Cedars Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlottesville, Virginia.
- Location
- 1242 Cedars Ct, Charlottesville, Virginia 22903
- CMS Provider Number
- 495153
- Inspections on file
- 24
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedars Healthcare Center during CMS and state inspections, most recent first.
The facility staff failed to administer medications timely for three residents, affecting their treatment for conditions like hypertension, Parkinson's, and COPD. A resident reported not receiving morning medications on time, while another experienced delays in COPD treatments, necessitating unscheduled doses. A third resident did not receive a critical inhaler for several days. Staff interviews revealed a practice of administering medications within an hour of the scheduled time, but documented delays exceeded this timeframe.
A resident received an incorrect dosage of propranolol due to a transcription error by the facility and a dispensing error by the pharmacy. The resident was prescribed a low dose with a specific titration schedule for drug-induced tremor, but received a higher dose than ordered. The facility's nurse was unable to provide evidence of proper administration, and the pharmacy confirmed sending full tablets instead of half tablets.
A long-term care facility failed to ensure the availability of medications for several residents, resulting in missed doses and non-compliance with physician orders. Residents experienced issues with medications such as Gabapentin, Propranolol, Bevespi, and Breo Ellipta due to delays in delivery, pharmacy errors, and insurance coverage issues. The facility's policies on medication administration were not effectively followed, contributing to the deficiencies.
The facility staff failed to maintain sanitary conditions in the kitchen, with issues such as wet nesting of dishes, improper use of hair nets, and inadequate dishwashing procedures. Observations showed staff plating food without beard guards and not following proper dishwashing protocols, leading to potential bacterial growth. The facility's policies did not adequately address these issues, and the administrator was informed of the deficiencies.
The facility failed to implement its abuse policy by not conducting timely criminal background checks for 14 employees and not obtaining checks for 9 others, including key staff. Additionally, the facility did not verify the professional licenses of 5 employees before they worked with residents, despite policy requirements. These lapses were identified during a survey and an HR audit.
Several residents in an LTC facility did not receive medications as ordered due to pharmacy delivery delays and communication lapses. Residents with conditions like chronic pain and opioid dependence missed doses of methadone, Suboxone, and other medications. The facility's policy on missed medications was not effectively followed, leading to deficiencies in care.
A long-term care facility failed to ensure the availability of medications for several residents, leading to missed doses and inadequate pain management. Residents experienced delays in receiving prescribed medications such as Percocet, Methadone, Suboxone, and various ointments and eye drops due to pharmacy delivery issues and inadequate medication management systems. Staff interviews revealed ongoing challenges with timely medication deliveries and reordering processes.
The facility failed to store medications properly on the 200-unit and 300-unit. Unopened insulin and eye drops were found at room temperature instead of refrigerated, and lorazepam was not secured in a locked compartment. Staff were unaware of the reasons for these storage issues, and the facility's policy requires medications to be stored according to manufacturer recommendations.
Facility staff failed to maintain sanitary conditions in food handling and dishwashing. Staff were observed without proper hair restraints, and dishwashing procedures did not include rinsing or proper drying, contrary to facility policies. These deficiencies were confirmed by the dietary services district manager.
The facility failed to educate and offer pneumococcal vaccinations to several residents, as required by its infection control policy. Documentation of immunization status and history was missing or outdated for all residents reviewed. The regional infection preventionist confirmed the lack of documentation and acknowledged that records should have been updated with the most recent vaccine information.
The facility failed to report and document abuse allegations for three residents, including a serious rape allegation, a CNA-related incident, and a resident-to-resident abuse case. The facility did not submit follow-up reports or notify required agencies in a timely manner, and there were lapses in documentation and reporting procedures.
A resident with severe psychiatric symptoms alleged rape while at a facility, but the staff failed to provide credible evidence of an investigation. The DON believed the allegation was against a hospital, not the facility, and did not pursue further action. The facility's abuse policy was not followed, and the administrator confirmed no investigation evidence was available.
A facility failed to develop a care plan for a resident with incontinence, despite assessments indicating the need. The resident, diagnosed with incontinence of bowel and bladder, confirmed experiencing episodes, and an LPN acknowledged the oversight. The issue was presented to the administrator.
Facility staff failed to administer oxygen according to physician's orders for three residents. One resident's concentrator was set at 2.5 LPM instead of 5 LPM, causing shortness of breath. Another resident's concentrator was set at 5 LPM instead of the prescribed 2 LPM. A third resident received oxygen at 2 LPM instead of 5 LPM, despite normal oxygen saturation levels. These issues were discussed with the facility's administration.
The facility exceeded the acceptable medication error rate of 5%, reaching 6.67%, due to two incidents where medications were unavailable. A resident did not receive gentamicin eye drops as the RN could not find them, and another resident did not receive Lactulose because the LPN could not locate it and the pharmacy had not sent it. The facility's policy requires medications to be reordered at least three days in advance, but there was no evidence of a reorder for the Lactulose.
The facility failed to provide routine dental services to two residents, leading to deficiencies in their care. One resident required dental extractions and follow-up care but did not receive it, while another resident experienced difficulty eating due to missing upper teeth and was not scheduled for dental services in a timely manner. Both residents expressed their need for dental care, but the facility did not adequately address these needs.
A resident with severe protein calorie malnutrition and other conditions did not receive the prescribed therapeutic diet during lunch. The meal ticket indicated a regular advanced dysphagia diet with fortified pudding parfait and pureed meat with gravy, which were missing. A nurse confirmed the discrepancy, and the dietary manager acknowledged the oversight.
A resident with a regular diet and a preference for fresh fruit was not served the fruit salad listed on their meal ticket, despite it being part of their documented food preferences. The dietary manager admitted the oversight, noting that fruit plates were prepared daily but not served as required. The resident's care plan highlighted the need to maintain proper nutrition, yet the failure to provide the preferred fruit was not corrected until identified during the survey.
A resident's clinical record inaccurately included hospice notes for other residents due to a clerical error. The medical records clerk admitted to scanning and uploading the notes incorrectly, leading to the misfiling. The resident had severe cognitive impairments and multiple diagnoses, including diabetes and chronic kidney disease.
An LPN failed to follow infection control practices during a medication pass, handling medications with cross-contaminated gloved hands. The LPN used a computer and touched various surfaces before directly handling medications with her fingers, contrary to the facility's policy requiring standard precautions. The issue was acknowledged by the DON and administrator.
The facility failed to educate and offer COVID-19 vaccines to two residents, as required by its infection control policy. The residents' clinical records lacked documentation of their immunization status and any education or offering of the vaccine since their admission. The regional infection preventionist confirmed that these steps should have been completed upon admission.
A resident with a physician's order for 5 liters per minute of oxygen via tracheostomy mask experienced shortness of breath due to malfunctioning oxygen concentrators. The concentrators were unable to deliver the prescribed oxygen flow, as confirmed by an LPN who observed the incorrect settings and acknowledged the need for properly functioning equipment.
A resident's comprehensive care plan for pressure injuries was not implemented as ordered, with treatments missing on several dates. The care plan included specific treatment orders for pressure ulcers, but the treatment administration record showed blank spaces, indicating missed treatments. Interviews with staff confirmed the expectation for individualized care and documentation, yet the facility failed to adhere to its policy for optimal personalized care.
The facility staff failed to document incontinence care for three residents, as evidenced by missing entries in ADL records. Despite residents being dependent for toileting, documentation gaps were found for several months. Interviews with CNAs confirmed that care was to be documented in PCC, but records were incomplete. The facility's policy required routine care, including incontinence care, to be provided by CNAs under supervision.
The facility staff failed to provide ordered treatments for two residents, leading to deficiencies in care. One resident did not receive prescribed wound care for an arterial heel wound on multiple occasions, as evidenced by blank spaces in the TAR and lack of documentation. Another resident's nephrostomy tube output was not monitored and recorded as ordered, with several shifts missing documentation. The executive director and DON were informed, but no further information was provided.
A resident with stage three and stage four pressure injuries did not receive physician-ordered treatments on multiple occasions. The treatments were not documented in the treatment administration record, and interviews with staff confirmed the lack of adherence to the facility's policy on pressure injury care.
A resident with severe cognitive impairment and identified as an elopement risk was found outside the facility, indicating a failure in monitoring and supervision. The resident's wander guard, intended to prevent elopement, was not consistently checked or documented as required. Staff interviews confirmed the need for daily and shift checks, but documentation gaps contributed to the incident.
A resident with a history of impulsive behaviors and suicidal ideation was able to climb out of a window onto the roof, leading to a fall and ongoing safety concerns. Despite being independent in daily activities, the resident's care plan noted impulsive behaviors, but the facility failed to secure the environment adequately. The resident expressed suicidal intentions and attempted to jump from the roof again, highlighting the facility's failure to maintain a safe environment.
A resident with a history of medical conditions was not allowed to make decisions regarding her treatment, despite being cognitively capable. She requested to go to the hospital due to abdominal pain but was given medication instead, leading her daughter to call 911. Staff interviews confirmed that residents have the right to make their own treatment decisions, but the facility failed to honor this right.
A resident with a history of impulsive behaviors and psychiatric disorders climbed out of a window, resulting in a fall. Despite expressing suicidal ideation and a plan, the facility failed to report the incident to authorities in a timely manner, violating their occurrence reporting policy.
A resident with severe cognitive impairment and an indwelling catheter did not receive consistent catheter care and output documentation as required by the facility's policy. Despite staff claims of performing these tasks, the treatment administration record showed missing entries for catheter care and output on multiple dates and shifts. The facility's leadership was informed of these issues.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility staff failed to adhere to professional standards of practice regarding the timely administration of medications for three residents. Resident #2 reported not receiving her morning medications on time, with multiple instances documented where medications scheduled for 7 a.m., 8 a.m., and 9 a.m. were administered several hours late. This included critical medications such as propranolol for hypertension and carbidopa-levodopa for Parkinson's. The resident expressed that despite informing the nursing staff, the issue persisted. Resident #4 also experienced delays in medication administration, particularly with treatments for COPD. The Medication Admin Audit Report showed that medications scheduled for 7 a.m. were often administered after 10 a.m., and on one occasion, a scheduled 7 a.m. albuterol nebulizer treatment was not given until 6:37 p.m. This delay necessitated an unscheduled prn dose earlier in the day, which was not documented until much later. Resident #5 reported not receiving his Breo Ellipta inhaler for several days, which is crucial for managing his COPD. The medication administration record confirmed that the inhaler was not administered on multiple days, and there was no documentation of physician notification regarding these omissions. Interviews with nursing staff and the medical director revealed a practice of administering medications within an hour of the scheduled time, but the documented delays exceeded this timeframe, indicating a failure to maintain therapeutic levels as intended by the facility's policy and professional standards.
Medication Dosage Error Due to Transcription and Pharmacy Dispensing Mistakes
Penalty
Summary
The facility staff failed to accurately transcribe a physician's order for a resident, leading to the administration of an incorrect medication dosage. The resident, who had a neurologist's assessment indicating drug-induced tremor and parkinsonism, was prescribed propranolol at a low dose with a specific titration schedule. However, the facility transcribed the order incorrectly, resulting in the resident receiving a higher dose than prescribed. The medication administration record showed that the resident received three doses daily, but the supply was depleted earlier than expected, indicating that the resident likely received the full 10 mg tablet instead of the prescribed half tablet. Further investigation revealed that the pharmacy had also contributed to the error by sending full tablets instead of half tablets as ordered. The nurse on duty was unable to provide evidence of the medication being administered as documented, and the pharmacist confirmed the error in dispensing the medication. The facility's director of nursing acknowledged the transcription error and the discrepancy with the pharmacy's supply, which led to the resident receiving an incorrect dosage of propranolol.
Medication Availability Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to ensure the availability of medications for several residents, leading to missed doses and non-compliance with physician orders. Resident #1 did not receive Gabapentin for neuropathy for three consecutive days due to a hold order placed when the medication was unavailable. The attending physician noted frequent issues with medication availability, particularly with narcotics, and attributed some of the problems to the use of agency staff unfamiliar with the residents. The medication was eventually found in the facility, but not before several doses were missed. Resident #2 experienced similar issues with the blood pressure medication Propranolol. The resident missed multiple doses over several days, with documentation indicating the medication was out of stock or awaiting delivery. An error by the pharmacy resulted in the resident receiving the incorrect dosage, as full tablets were dispensed instead of the prescribed half tablets. This error contributed to the depletion of the medication supply, leaving the resident without the necessary medication. Residents #4 and #5 also faced medication availability issues with their respiratory medications, Bevespi and Breo Ellipta, respectively. Both residents missed several doses due to delays in delivery and issues with insurance coverage. The facility's contracted pharmacy confirmed delays in dispensing the medications, and the facility staff were unable to provide the medications as ordered. The facility's policies on medication administration and handling missed medications were not effectively followed, contributing to the deficiencies observed.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the main kitchen, affecting food storage, preparation, and service. Observations revealed that dishes were not allowed to air dry and were being stacked while wet, which can lead to bacterial growth. During meal service, a dietary aide was seen plating food without a beard guard, despite having visible facial hair. Additionally, a cook was observed preparing food without a hair net, and another dietary aide's hair net did not adequately cover her hair. The facility's food services district manager acknowledged these issues and stated that larger hair nets would be provided. Further observations indicated that the facility staff did not properly wash dishes, as a dietary aide was seen using only two of the three sinks in the manual washing process, skipping the rinse step. The facility's policy on manual warewashing did not address the need for rinsing dishes. The dietary services district manager confirmed these observations and attempted to correct the process. The facility administrator was informed of these deficiencies during end-of-day meetings, but no additional information or corrective actions were provided in the report.
Failure to Implement Employee Pre-Screening and License Verification
Penalty
Summary
The facility staff failed to implement their abuse policy regarding the pre-screening of employees, as evidenced by the review of 26 employee records. For fourteen employees, the facility obtained criminal background checks from the Virginia State Police beyond 30 days from hire, with some employees being hired as much as 1 year and 8 months prior to the background check being obtained. The Human Resource Manager (HRM) conducted an audit and re-ran criminal background checks for these employees, but the initial failure to comply with the policy was noted. Additionally, the facility staff failed to obtain criminal background checks for nine employees, including key personnel such as the human resources manager and the director of nursing. Despite the HRM's audit identifying seven of these employees as lacking a background check, no checks were on file at the time of the survey. Two employees hired after the audit also did not have background checks on file, indicating ongoing non-compliance with the facility's policy. Furthermore, the facility staff did not verify the professional licenses of five employees before allowing them to work with residents. This included failing to verify the licenses of a certified nursing assistant, a licensed practical nurse, and the facility administrator. The HRM stated that license look-ups are conducted during interviews, but there was no evidence that the facility reviewed additional public information or disciplinary actions against licenses, as required by their policy. These deficiencies highlight significant lapses in the facility's adherence to its abuse prevention policies.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to administer medications as ordered by physicians for several residents, leading to deficiencies in care. Resident #20 did not receive methadone for pain management on multiple occasions due to delays in pharmacy delivery, despite the medication being reordered. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) acknowledged ongoing issues with timely pharmacy deliveries, but no immediate solutions were provided. Resident #20, however, did not report any pain concerns from the missed doses. Resident #40 did not receive Calmoseptine ointment as ordered for folliculitis because it was not ordered from the pharmacy, despite being an in-house stocked item. The LPN was unsure why the ointment was unavailable, and the supply clerk confirmed that no request for the ointment had been made. This oversight resulted in the resident not receiving the prescribed treatment for several days. Other residents, including Resident #93, Resident #80, Resident #70, Resident #77, and Resident #323, also experienced missed doses of various medications due to similar issues with pharmacy deliveries and communication lapses. These residents had conditions such as chronic pain, opioid dependence, and allergic conjunctivitis, which required timely medication administration. The facility's policy on missed medications was not effectively followed, as evidenced by the lack of timely reordering and communication with the pharmacy and physicians.
Medication Availability Issues in LTC Facility
Penalty
Summary
The facility failed to ensure the availability of medications for several residents, leading to missed doses and inadequate pain management. Resident #69, who had a broken foot, did not receive her prescribed pain medication, Percocet, on a specific date due to a delay in delivery from the pharmacy. Similarly, Resident #80, who was managing cancer-related pain with Methadone, experienced multiple instances where the medication was not administered as ordered, with nursing notes indicating delays in pharmacy delivery. Resident #70, who was prescribed Suboxone for opioid dependence, also faced issues with medication availability. The facility's system for accounting for controlled drugs was inadequate, as evidenced by discrepancies in the recorded quantity of Suboxone. Additionally, Resident #20 did not receive Methadone for several days due to pharmacy delivery issues, despite the medication being reordered in advance. The Director of Nursing acknowledged ongoing issues with timely medication deliveries from the pharmacy. Other residents, including Resident #40, Resident #93, and Resident #274, also experienced missed doses of various medications due to unavailability. These included Calmoseptine ointment, eye drops, and Lactulose, with nursing staff citing delays in pharmacy deliveries and issues with reordering processes. Interviews with staff and residents highlighted a pattern of medication management failures, with the facility's policies on medication administration and reordering not being effectively implemented.
Improper Storage of Medications on Two Units
Penalty
Summary
The facility failed to properly store medications on two of its units, the 200-unit and the 300-unit, as observed during a survey. On the 300-unit, an unopened vial of Humalog insulin was found stored at room temperature on a medication cart, despite the label indicating it should be refrigerated until opened. Additionally, a 30 ml bottle of liquid lorazepam, a controlled medication, was stored in the medication refrigerator without being secured in a separately locked, permanently affixed compartment. The licensed practical nurse (LPN) on the 300-unit was unaware of why the insulin was improperly stored and confirmed the absence of a lock box for controlled medications in the refrigerator. On the 200-unit, two unopened bottles of Xalatan eye drops and three Promethegan suppositories were also found stored at room temperature on a medication cart, contrary to their labels which instructed refrigeration. The registered nurse (RN) on the 200-unit verified that the medications had not been opened and was unsure why they were not stored in the refrigerator. The director of nursing (DON) acknowledged that medications were supposed to be refrigerated as labeled and suggested that someone might have mistakenly placed them on the cart instead of in the refrigerator. The facility's policy on medication storage, revised in August 2024, mandates that medications be stored according to manufacturer recommendations and that controlled substances requiring refrigeration be kept in a locked box within the refrigerator.
Sanitation Deficiencies in Food Handling and Dishwashing
Penalty
Summary
The facility staff failed to adhere to sanitary practices in food storage, preparation, and service, as observed in the main kitchen and dining room. During meal service, staff members were seen without proper hair restraints, such as hair nets and beard guards, which are necessary to prevent food contamination. Specifically, a dietary aide was observed plating food without a beard guard, and a cook was seen preparing food without a hair net. Another dietary aide's hair net was insufficient to cover her hair, and the facility's social services director was also seen in the kitchen without a hair net. The facility's policy requires all staff to have their hair off the shoulders and properly restrained, which was not followed. Additionally, the facility staff did not wash dishes in a manner that prevents contamination. A dietary aide was observed using only two of the three sinks for manual dishwashing, skipping the rinse step before sanitizing. The facility's policy did not address the need for rinsing dishes. Furthermore, after dishwashing, dishes were stacked wet, which could lead to bacterial growth. The facility's policy states that all dishware should be air-dried and properly stored, which was not adhered to. These observations were confirmed by the dietary services district manager and brought to the attention of the facility administrator.
Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility staff failed to educate and offer pneumococcal immunizations according to the facility's infection control policy for several residents. Specifically, three out of five residents reviewed did not have documentation of education or an offer of the pneumococcal vaccine, and their records lacked any status or history of pneumococcal immunizations. Additionally, the immunization status was not up to date in the clinical records for all five residents reviewed. The regional infection preventionist confirmed the absence of documentation regarding the pneumococcal immunization status and education for these residents. The facility's policy mandates that residents be offered education and the pneumococcal vaccine unless contraindicated or already immunized. However, the clinical records for two residents were not updated with the most recent vaccine status, despite evidence of additional vaccinations. The regional infection preventionist acknowledged that immunization history should be obtained upon admission and that the records should have been updated accordingly. These findings were discussed with the administrator and regional consultants, but no further information was provided before the survey concluded.
Failure to Report and Document Abuse Allegations
Penalty
Summary
The facility staff failed to report allegations of abuse for three residents, including a serious allegation of rape by a resident who was no longer at the facility. The initial report was made to the state survey agency, but the facility did not submit a follow-up report with the investigation findings. The Director of Nursing (DON) believed a follow-up was unnecessary as the allegation was against a hospital, not the facility. However, the facility administrator, who was the abuse coordinator, admitted there was no evidence of a completed investigation or reported results. In another incident, the facility staff did not notify all required agencies about an abuse allegation involving a resident and a certified nursing assistant (CNA). The facility attempted to fax the report to the Virginia Department of Health Professions (DHP) but failed to confirm successful transmission. Additionally, the CNA's employee file lacked a sworn statement or criminal background check, indicating a lapse in proper documentation and reporting procedures. The facility also delayed reporting an allegation of resident-to-resident abuse for another resident. The incident was reported two days late, contrary to the administrator's acknowledgment of the requirement to report within two hours. The administrator could not explain the delay, highlighting a failure in adhering to the mandated reporting timelines. These deficiencies indicate a pattern of inadequate reporting and documentation of abuse allegations within the facility.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility staff failed to provide credible evidence of an investigation following an allegation of sexual abuse made by a resident. The resident, who had a history of severe psychiatric symptoms and was under an emergency custody order, alleged that she was raped while she was a resident at the facility. The facility documentation and electronic health records indicated that the resident was discharged from the facility and later made the allegation while at a hospital. The facility provided a one-page document stating that an investigation had started, but no evidence of an investigation or resident assessments was available. The Director of Nursing (DON) stated that the allegation was against the hospital, not the nursing facility, and therefore did not pursue further action. The facility administrator, who was the abuse coordinator, confirmed that no investigation evidence was available and acknowledged that the process was not properly commandeered due to being in training. The facility's abuse policy requires the Executive Director to determine when an investigation is needed and to direct it, but this procedure was not followed in this case.
Failure to Develop Care Plan for Incontinence
Penalty
Summary
The facility failed to develop a complete care plan for a resident, identified as Resident #5, who was diagnosed with incontinence of bowel and bladder, chronic congestive heart failure, and chronic atrial fibrillation. The resident's most recent Minimum Data Set (MDS) assessment indicated that they were always incontinent of bowel and bladder and had a cognitive score of 14 out of 15, suggesting they were cognitively intact. Despite these assessments, the resident's care plan did not include a plan for managing incontinence. During an interview, the resident confirmed experiencing incontinent episodes and acknowledged the staff's efforts to keep them clean and dry. An LPN, serving as the MDS coordinator, acknowledged that a care plan for incontinence should have been created upon the resident's admission and updated accordingly. This deficiency was presented to the facility administrator during a staff meeting.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to provide appropriate respiratory care to three residents by not administering oxygen according to the physician's orders. For one resident, the oxygen concentrator was set at 2.5 liters per minute instead of the prescribed 5 liters per minute via tracheostomy mask for hypercarbia. Despite attempts to adjust the setting, the concentrator was not functioning properly, and the resident reported experiencing shortness of breath at night. Another resident's oxygen concentrator was set at 5 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula. The discrepancy was identified and corrected by a licensed practical nurse, who was unsure why the setting was incorrect. A third resident, diagnosed with chronic congestive heart failure and chronic atrial fibrillation, was observed receiving oxygen at 2 liters per minute, despite a physician's order for 5 liters per minute continuous via nasal cannula. The resident's oxygen saturation level was within normal range, but the oxygen setting was not in accordance with the physician's order. The licensed practical nurse assigned to this resident acknowledged the incorrect setting after reviewing the order. These deficiencies were discussed with the facility's administrator and corporate staff, but no additional information was provided before the exit conference.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5 percent, resulting in a rate of 6.67 percent. During a medication pass observation, a registered nurse (RN) did not administer gentamicin eye drops to a resident as ordered by the physician. The RN was unable to locate the drops in the medication cart and stated that they were not available, indicating that the pharmacy would be contacted. The resident's clinical record showed a physician's order for the eye drops to be administered twice daily, but the morning dose was missed. This issue was discussed with the administrator and regional consultants, but no further information was provided before the survey concluded. Additionally, another resident did not receive Lactulose, a medication for constipation, during a medication pass. A licensed practical nurse (LPN) could not find the Lactulose in the medication cart or the medication room and noted that the pharmacy had not sent it. The LPN mentioned that the resident sometimes refused the medication and did not offer it during the pass. The LPN had attempted to reorder the medication two days prior, but there was no evidence of the reorder in the computer system. The facility's policy requires medications to be reordered at least three days in advance to ensure availability. This finding was presented to the administrator and corporate staff, with no additional information provided before the exit conference.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility staff failed to provide routine dental services to two residents, leading to deficiencies in their care. For Resident #80, the staff did not arrange for necessary dental extractions and follow-up care after a recommendation was made. Despite the resident's inability to eat solid food due to dental issues and cancer, and a recommendation for extractions to facilitate denture fabrication, there was no evidence of any consultations with an oral surgeon or attempts to arrange further dental services. The resident was unable to be seen at a dental clinic due to expired identification, and the facility social workers were unaware of this issue. The facility did not provide evidence of any follow-up until a progress note indicated an appointment was made for a future date. For Resident #4, the facility failed to arrange for dental services despite the resident's reported difficulty eating due to the absence of upper teeth. The resident had previously had teeth extracted at another facility with a promise of replacement, which was not fulfilled. Upon admission to the current facility, the resident expressed the need to see a dentist, but was not placed on the list for dental services until much later. The social worker assistant acknowledged the oversight, and the resident had not been seen by the facility's dentist since admission. The resident continued to express the need for dental care, including cleaning of the remaining teeth and obtaining upper dentures.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility staff failed to provide a therapeutic diet as prescribed for a resident diagnosed with severe protein calorie malnutrition, dementia, and iron deficiency anemia. The resident, who had a cognitive score indicating intact cognition, was observed during lunch not receiving the complete meal as indicated on their meal ticket. Specifically, the meal ticket prescribed a regular advanced dysphagia diet with an added half cup of fortified pudding parfait and a bowl of pureed meat with gravy, which were missing from the tray. A registered nurse assigned to the resident confirmed the discrepancy and indicated she would inform the kitchen. The dietary manager later acknowledged that the food items were available but had not been added to the meal tray. The resident's clinical record included a dietary progress note indicating a history of weight loss and a recommendation for fortified pudding parfait with two meals, which was ordered on a previous date. This deficiency was presented to the facility's administrator and director of nursing during a staff meeting.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility staff failed to honor the food preferences of Resident #93, who was part of the survey sample. Resident #93, who was cognitively intact and had a regular diet prescribed, expressed a preference for fresh fruit, which was documented in their food preference assessment. Despite this, the resident reported not receiving the fruit salad listed on their meal ticket during lunch. This was confirmed through observation on November 20, 2024, when the resident was served all items on the meal ticket except the fresh fruit plate. The dietary manager acknowledged the oversight, stating that fruit plates were prepared daily and should have been served according to the meal ticket. The resident's care plan, revised in June 2024, indicated a risk of nutrition problems and included interventions to maintain proper nutrition, such as providing the diet as ordered and identifying food preferences. However, the failure to serve the fresh fruit as per the resident's preference and meal ticket was not addressed until it was brought up during the survey.
Inaccurate Clinical Record Due to Misfiled Hospice Notes
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for one of the residents in the survey sample. Specifically, the clinical record of a resident included hospice notes that were intended for three other residents. This error was discovered during a review of the resident's clinical record, which revealed that hospice documentation for other residents was mistakenly included. The resident in question was admitted with multiple diagnoses, including diabetes, adult failure-to-thrive, protein-calorie malnutrition, chronic kidney disease, anxiety, and depression, and was assessed with severe cognitive impairments. The medical records clerk admitted to the error during an interview, explaining that hospice notes were sent to the facility on paper and were scanned and uploaded to the clinical record. The clerk acknowledged that the notes were scanned together and incorrectly uploaded to the wrong resident's record. This issue was discussed with the facility's administrator and regional consultants, but no additional information was provided before the survey concluded.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility staff failed to adhere to proper infection control practices during a medication pass on one of the units. An LPN was observed handling medications with cross-contaminated gloved hands. During the medication pass for Resident #15, the LPN sanitized her hands, applied gloves, and then used the computer before reaching into the medication cart to retrieve medications. The LPN was seen popping medications into her hand and reaching into bulk bottled medications with her fingers before placing them into a medication cup for distribution to the resident. The same LPN repeated this process for another resident, Resident #42, by sanitizing her hands, applying gloves, using the computer, and then handling medications with her fingers. The LPN acknowledged the difficulty in retrieving medications from bottles when they are nearly empty. The facility's policy on medication administration requires the use of standard precautions, which were not followed in this instance. The findings were presented to the Director of Nursing and the administrator, who confirmed that the observed practices were not in line with the facility's policy.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility staff failed to educate and offer COVID-19 immunizations to two residents, as required by the facility's infection control policy. During an infection control survey, it was found that there was no documentation of COVID-19 immunization status for these residents. The clinical records lacked evidence of any education about or offering of the COVID-19 vaccine since their admission to the facility. The regional infection preventionist confirmed that the immunization status should have been obtained upon admission, and vaccines should have been offered if not already received. The facility's policy mandates that residents be educated about the risks and benefits of the COVID-19 vaccine, screened for prior immunization, and have their vaccination documented in their medical records. However, these steps were not followed for the two residents in question.
Oxygen Concentrator Malfunction
Penalty
Summary
The facility staff failed to ensure that an oxygen concentrator was functioning properly for a resident, leading to a deficiency in care. The resident, who had a physician's order for oxygen therapy at 5 liters per minute via tracheostomy mask for hypercarbia, reported experiencing shortness of breath at night due to malfunctioning equipment. During an interview, it was observed that the oxygen concentrator was set at 2.5 liters per minute, contrary to the prescribed 5 liters. A Licensed Practical Nurse (LPN) confirmed the incorrect setting and acknowledged the need for a concentrator capable of delivering the required oxygen flow. A subsequent observation revealed a new concentrator in the resident's room, but it was also unable to reach the necessary 5 liters per minute, indicating ongoing equipment issues.
Failure to Implement Comprehensive Care Plan for Pressure Injuries
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for a resident, identified as Resident #4, specifically regarding pressure injury treatments. The resident's care plan, dated September 6, 2023, indicated the presence of a pressure ulcer on the right heel and a wound on the left Achilles, with specific treatment orders documented in the clinical record. These orders included cleansing the wounds and applying specific dressings daily. However, a review of the treatment administration record (TAR) for May 2024 revealed that treatments were not administered on several dates, as evidenced by blank spaces on the TAR and the absence of corresponding documentation in the nurses' notes. Interviews with facility staff, including an LPN and administrative staff members, confirmed the expectation that care plans should be individualized and that treatments should be documented on the TAR. Despite this, the treatments for the resident's pressure injuries were not consistently documented or administered as ordered. The facility's policy on the Plan of Care emphasizes the importance of providing resident-focused and optimal personalized care, which was not adhered to in this instance. The executive director and director of nursing were made aware of the concern, but no further information was provided before the survey exit.
Incontinence Care Documentation Deficiency
Penalty
Summary
The facility staff failed to provide incontinence care for three residents, as evidenced by missing documentation in the ADL records. Resident #3, who was not cognitively impaired and dependent for toileting, had multiple instances of missing documentation in December 2023 and January 2024. Interviews with CNAs revealed that incontinence care was supposed to be documented in PCC, but the records were incomplete. The facility's policy required routine daily care, including incontinence care, to be provided by CNAs under the supervision of a licensed nurse. Resident #6, also not cognitively impaired and dependent for toileting, had missing documentation in the ADL records for June and July 2024. Despite the resident stating that care was usually provided, there were gaps in the documentation. Interviews with CNAs confirmed that incontinence care was to be documented in PCC, but the records did not reflect consistent care. The facility's policy emphasized the importance of maintaining skin integrity and providing care with dignity. Resident #7, who was moderately cognitively impaired and dependent for toileting, had missing documentation in the ADL records for June, July, and August 2024. Although the resident reported that care was provided when called, the documentation was incomplete. The CNAs reiterated the process of documenting incontinence care in PCC, but the records were not comprehensive. The facility's policy outlined the need for routine care, including incontinence care, to be provided by trained CNAs.
Failure to Administer Wound Care and Monitor Nephrostomy Output
Penalty
Summary
The facility staff failed to provide physician-ordered treatments for two residents, leading to deficiencies in care. For one resident, the staff did not administer the prescribed wound care treatments for an arterial wound on the left lateral heel on multiple occasions in May 2024. The treatment administration record (TAR) showed blank spaces for the dates when the treatment was missed, and there was no documentation in the nurses' notes to indicate that the treatments were completed. The facility's policy on wound care required that residents with skin integrity issues receive treatment based on the wound's characteristics, but this was not adhered to in this case. For another resident, the facility staff failed to measure and record the output from a nephrostomy tube as ordered by the physician. The TARs for July and August 2024 showed that the output was not monitored and recorded on several shifts, and there was no documentation in the nurses' notes for those dates. The purpose of monitoring the nephrostomy tube output is to assess urine output, but the facility did not have a specific policy for this procedure. The executive director and director of nursing were informed of these concerns, but no further information was provided before the survey exit.
Failure to Administer Physician-Ordered Pressure Injury Treatments
Penalty
Summary
The facility staff failed to provide physician-ordered treatments for a resident's pressure injuries on multiple occasions in May 2024. The resident had a stage three pressure injury on the right heel and a stage four pressure injury on the left Achilles. Physician orders required daily cleansing and application of silvasorb gel and wound dressings for both injuries. However, the treatment administration record (TAR) for May 2024 showed that these treatments were not administered on several dates, as indicated by blank spaces on the TAR. Additionally, there were no nurses' notes documenting that the treatments were performed on those dates. Interviews with facility staff revealed that pressure injury treatments are recorded on the TAR, and nurses are expected to sign off on the TAR to confirm that treatments have been administered. Despite this procedure, the treatments were not documented as completed on the specified dates. The facility's policy on slough treatment requires the implementation of treatment as ordered, which was not adhered to in this case. The executive director and director of nursing were informed of the issue, but no further information was provided before the survey exit.
Failure to Monitor Wander Guard Leads to Resident Elopement
Penalty
Summary
The facility staff failed to provide a safe environment for Resident #9, who was identified as an elopement risk due to severe cognitive impairment and other medical conditions such as dementia, hypertension, and macular degeneration. The resident was admitted with a wander guard device intended to prevent elopement by triggering an alarm if the resident approached exit doors. However, documentation revealed multiple instances where the wander guard's placement and functionality were not checked or recorded as required by the facility's policy. Specifically, there were numerous dates across May, June, July, and August where the treatment administration record (TAR) lacked documentation of the wander guard's functioning and placement checks. On June 30, 2024, Resident #9 was found outside the building in the parking lot by a social worker, indicating a failure in monitoring and supervision. The resident was assisted back inside, and it was noted that the wander guard was functioning properly at that time. Interviews with facility staff, including an LPN and a CNA, confirmed that the wander guard should be checked for function daily and for placement every shift, with documentation on the TAR. Despite these protocols, the lack of consistent documentation and monitoring contributed to the resident's elopement, highlighting a deficiency in ensuring a safe environment for residents at risk of wandering.
Failure to Maintain Safe Environment for Resident
Penalty
Summary
The facility staff failed to maintain a safe environment for a resident who was admitted with diagnoses including tracheostomy, hypertension, and psychoactive substance abuse. The resident, who had intact cognition and was independent in daily activities, exhibited impulsive behaviors related to loss of independence, such as attempting to exit through unauthorized doors and climbing out of a facility window. Despite these behaviors being noted in the resident's care plan, the facility did not adequately secure the environment to prevent such incidents. On one occasion, the resident climbed out of a window onto the roof, which was not adequately secured, leading to a fall and a small abrasion above the left eyebrow. The incident was reported, and the window was fixed immediately. However, the resident continued to express suicidal ideation and attempted to jump from the roof again, indicating ongoing safety concerns. The facility's response included initiating one-to-one staffing and conducting a psychiatric evaluation, but the resident refused to go to the emergency department, and EMS determined he was in his right mind. Interviews with staff revealed that the maintenance director was aware of the damaged window and had repaired it after the incident. The facility's policy on elopement prevention and management was reviewed, highlighting the need for secure exits and windows. Despite these measures, the resident's behavior and the facility's response indicated a failure to ensure a safe environment, as the resident was able to access hazardous areas and expressed intentions to harm himself.
Failure to Respect Resident's Treatment Decisions
Penalty
Summary
The facility failed to allow a resident to make decisions regarding her treatment, which was identified during a review of documentation and staff interviews. The resident, who was not cognitively impaired, had a history of medical conditions including encephalopathy, COPD, CHF, and diabetes mellitus. Despite being fully capable of making her own decisions, the resident's requests to go to the hospital due to abdominal pain were not immediately honored. On one occasion, the resident requested to go to the hospital due to stomach cramping but was instead given medication and monitored, leading her daughter to call 911 for assistance. Interviews with facility staff, including an LPN and an RN, revealed that the resident had a history of calling EMS or her daughter if her medical needs were not met to her satisfaction. The staff acknowledged that residents have the right to make their own treatment decisions, including the right to go to the ER if they wish. The facility's Resident Rights policy supports this, stating that residents have a choice and a voice in their treatment. However, the facility's actions did not align with this policy, resulting in a deficiency in respecting the resident's right to make decisions about her care.
Failure to Report Resident's Self-Harm Incident
Penalty
Summary
The facility staff failed to report an allegation of a resident being on the roof with potential for self-harm. The resident, who was cognitively intact and independent in daily activities, had a history of impulsive behaviors and was noted to have attempted to exit through unauthorized doors and windows. On a specific date, the resident climbed out of a window, resulting in a fall and a minor injury. Despite the incident, the resident was assessed and found to be within normal limits, and the necessary notifications were made to the medical provider and director of nursing. Further investigation revealed that the resident had expressed suicidal ideation with a plan, as documented by a psychiatric nurse practitioner. The resident had a history of attention-deficit hyperactive disorder and major depressive disorder, and staff reported that the resident had previously jumped off the roof. The resident expressed a willingness to go to the hospital for further psychiatric evaluation, acknowledging the unsafe nature of his behavior. Despite these serious incidents and the resident's expressed suicidal ideation, the facility failed to report the situation to the appropriate authorities in a timely manner. The facility's occurrence reporting policy mandates the administrator to oversee timely reporting to federal, state, and local authorities, which was not adhered to in this case. This oversight in reporting the resident's behavior and potential for self-harm constituted a deficiency in the facility's compliance with regulatory requirements.
Failure to Document Catheter Care and Output
Penalty
Summary
The facility staff failed to provide appropriate treatment and services for a resident's indwelling catheter. The resident, who was admitted with diagnoses including toxic encephalopathy, obstructive/reflux uropathy, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for daily activities. The comprehensive care plan required monitoring and documenting intake and output as per facility policy, and providing Foley catheter care as needed and daily. However, the treatment administration record (TAR) showed missing documentation for Foley care on specific dates and shifts, as well as missing output documentation on several shifts. Interviews with facility staff revealed inconsistencies in the documentation process. An LPN stated that catheter care and output documentation were recorded on the TAR, but the records did not reflect this consistently. The facility's catheter care policy required catheter care to be performed twice daily, but the documentation did not support adherence to this policy. The executive director, director of nursing, and interim executive director were informed of these concerns, but no further information was provided prior to the exit.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
