure Medication Orders and Monitor Blood Pressure
Penalty
Summary
Facility staff failed to clarify and appropriately implement physician orders for as-needed blood pressure medications for one resident. The resident had a physician order for Midodrine 10 mg via PEG tube every eight hours as needed for orthostatic hypotension, to be given when systolic blood pressure (SBP) was under 100 mmHg, and a separate order for Clonidine to be given by mouth every eight hours as needed for hypertension, to be given when SBP was over 170 mmHg. Review of the clinical record did not show that the resident’s blood pressure was being taken every eight hours to determine whether either of these PRN medications was needed. During an interview, an LPN stated that when a medication requires a blood pressure check, the nurse should take the blood pressure and then administer or hold the medication according to the physician’s order. In another interview, the regional director of clinical services reported that the facility had previously been cited regarding Midodrine orders and had addressed this with physicians by changing such orders from PRN to scheduled doses with hold parameters, and also stated that it was unusual to have a PRN order for Clonidine and that these orders needed clarification. Administrative staff, including the administrator, DON, and regional director of operations, were informed of these findings, and no additional information was provided before survey exit.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Facility staff failed to administer Midodrine according to physician orders for one resident with hypotension related to end stage renal disease and dependence on dialysis. The physician’s order, dated 11/4/2025, specified Midodrine 10 mg via PEG tube every 8 hours to be given only when the resident’s systolic blood pressure (SBP) was under 100 mmHg. The comprehensive care plan documented the resident’s hypotension and directed staff to give medications as ordered and monitor vital signs as ordered and as clinically indicated. The facility’s medication administration policy required staff to validate physician-ordered parameters prior to medication administration. Despite these orders and policies, the January 2026 MAR showed that Midodrine was administered on multiple occasions when the resident’s SBP was above 100 mmHg. Specifically, the drug was given when blood pressures were recorded as 126/80, 122/76, 126/86, 148/80, 125/78, and 117/83. During an interview, an LPN stated that when a medication has blood pressure parameters, the nurse should take the blood pressure and then administer or hold the medication based on the physician’s order, and acknowledged that the Midodrine should not have been administered under the documented blood pressure readings. Administrative staff were informed of these findings, and no additional information was provided prior to survey exit.
Failure to Monitor Blood Sugar and Perform Post-Fall Neuro Checks
Penalty
Summary
Facility staff failed to provide care and services to promote the highest level of wellbeing for three residents by not following physician orders and facility policies. For one resident with diabetes, acute/chronic respiratory failure, and a tracheostomy, staff did not perform or document blood sugar checks as ordered before meals and at bedtime on multiple occasions. The resident was cognitively intact and dependent for most activities of daily living. Staff interviews confirmed that if blood sugar checks are not documented, there is no evidence they were performed, and review of the facility's policy indicated that a physician's order must be verified for such procedures. Two other residents, both with significant medical histories including cerebrovascular accident, atrial fibrillation, NSTEMI, diabetes, CHF, subdural hemorrhage, and tracheostomy, experienced falls resulting in head injuries and bleeding. In both cases, the facility failed to initiate and document neurological checks post-fall as required by facility policy and standard clinical practice. Staff interviews revealed that neuro checks should be started immediately after a fall, especially when the resident is on anticoagulants or has sustained a head injury, and should be documented on a paper flowsheet. However, administrative staff confirmed that there was no evidence of neuro checks being performed for either resident after their respective falls. Facility documentation and staff interviews consistently indicated that the required monitoring and documentation were not completed for these residents. The facility's own policies on obtaining fingerstick glucose levels and managing falls and fall risks were not followed, and there was no evidence provided to show that the necessary assessments and interventions were carried out as ordered or per policy.
Failure to Include Diabetes Management in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop a baseline care plan addressing diabetes and blood sugar monitoring for a newly admitted resident diagnosed with diabetes, acute/chronic respiratory failure, and a tracheostomy. Upon admission, the resident was assessed as not cognitively impaired and was dependent on staff for mobility, transfers, dressing, hygiene, toileting, and eating setup. The baseline care plan created at admission focused only on discharge planning and equipment needs, without including any interventions or monitoring related to the resident's diabetes or blood sugar levels. A physician's order for blood sugar checks before meals and at bedtime was present, but there was no evidence that the baseline care plan incorporated these orders or addressed diabetes management until several days after admission. Staff interviews confirmed that diabetes should have been included in the baseline care plan, and documentation review supported the omission. The deficiency was acknowledged by administrative staff, with no additional information provided prior to survey exit.
Failure to Implement Wound Care Recommendations and Repositioning Protocols
Penalty
Summary
Facility staff failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident, staff did not implement wound nurse practitioner recommendations for treatment of a right heel and a right anterior lower leg pressure injury. The wound nurse practitioner recommended specific treatments, such as skin prep for the right heel and various wound dressings for the lower leg injury, but these were not entered into the physician orders or the electronic treatment administration record (eTAR) in a timely manner. Observations confirmed that staff were unaware of any treatment in place for the right heel, and documentation showed a delay in implementing recommended treatments for the lower leg wound. Another resident experienced a worsening pressure injury due to the facility's failure to change treatment as recommended by the wound nurse practitioner. The resident was totally dependent on staff for turning and positioning, yet the recommended wound care was not implemented for an extended period. Documentation revealed that the prescribed frequency of wound care was not followed, and the wound increased in size during this time. Additionally, staff failed to turn and reposition the resident as required, with observations and interviews confirming that the resident was left in the same position for several hours and did not receive the necessary assistance overnight. A third resident with a stage 4 sacral pressure ulcer did not receive the wound nurse practitioner's recommended changes in wound care, including the use of medical grade honey fiber and dual antibiotic coverage for a suspected infection. The facility continued with an outdated treatment regimen, and documentation showed that turning and positioning tasks were not performed on multiple nights. The resident's wound worsened, with increased depth and slough, and the recommended interventions were not implemented prior to the resident's discharge to the hospital.
Failure to Maintain Clean, Homelike Environment and Address Odors
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across multiple nursing units and common areas. Persistent strong urine odors were observed in two of three nursing units and one of three common hallways over several days, despite ongoing cleaning efforts by housekeeping staff. The director of housekeeping acknowledged the difficulty in controlling odors, particularly in areas with residents requiring frequent changing and in units with poor ventilation. The presence of these odors was confirmed by both staff and surveyors during multiple observations. In addition to odor issues, staff failed to maintain privacy curtains in a clean and sanitary condition for several residents. Observations revealed privacy curtains hanging off their tracks and touching the floor, as well as curtains with visible brown stains and debris. These conditions persisted over multiple days and were not addressed until brought to the attention of the director of environmental services during the survey. The facility's policy requires a clean, sanitary, and orderly environment, including the maintenance of privacy curtains, but these standards were not met for the affected residents. Furthermore, staff failed to provide a clean environment for a resident who was left with a bloody pillowcase in contact with his body for at least two days. The resident, who was totally dependent on staff for turning and positioning and was cognitively intact, reported that no staff member offered to change the soiled pillowcase overnight. Both an LPN and a CNA interviewed during the survey agreed that this was not a clean or homelike environment for the resident. These deficiencies were observed and confirmed by surveyors and facility leadership during the survey process.
Failure to Timely Report and Investigate Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to implement policies and procedures for reporting and investigating abuse, neglect, and injuries of unknown origin (IUO) for multiple residents. In several cases, staff did not report IUOs to the state agency within the required timeframe, and documentation of final investigative reports was missing or incomplete. For example, one resident with severe cognitive impairment was found with a large bruise on her hand, and although staff notified the physician and responsible party, the injury was not reported to the state agency as an IUO until several days later. Staff interviews confirmed that the policy required reporting within two hours, but this was not followed. Another resident was discovered with significant bruising and was unable to recall any injury or trauma. The incident was not reported to the state agency until several days after discovery, and staff statements indicated a lack of immediate notification to management as required by policy. Additionally, for a resident with an allegation of neglect, there was no evidence that the final investigative report was sent to the state agency within the required five-day period. Staff interviews confirmed knowledge of the reporting requirements but acknowledged the failure to submit the necessary documentation. A further case involved a resident with severe cognitive impairment who was found with an old bruise of unknown origin. The incident was not reported to the state agency within the required two-hour window, and documentation of the report was incomplete. Staff interviews consistently indicated awareness of the facility's abuse and IUO reporting policies, including the need for immediate reporting and investigation, but these procedures were not consistently followed for the residents involved.
Failure to Implement Comprehensive Care Plans and Physician Orders
Penalty
Summary
Facility staff failed to implement comprehensive care plans for multiple residents, resulting in deficiencies related to wound care, pressure injury prevention, infection control, medication education, and tracheostomy care. For one resident with severe cognitive impairment and immobility, staff did not follow wound nurse practitioner recommendations for treating a right heel and right anterior lower leg pressure injury. Orders for recommended treatments, such as skin prep and specific wound dressings, were not entered or implemented in a timely manner, and documentation in the electronic treatment administration record (eTAR) did not reflect the recommended care until weeks after the initial assessment. Interviews with staff revealed a breakdown in communication and order entry processes between the wound nurse practitioner, facility wound nurse, and primary care physician. Another resident with multiple pressure injuries on the buttocks was not turned or repositioned according to the care plan, which required assistance every two hours. Observations showed the resident remained in the same position for extended periods, and the resident reported not being repositioned overnight. The care plan specifically noted the need for monitoring, reminders, and assistance with turning and positioning, but these interventions were not consistently provided. Additional deficiencies included failure to implement contact precautions for a resident with shingles, as staff wore gloves but not gowns and posted the incorrect precaution signage. For a resident with a tracheostomy, required care was not documented as completed on several shifts, as evidenced by blank entries in the respiratory administration record. Another resident receiving anti-anxiety medication did not receive documented education about the risks, benefits, and side effects of the medication, as required by the care plan. In each case, the facility's failure to follow individualized care plans and physician or practitioner recommendations led to lapses in care delivery and documentation.
Failure to Provide and Document Tracheostomy Care for Two Residents
Penalty
Summary
Facility staff failed to provide required tracheostomy care for two residents, as evidenced by missing documentation on the respiratory administration records. For one resident, a physician's order specified tracheostomy care every shift and as needed, but the clinical record showed that care was not documented on several night shifts in January and February. The facility's policy required tracheostomy care at least once daily for established tracheostomies and at least every eight hours for unhealed tracheostomies. Interviews with nursing staff confirmed that tracheostomy care includes cleaning around the stoma, changing gauze, and changing the inner cannula, and that completion of care is evidenced by signing the respiratory administration record. A second resident also had a physician's order for tracheostomy care every shift and as needed, but the clinical record revealed multiple instances in March and April where care was not documented during both day and night shifts. The absence of signatures on the respiratory administration record indicated that tracheostomy care was not provided as ordered. Facility administrative staff were made aware of these concerns during the survey process. No additional information was provided prior to the survey exit.
Failure to Complete Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to provide complete dialysis communication for a resident with end stage renal disease (ESRD) who required hemodialysis and had a left arm AV fistula. According to the clinical record and physician orders, staff were required to complete a dialysis communication form and record vital signs prior to transporting the resident to dialysis on each treatment day. However, review of the Hemodialysis Communication Records revealed multiple instances across November, December, and January where pre-dialysis or dialysis communication forms were not completed as required. The resident's care plan documented the ongoing need for hemodialysis, and staff interviews confirmed the process for completing and transmitting dialysis communication forms. Despite this, there were several dates where no documentation was present, indicating a failure to follow established protocols and facility policy, which required routine communication of relevant information to the dialysis center on treatment days.
Failure to Administer Ordered Medication Prior to Dialysis
Penalty
Summary
Facility staff failed to prevent significant medication errors for one resident who was receiving dialysis. According to physician orders, the resident was to receive Midodrine as needed for hypotension prior to dialysis, provided their systolic blood pressure was below 140. Review of clinical records, hemodialysis communication records, and electronic medication administration records (eMARs) showed that on multiple occasions, the resident's blood pressure was within the parameters for administration, but there was no documentation that the medication was given before dialysis. The care plan for the resident included instructions to administer medications as ordered and to monitor for side effects and effectiveness, but these interventions were not followed as documented. Interviews with facility staff, including an LPN and the medical doctor, confirmed that the expectation was for Midodrine to be administered on dialysis days when the resident's blood pressure was below 140. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not adhered to in this case. The deficiency was brought to the attention of the administrator, director of nursing, and regional clinical nurse, with no further information provided prior to the survey exit.
Failure to Provide Dignity and Timely Response to Resident Needs
Penalty
Summary
Facility staff failed to provide dignity for two residents. For one resident, staff did not answer the call bell in a timely manner. The resident, who was cognitively intact according to the most recent MDS assessment, was observed waiting 13 minutes for staff to respond to her call bell, despite seven staff members being present in the hallway. The resident reported that response times varied and that she had waited up to an hour for assistance. Facility policy required call bells to be answered as soon as possible, and a CNA confirmed that the expected response time was within two minutes. For another resident, staff failed to provide dignity and respect in the dining room. A sign was posted at the entrance of the dining room stating that any residents arriving after a certain time must get their tray from their room or hallway. The resident, also cognitively intact per the most recent MDS, expressed dislike for the sign but felt compelled to follow the rule. Interviews with dietary and activities staff revealed uncertainty about who posted the sign. Facility policy required residents to be treated with dignity and respect at all times.
Failure to Inform Resident of New Medication Orders and Associated Risks
Penalty
Summary
Facility staff failed to notify a cognitively intact resident of new physician orders for the administration of Percocet and Xanax, including the associated risks, benefits, and alternatives. The resident, who had diagnoses including cancer of the larynx and anxiety, was admitted with a PEG tube and was capable of making daily decisions as indicated by a high BIMS score. Despite physician orders for these controlled medications and documented administration on multiple occasions, there was no evidence that the resident was informed in advance about the medications or their potential effects. The resident's care plan included an intervention to educate the resident and their family or caregivers about the risks, benefits, and side effects of medications being given. However, interviews with facility staff confirmed that no documentation or evidence existed to show that this education or notification occurred prior to the administration of Percocet and Xanax. The facility's policy requires residents to be informed and participate in care planning and treatment, but this was not followed in this instance.
Failure to Ensure Resident Access to Personal Possessions After Room Change
Penalty
Summary
Facility staff failed to ensure that a resident's personal clothing and possessions were properly relocated and accessible following a room change. During an observation, it was found that the resident's clothing, including pajama pants, sweatshirts, and water bottles, remained in a vacant room that the resident had never occupied, rather than being moved to the resident's current room. Staff interviews confirmed that the clothing belonged to the resident and acknowledged that all personal items should have been transferred to the new room. Additionally, other items such as a pressure-reducing boot and linens of unclear status were found in the room, with some items not labeled with a resident's name. The resident, who was moderately cognitively impaired according to a recent BIMS assessment, expressed awareness that his clothing was missing and stated that he wanted his clothes in his current room. Facility policy requires staff to treat residents with respect and dignity and to protect residents from misappropriation of property. The failure to ensure the resident's personal possessions were accessible and properly managed resulted in a deficiency related to resident rights and respect for personal property.
Failure to Provide Privacy During Resident Assessments
Penalty
Summary
Facility staff failed to maintain privacy for two residents during medical assessments. The nurse practitioner was observed assessing one resident's chest, back, and abdomen with a stethoscope in the dining room while other residents were present. Similarly, another resident was assessed in the same public setting, with the nurse practitioner palpating the resident's neck and listening to their chest and back in the dining room. These assessments were conducted in the presence of other residents, rather than in a private setting as required by facility policy. Interviews with an LPN confirmed that resident assessments are typically performed in private settings and that conducting such assessments in the dining room would only be appropriate in an emergency. The nurse practitioner acknowledged that while assessments are usually done in residents' rooms, they are sometimes performed in public areas for timing reasons. Facility leadership was made aware of these incidents, and the facility's policy was reviewed, which mandates the protection of resident privacy during treatment procedures.
Failure to Attempt Alternatives Before Administering Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident was free from chemical restraint by not documenting or attempting alternative interventions prior to administering Xanax (Alprazolam), a psychotropic medication. The resident in question was admitted with a diagnosis that included anxiety and was assessed as cognitively intact, scoring 14 out of 15 on the Brief Interview for Mental Status (BIMS). The physician's order allowed for Xanax to be given as needed for anxiety via PEG-tube for 14 days, and the medication administration record showed that the resident received Xanax on multiple occasions. During interviews, administrative and clinical staff confirmed that there was no evidence of attempts at alternative interventions before administering the medication. This lack of documented or attempted non-pharmacological interventions prior to the use of a controlled drug constituted a failure to prevent the unnecessary use of psychotropic medications and the use of a chemical restraint.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to timely report injuries of unknown origin (IUO) for three residents, as required by facility policy and state regulations. In one case, a resident with severe cognitive impairment was found with a large bruise on her left hand while in the dining room. Although the injury was observed and reported internally to the medical doctor, responsible party, and unit manager, the incident was not reported to the state agency until three days later. Staff interviews confirmed that the injury was unwitnessed, the resident was unable to provide a statement due to dementia, and the facility's policy required reporting IUOs within two hours of discovery. Another resident, also with severe cognitive impairment, was discovered with a large bruise on the left upper extremity after being transferred between units. The resident had no recall of injury or trauma, and staff statements indicated no witnessed incident. The IUO was not reported to the state agency until several days after discovery, despite staff and administrative interviews confirming that such incidents should be reported immediately and within two hours if the cause is unknown. A third resident was found with a bruise of unknown origin on the upper left side of the forehead. The injury appeared to be in the healing stage, and no staff could confirm any fall or incident that could have caused it. The incident was not reported to the state agency within the required two-hour timeframe. Facility policy clearly defined immediate reporting requirements for suspected abuse, neglect, or IUO, but these were not followed in these cases, as confirmed by staff and administrative interviews and documentation review.
Failure to Submit Follow-Up Investigative Reports to State Agency
Penalty
Summary
Facility staff failed to submit required follow-up investigative reports to the state agency for two residents following incidents involving allegations of neglect and injury of unknown origin. For one resident, who was cognitively intact according to the most recent MDS assessment, an incident report documented an allegation of neglect. However, review of facility records, including fax confirmation sheets and the incident file, did not show evidence that the final investigative report was sent to the state agency within the required timeframe. Interviews with facility staff, including the unit manager and administrator, confirmed the absence of documentation showing submission of the follow-up report as required by facility policy. For another resident, who was severely cognitively impaired and had a diagnosis including Alzheimer's disease, an incident report documented a bruise of unknown origin. Although initial reporting to the state agency was evidenced by fax confirmation, there was no documentation confirming that the follow-up investigative report was sent within five business days as required. Staff interviews indicated an understanding of the reporting requirements, but review of the fax confirmation sheets and incident documentation failed to provide evidence that the follow-up report was submitted to the state agency.
Failure to Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
Facility staff failed to follow professional standards of practice for monitoring a resident after an unwitnessed fall. Specifically, for one resident who was assessed as being at moderate risk for falls and was taking anticoagulant medication, there was no documented evidence of neurological checks being completed after the resident was found on the floor. The facility's own policy required observation and documentation of neuro checks for approximately 48 hours following an unwitnessed fall, but the clinical record did not contain this documentation. The resident's progress notes indicated that after being found on the floor, an initial assessment was performed, and the responsible party and nurse practitioner were notified. The notes referenced that a neurological assessment was in place, but there was no further evidence of ongoing neuro checks in the medical record between the time of the fall and the resident's departure for a medical appointment the following day. Interviews with staff confirmed that neuro checks should have been performed and documented, but no such documentation could be produced. The facility's fall investigation also failed to provide evidence of completed neuro checks, despite indicating that they had been initiated. The care plan for the resident identified a risk for falls due to multiple medical conditions, including impaired mobility, respiratory failure, and infection. Administrative and clinical staff were unable to provide any additional documentation of neuro checks when asked, confirming the deficiency in following professional standards for post-fall monitoring.
Catheter Collection Bag Not Maintained Off Floor
Penalty
Summary
Facility staff failed to maintain proper positioning of an indwelling urinary catheter collection bag for a resident diagnosed with paraplegia and obstructive uropathy, who was totally dependent on staff for turning and positioning. On multiple occasions, the resident was observed sitting up in bed with the catheter collection bag lying completely on the floor. These observations occurred on two consecutive days, despite the resident having a physician's order to maintain a straight drain catheter and being cognitively intact for making daily decisions. Interviews with both an LPN and a CNA confirmed that catheter bags should not be in contact with the floor due to infection risks. Review of the facility's urinary catheter care policy also specified that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated complications, including urinary tract infections. The deficiency was communicated to facility administrative and clinical leadership, and no additional information was provided prior to exit.
Failure to Document Non-Pharmacological Pain Interventions Prior to PRN Medication Administration
Penalty
Summary
Facility staff failed to implement a complete pain management program for one resident who was cognitively intact and had a physician's order for prn (as needed) Percocet for pain. The clinical record and electronic medication administration record (eMAR) showed that the resident received Percocet on multiple occasions, but there was no documentation that non-pharmacological interventions were attempted prior to administering the medication on at least two of those dates. Progress notes and the eMAR lacked evidence of such interventions, despite facility policy requiring evaluation and documentation of non-pharmacological pain management methods before administering prn pain medication. During staff interviews, an LPN confirmed that the standard procedure is to assess the resident, attempt non-pharmacological interventions, and only administer prn pain medication if those interventions are ineffective. The LPN also acknowledged that there was no documentation of non-pharmacological interventions for the resident on the specified dates. The facility's policy further supports the requirement to monitor and document the effectiveness of non-pharmacological interventions as part of pain management.
Failure to Address and Document Resident's Medication Refusal Prior to Dialysis
Penalty
Summary
Facility staff failed to ensure that a resident was under appropriate physician care regarding the refusal of prescribed medications prior to dialysis. The resident, who was cognitively intact and able to make daily decisions, consistently refused to take morning medications on dialysis days, believing that the medications would be flushed out during the dialysis process. This refusal was documented multiple times in the medication administration record and nurses' notes, with staff indicating that the physician was aware of the refusals but did not provide new orders or address the issue in the clinical record. Interviews with staff and the physician confirmed that the physician was aware of the resident's ongoing refusal and had discussed the risks with the resident, but failed to document these conversations or provide further education or consultation as recommended by facility policy. The resident reported that no staff, including the physician, had addressed his concerns or refusal of medications. Facility policy requires physicians to supervise medical care, participate in assessment and care planning, and provide consultation or treatment as needed, but these actions were not documented or carried out in this case.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
Facility staff failed to provide evidence of monitoring anticoagulant medication use for one resident from 2/1/25 to 2/11/25. The resident, who had a history of pulmonary embolism and was on anticoagulant therapy with Apixaban as ordered by the physician, was readmitted to the facility and assessed as taking anticoagulant medication on the most recent MDS. The physician's orders and the resident's care plan both indicated the need for monitoring for signs and symptoms of anticoagulant complications, including bleeding, bruising, and changes in vital signs. Despite these orders and care plan interventions, the electronic medication administration record (eMAR) showed that while Apixaban was administered as prescribed, documentation of anticoagulant monitoring did not begin until the night shift on 2/12/25. There was no evidence of monitoring for adverse effects or complications related to anticoagulant use from 2/1/25 to 2/11/25. Staff interviews confirmed that monitoring should occur every shift and be documented in the eMAR, but this was not done during the specified period. Facility policies also required clinical and laboratory monitoring for residents on anticoagulants.
Failure to Follow Infection Control Practices for Multiple Residents
Penalty
Summary
Facility staff failed to follow infection control practices for three residents. For one resident with a tracheostomy, a respiratory therapist was observed performing tracheostomy care without adhering to proper glove and hand hygiene protocols. The staff member donned clean gloves, touched potentially contaminated surfaces, and then proceeded to open sterile supplies and don sterile gloves over the soiled gloves. The staff member continued to provide care, including cleaning the stoma and replacing the inner cannula, without changing gloves or performing hand hygiene as required by facility policy and CDC guidelines. Another resident, who was totally dependent on staff for turning and positioning and had a diagnosis of paraplegia, was observed multiple times with a pillowcase containing a moderate amount of blood in contact with his leg. Despite these observations, staff did not offer to change the soiled pillowcase, and the resident reported that no staff member had offered to change it overnight. Interviews with nursing staff confirmed that a bloody pillowcase should not remain in contact with a resident due to infection control concerns. For a third resident with a physician's order for contact precautions due to shingles, staff failed to implement the required transmission-based precautions. During a transfer using a mechanical lift, staff wore gloves but did not wear gowns as required for contact precautions, and the signage on the resident's door indicated enhanced barrier precautions instead of contact precautions. Staff involved in the transfer stated they were unaware of the need for isolation precautions and did not wear gowns during the care activity.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care, specifically turning and positioning, for four dependent residents. These residents, identified as R2, R3, R4, and R5, were all admitted with various medical conditions that rendered them dependent on staff assistance for bed mobility, transfers, bathing, dressing, toileting, and eating. The comprehensive care plans for these residents included specific interventions for turning and repositioning every two hours to prevent skin breakdown and other complications. Documentation reviews revealed that the ADL care, particularly bed mobility and turning/positioning, was not consistently recorded for these residents on several dates and shifts. For instance, R2's documentation was missing on multiple evening and night shifts, while R3, R4, and R5 also had similar documentation gaps on various shifts. Interviews with CNAs confirmed that the expected practice was to turn residents every two hours and document it in the ADL form, yet this was not consistently done. The facility's administrative staff, including the administrator, director of nursing, regional director of operations, and regional nurse consultant, were informed of these findings. However, no further information or corrective actions were provided before the exit of the surveyors. The lack of documentation and adherence to care plans indicates a failure in providing necessary care for dependent residents, potentially impacting their health and well-being.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for three residents, leading to deficiencies in care. For Resident #7, the staff did not administer treatments as ordered for impaired skin integrity. The treatment administration record (TAR) showed multiple blanks for the prescribed treatments on specific dates, indicating that the treatments were not given. This was confirmed during an interview with an LPN, who acknowledged the importance of following the care plan. Resident #4's care plan was not followed regarding the administration of medications for altered cardiovascular status, seizure medication, and pain management. The medication administration record (MAR) showed that Midodrine was administered despite blood pressure readings outside the prescribed parameters. Additionally, Gabapentin and Oxycodone were not administered as ordered, with documentation indicating issues with pharmacy orders and lack of proper documentation in the nurse's notes. For Resident #3, the facility staff failed to administer medications and treatments as ordered for pressure ulcers, GERD, and antibiotic therapy. The TAR and MAR showed blanks and indications that medications were not administered, with notes suggesting delays in pharmacy orders. The emergency medication backup system had the necessary medications available, yet they were not utilized. Interviews with staff confirmed the care plan's purpose and the need for adherence, but the deficiencies persisted.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility staff failed to administer medications and treatments according to physician orders for two residents, leading to deficiencies in care. For Resident #3, the staff did not administer the prescribed treatments for an abdominal surgical wound and calluses on the right great toe and right lateral foot. The treatment administration record (TAR) lacked documentation for the day shift on January 20, 2025, indicating the treatments were not administered. Additionally, the staff failed to provide Vancomycin and Sucralfate as ordered, with the medication administration record (MAR) showing a code indicating the drugs were not administered. The nurse's notes revealed that the medications were ordered from the pharmacy but were not available in the emergency medication backup system, and there was no documentation of contacting the physician for further instructions. For Resident #4, the facility staff administered Midodrine despite the resident's blood pressure being outside the prescribed parameters on three occasions. The MAR documented the administration of the medication, but the nurse's notes did not provide any explanation for administering the medication against the physician's orders. Furthermore, the staff failed to administer Gabapentin as ordered, with the MAR indicating the medication was on hold, and the nurse's notes lacked documentation explaining the hold. The narcotic count sheet showed discrepancies in the available doses, suggesting the medication was not administered as prescribed. Additionally, the staff did not administer Oxycodone as ordered for Resident #4, with the MAR indicating the medication was not administered on two occasions. The nurse's notes documented issues with the pharmacy not receiving the prescription, but there were available tablets in the narcotic drawer that could have been used to administer the correct dose. These failures in medication administration and documentation highlight significant deficiencies in the facility's adherence to physician orders and medication management policies.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility staff failed to provide adequate care and services for the treatment of pressure injuries for three residents. For Resident #7, the staff did not apply physician-prescribed treatments, including Betadine and [NAME] Prep, to treat deep tissue injuries on both heels. The treatment administration record (TAR) lacked documentation for several dates, indicating missed treatments. The wound care nurse practitioner acknowledged that missing treatments could negatively affect the healing process, although it was unclear if this occurred for Resident #7. For Resident #9, the facility staff did not adhere to proper infection control practices during wound care. An LPN was observed performing wound care without changing gloves after removing a soiled dressing and before cleaning the wound. This action was contrary to the facility's wound treatment policy, which requires changing gloves and performing hand hygiene between these steps. The LPN admitted to the oversight during an interview. Resident #3's care was also deficient, as there was no documentation of the administration of treatments for pressure injuries on a specific date. The physician orders required daily cleansing and application of various treatments to the resident's wounds, but the TAR did not reflect this for the day shift on the specified date. The facility's comprehensive care plan emphasized the importance of administering treatments as ordered, but this was not evidenced in the records.
Failure to Notify Physician of Unadministered Medications
Penalty
Summary
The facility staff failed to notify the physician and responsible party when medications were not administered to a resident, identified as Resident #4, as per the physician's orders. The resident was readmitted on January 4, 2025, with orders for Sucralfate and Vancomycin to be administered via PEG-tube twice daily. However, the Medication Administration Record (MAR) indicated that these medications were not administered at the scheduled times, marked with a code '22' for 'Drug/Treatment Not Administered.' Despite the availability of these medications in the facility's emergency backup system, they were not administered, and the physician was not notified of the unavailability. An interview with an LPN revealed that the facility has a backup pharmacy system and a policy for handling unavailable medications, which includes notifying the physician and obtaining new orders if necessary. However, the LPN confirmed that the nurse should document the reason for not administering the medication and notify the physician and responsible party, which was not done in this case. The facility's policy on unavailable medications was not followed, leading to a deficiency in care for Resident #4.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to protect a resident from sexual abuse by another resident. The incident involved a female resident with severe cognitive impairment, as indicated by a BIMS score of zero, who was found in a compromising situation with a male resident. The male resident, who also had cognitive impairments, was observed by a CNA engaging in inappropriate sexual behavior with the female resident. The female resident was found undressed from the waist down, and the male resident was seen coming out of the bathroom fully clothed. The incident was immediately reported to the unit manager, and the responsible parties, including the medical doctor and hospice, were informed. A police report was filed, and the female resident was sent to the emergency room for a possible sexual assault evaluation. The male resident was placed under 1:1 supervision following the incident. Both residents were noted to have cognitive impairments, with the male resident having a history of sexual ideation and the female resident having a history of seeking male attention. The facility's investigation revealed that the male resident had no prior offenses on the Virginia State Police Sex Offenders screening, although there was no evidence of a screening being conducted at the time of his admission. Staff interviews indicated that the male resident was generally independent in his activities of daily living and had made comments about being attractive to women. The facility's synopsis of the event noted that neither resident had any recollection of the incident, and no injuries were observed on the female resident.
Failure to Document Medication Administration and Notification
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, specifically regarding the documentation of medication administration. The physician's order required Metoprolol Tartrate to be administered twice daily via PEG-tube for essential hypertension. However, on a scheduled dose, the medication was marked as 'Hold' without any documented notification to the doctor or responsible party explaining why the medication was not administered. Additionally, there were no documented parameters for holding the medication, which is a critical aspect of medication management. An interview with an LPN revealed that if a medication is unavailable, the nurse should document the reason in the clinical record and notify the doctor and responsible party. Despite this protocol, the nurse practitioner confirmed that she was informed via text about the medication being held, but this communication was not documented in the resident's clinical record. The facility's policy on charting and documentation requires notification of family, physician, or other staff when indicated, which was not adhered to in this instance.
Deficiency in Kitchen Utensil Sanitation
Penalty
Summary
The facility staff failed to maintain food preparation utensils in good repair and in a sanitary manner in the kitchen. During an observation, a metal shelving unit was found to contain serving and food preparation utensils that were not clean. Specifically, a metal serving spoon, a metal slotted spoon, and an ice cream scoop were observed with visible debris. Additionally, a plastic spatula was found with a broken tip, and a brush was noted to be charred, oily, and with stiffened bristles. The dietary manager acknowledged that these utensils should have been clean and ready for use, and proceeded to wash the dirty utensils and discard the damaged ones. The facility's sanitation policy, dated November 2022, requires that all utensils, counters, shelves, and equipment be kept clean, maintained in good repair, and free from defects that may affect their use or proper cleaning. The administrator, director of nursing, regional director of operations, and regional nurse consultant were informed of these findings. No further information was provided before the exit of the surveyors.
Deficiencies in Resident Record-Keeping and Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for three residents, leading to deficiencies in documentation and care. For one resident, the facility continued to document the changing of a urinary drainage bag on shower days even after the Foley catheter was discontinued. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the error in the Treatment Administration Record (TAR), which inaccurately recorded the treatment as completed on several dates after the catheter was removed. Another resident's medical record contained conflicting information regarding advanced directives. The physician orders indicated a 'Full Code' status, while other documents, including a social services assessment, incorrectly noted the resident as having no advanced directives and being 'Do Not Resuscitate' (DNR). Interviews with social services staff revealed that the error might have been due to incorrect documentation, as the staff member admitted to possibly clicking the wrong box. For the third resident, the facility failed to document efforts to arrange a dental consult for a toothache. Although a nurse practitioner had noted the need for a dental evaluation, the clinical record did not reflect any follow-up actions. Interviews with staff revealed that the resident's family had refused an outside dental consult, preferring the facility's visiting dentist. However, this refusal and the subsequent arrangements were not documented in the resident's medical record, highlighting a gap in communication and record-keeping.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to implement comprehensive care plans for four residents, leading to deficiencies in their care. Resident #429, who was admitted with respiratory failure and a urinary catheter, did not receive consistent documentation of urinary catheter care as required by the care plan. The treatment administration record (TAR) showed missing documentation for catheter maintenance and urinary output on multiple shifts in February and March 2024. Interviews with staff confirmed that the care plan was not implemented as intended. Resident #128, who required dialysis due to end-stage renal disease, also experienced lapses in care plan implementation. The care plan specified dialysis on certain days and emergency care for the dialysis site, but there was no documentation of bleeding checks on specific dates, and communication sheets were missing for two dialysis sessions. This lack of documentation indicates that the care plan was not fully executed, as confirmed by staff interviews. Similarly, Resident #479 and Resident #84 experienced failures in the implementation of their care plans. Resident #479, who had a urinary catheter, did not receive documented catheter care on several occasions, as evidenced by blank spaces in the TAR. Resident #84, who had a tracheostomy, had numerous instances of missing documentation for respiratory therapy care, including trach care, oral care, and humidified air administration. Interviews with staff revealed that if care was not documented, it was not considered completed, highlighting a significant gap in care plan adherence.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility staff failed to maintain the highest level of well-being for two residents by not adhering to physician orders. For Resident #229, the staff did not obtain daily weights as ordered by the physician. The resident, who was severely cognitively impaired, had a comprehensive care plan that required daily weight monitoring due to potential nutritional problems related to multiple health conditions, including obesity, acute kidney injury, and congestive heart failure. However, the medication administration record (MAR) showed multiple instances where weights were not documented, and in some cases, it was indicated that the treatment was not administered. Interviews with the unit manager revealed that blanks on the MAR indicated the task was not done, and other notations like '22' and 'X' also signified non-compliance with the order. For Resident #479, the facility staff failed to provide physician-ordered treatments for the resident's surgical wounds on several occasions. The resident had surgical wounds on the left hip, left foot, and right foot, with specific orders for wound care that were not followed on multiple dates in February 2024. The treatment administration record (TAR) showed blank spaces where treatments should have been documented, and nurses' notes did not provide evidence that the treatments were completed. An interview with an LPN confirmed that treatments are evidenced by signing off on the TAR, which was not done in this case. The facility's policy required that wound treatments be applied as ordered, which was not adhered to for this resident.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility staff failed to provide proper care and services for urinary catheters for three residents, leading to deficiencies in maintaining sanitary conditions and following physician orders. For Resident #129, the staff did not maintain the urinary catheter drainage bag in a sanitary manner, as it was observed touching the floor on multiple occasions. This was against the guidelines that require the drainage bag to be kept off the floor to prevent bacterial contamination. Interviews with a CNA and an LPN confirmed that the catheter bag should not touch the floor, yet it was observed in this unsanitary condition. Resident #429's care plan was not implemented as required. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, had missing documentation for urinary catheter care on several dates in February and March 2024. The care plan required monitoring for signs of urinary tract infections and maintaining a clean area around the catheter, but the treatment administration record (TAR) showed gaps in documentation, indicating that care was not provided as ordered. An LPN confirmed that if there was no documentation, the care was not performed. For Resident #479, the facility staff failed to provide physician-ordered urinary catheter care on multiple dates in February 2024. The TAR showed blank spaces for catheter care on specific dates, and nurses' notes did not document that the treatments were completed. An LPN stated that treatments are evidenced by signing off on the TAR, which was not done in this case. The facility's administrative staff, including the administrator and director of nursing, were made aware of these concerns, but no further information was provided before the survey exit.
Failure to Provide Documented Respiratory Care
Penalty
Summary
The facility staff failed to provide adequate respiratory care services for three residents, as evidenced by the lack of documentation and adherence to physician orders. Resident #128, who was admitted with multiple diagnoses including diabetes mellitus, acute/chronic respiratory failure, and end-stage renal disease, did not receive respiratory therapy as per physician orders. The respiratory administration record (RAR) showed missing documentation for ventilator settings, changing of disposable inner cannula, and trach care on several dates. Interviews with the director of respiratory services confirmed that if care is not documented, it was not provided. Resident #165, who had a tracheostomy and was on a ventilator, also did not receive respiratory services as ordered. The RAR for July 2024 showed missing documentation for changing nebulizer tubing, trach ties, disposable inner cannula, and trach care. The respiratory therapist confirmed that the absence of documentation indicated that the care was not performed. The comprehensive care plan for this resident highlighted the need for respiratory treatments and monitoring, which were not consistently documented. Resident #84, who also had a tracheostomy, experienced similar issues with missing documentation for respiratory services. The RARs for February, April, May, June, and July 2024 showed numerous blanks for trach care, oral care, humidified air via trach collar, and verification of ambu bag and back-up trach presence. Interviews with the respiratory therapist reiterated that the lack of documentation meant the care was not provided. The comprehensive care plan for this resident emphasized the need for respiratory therapy, which was not consistently documented or performed.
Failure to Maintain Resident Dignity During Medication Administration
Penalty
Summary
The facility staff failed to provide dignity for Resident #282 during medication administration via a PEG tube. The resident, who was admitted with a PEG tube and had a physician's order for nothing by mouth, was observed on 7/23/24 at 8:43 a.m. lying in bed while an LPN raised the resident's gown, exposed the abdomen, and administered medications. During this process, the room door was left open, and the privacy curtain was not pulled, making the resident visible from the hallway. This lack of privacy was confirmed by an interview with another LPN, who stated that nurses should ensure privacy by pulling the curtain and shutting the door during such procedures. The facility's medication administration policy did not include information regarding maintaining dignity.
Confidentiality Breach by LPN
Penalty
Summary
The facility staff failed to maintain confidentiality for three residents, identified as Residents #21, #162, and #44, during a survey. An LPN left a sheet of paper containing confidential information on top of a medication cart in the hallway while she walked to the medication room, leaving the cart out of her line of sight. The paper included residents' pictures, names, and specific medical information such as blindness and dialysis schedules. This breach of confidentiality was observed by surveyors as a resident and staff member walked past the unattended cart. The LPN admitted to using the sheet as a cheat sheet to help her remember the residents' information, acknowledging that she should not have left it exposed where others could view it. The facility's policy on confidentiality and personal privacy mandates safeguarding residents' personal and medical records, which was not adhered to in this instance. The administrator and director of nursing were informed of the incident, but no further information was provided before the survey exit.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility staff failed to notify the long-term care ombudsman of a facility-initiated transfer for a resident who experienced a choking incident. On the morning of the incident, the resident was choking on a peanut butter sandwich, and despite the Heimlich maneuver being performed, the resident remained unable to breathe. Emergency medical services were called, and the resident was transferred to a hospital for evaluation. The clinical record indicated that the responsible party and physician were notified, but there was no evidence of notification to the ombudsman. Interviews with facility staff revealed that the ombudsman was not notified of the transfer. The LPN involved stated that clinical information was sent to the hospital but not to the ombudsman. The care navigator, responsible for ombudsman notifications, confirmed that they could not find evidence of notification for this transfer. The facility's policy required notification to the ombudsman when practicable, but this was not adhered to in this case. The administrative staff, including the administrator and director of nursing, were informed of the deficiency, but no further information was provided before the survey exit.
Medication Cart Security Breach on Tuckahoe Unit
Penalty
Summary
The facility staff failed to store medications securely in a locked compartment for one of the seven medication carts on the Tuckahoe unit. An LPN left the medication cart unlocked on multiple occasions while attending to residents in their rooms and while in a medication room, during which the cart was not in her line of sight. This occurred on three separate instances within a short time frame. Another LPN confirmed that the medication carts should be locked when unattended to prevent unauthorized access. The facility's policy mandates that medication carts must be kept closed and locked when out of the sight of the medication nurse or aide. The administrative staff, including the administrator and the director of nursing, were informed of these incidents.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility staff failed to maintain a clean and homelike environment for two residents, leading to deficiencies in care. For Resident #86, the staff did not change a blanket with a large brown stain from the afternoon of July 22, 2024, through the morning of July 23, 2024. The resident, who was severely impaired in making daily decisions due to dementia, was observed with the stained blanket multiple times, and a strong urine smell was initially present. Despite the resident's cognitive status and history of resistive behavior, the facility's policy required that soiled linens be changed immediately, which was not adhered to in this case. For Resident #4, the facility staff failed to maintain the bed in a clean and homelike manner, as food debris was noted on the side rails. Observations on July 22 and July 23, 2024, revealed a brown substance on the grab bars on both sides of the bed, which was not identified or cleaned until July 24, 2024. The LPN and director of environmental services were unable to determine the nature of the substance, and it was not addressed until it was brought to the attention of the housekeeping staff. The facility's policy on providing a homelike environment emphasizes the importance of maintaining a clean, sanitary, and orderly environment, including clean bed and bath linens. However, the observations and interviews with staff members revealed a failure to adhere to these standards, resulting in the deficiencies noted for both residents. The administrative staff, including the administrator and director of nursing, were made aware of these concerns, but no further information was provided before the survey exit.
Deficiencies in Timely ADL Assistance and Documentation
Penalty
Summary
The facility staff failed to provide timely assistance for activities of daily living (ADL) for two residents, leading to deficiencies in care. For one resident, the staff did not respond promptly to a call light, which was activated for incontinence care. The call light remained on for over 30 minutes while staff members were observed at the nurse's station. Interviews with staff confirmed that call lights should be answered promptly, ideally within 10-15 minutes, to meet residents' needs. The facility's policy also mandates timely responses to call lights, but this was not adhered to in this instance. Another resident, who was severely cognitively impaired and dependent on staff for all ADLs, did not have documented evidence of incontinence care, dressing, and personal hygiene on several occasions. The resident's care plan indicated a need for complete assistance with these tasks. Interviews with a CNA revealed that care is documented on an ADL form, and if not documented, it is assumed the care was not provided. The lack of documentation suggests that the necessary care may not have been delivered, as required by the resident's care plan.
Failure to Provide Colostomy Care as Ordered
Penalty
Summary
The facility staff failed to provide physician-ordered colostomy care for a resident, identified as Resident #479, on multiple occasions in February 2024. The resident's clinical record included orders to empty the colostomy bag as needed and every shift, and to remove the colostomy appliance, provide skin care, and reapply the appliance once every three days. However, the treatment administration record (TAR) showed that the colostomy bag was not emptied during the day shift on two specific dates, and the colostomy appliance was not removed, skin care was not provided, and the appliance was not reapplied for a period of six days. Nurses' notes also lacked documentation of these treatments being completed on the specified dates. During an interview, an LPN confirmed that treatments like colostomy care are evidenced by signing off on the TAR. The facility's policy on colostomy/ileostomy care required documentation of the procedure in the resident's documentation form, which was not adhered to in this case. The administrator and director of nursing were informed of these concerns, but no further information was provided before the survey exit.
Failure to Provide Adequate Dialysis Care for Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for two residents, both of whom required hemodialysis due to end-stage renal disease (ESRD). Resident #46, who was not cognitively impaired and dependent on assistance for daily activities, had a care plan that included monitoring a left arm fistula and a Perma Cath. However, there was no documentation of the required checks for bleeding, drainage, signs of infection, and the presence of bruit and thrill on specific dates in July 2024. Additionally, there was no evidence of communication sheets being sent to the dialysis center on two occasions. Interviews with staff revealed that these checks and communications were supposed to be documented in the treatment administration record (TAR), but this was not consistently done. Similarly, Resident #128, who also had ESRD and was dependent on assistance, had a care plan that required monitoring for bleeding at the dialysis site. The facility failed to document bleeding checks on specific dates in June 2024, and there was no evidence of communication sheets for dialysis appointments in early July 2024. The registered nurse interviewed confirmed the process for monitoring and documentation, but the records did not reflect consistent adherence to these procedures. The facility's policy on the care of residents with ESRD was not followed, as evidenced by the lack of documentation and communication regarding the residents' dialysis care.
Unsafe Heating/Air Conditioning Unit in Resident Room
Penalty
Summary
The facility staff failed to maintain a heating/air conditioning unit in a safe condition in a resident's room. During an observation, it was noted that the grill on the upper surface of the unit had one missing slat, leaving a space of approximately two inches open, and four other slats were broken but still attached. The broken and missing slats had sharp edges, posing a potential safety hazard. This observation was confirmed during a follow-up visit with the director of maintenance, who acknowledged the unit as a safety hazard that needed replacement. The facility's maintenance policy requires that all building areas, grounds, and equipment be maintained in a safe and operable manner at all times. The maintenance department is responsible for ensuring compliance with federal, state, and local laws, regulations, and guidelines, and for keeping the building in good repair and free from hazards. Despite these requirements, the heating/air conditioning unit in the resident's room was not maintained according to the facility's policy, leading to the identified deficiency. Key administrative staff, including the administrator, director of nursing, regional director of operations, and regional nurse consultant, were informed of the issue, but no further information was provided before the exit.
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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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