Charlottesville Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlottesville, Virginia.
- Location
- 505 West Rio Road, Charlottesville, Virginia 22901
- CMS Provider Number
- 495178
- Inspections on file
- 23
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Charlottesville Health & Rehabilitation Center during CMS and state inspections, most recent first.
Due to low weekend staffing, only two CNAs were available to care for 59 residents on one unit, resulting in residents not receiving showers as per their preferences. Staff prioritized essential care, providing hygiene and shortened bed baths, and ensured residents were fed and safe, but were unable to meet all resident preferences for showers.
A resident was administered Amitriptyline and Trazodone after admission when staff used the at-home medication list instead of the hospital discharge summary, resulting in unnecessary psychotropic medication use. Despite repeated requests from the resident's son and documentation by the nurse practitioner to discontinue these medications, they were only held temporarily and then restarted. Facility staff confirmed the error, and policy review showed a lack of a specific protocol for psychotropic medication use.
A review of staffing records and staff interviews revealed that only two CNAs were scheduled on a unit with 59 residents during weekend day shifts, despite the facility's assessment calling for four to five CNAs per shift. Staff confirmed that essential care was prioritized and some tasks, such as showers, were not completed due to the low staffing, though no incidents or resident complaints were documented.
A resident with multiple medical conditions and moderate cognitive impairment was discharged without the facility arranging for home health therapy services as indicated in the discharge instructions. Staff interviews and record reviews revealed a lack of documentation and follow-through in setting up these services, resulting in the resident only receiving home health therapy after a primary care provider referral post-discharge.
Staff did not follow physician discharge orders for a resident's admission, instead entering medications from the at-home list that were not included in the hospital discharge summary. Interviews with LPNs, the DON, and the regional clinical director confirmed that non-discharge medications were added, and the NP was unaware of the error. Facility policy required adherence to prescriber orders, but unfamiliarity with the discharge summary format led to the deficiency.
A resident was prescribed amitriptyline for depression without a corresponding diagnosis, and antipsychotic medications were not discontinued as requested by the resident's son. The nurse practitioner and nursing staff failed to verify the presence of a depression diagnosis in the medical record, resulting in medications being continued without proper justification or review, contrary to facility policy.
The facility did not ensure accurate and complete medical records for two residents. One resident was documented as having depression and was prescribed amitriptyline without a corresponding diagnosis, and antipsychotic medications were not discontinued as requested. Another resident's stage three pressure ulcer was inconsistently documented in progress notes and skin assessments, with discrepancies confirmed by the DON and nurse consultant.
Staff did not follow posted menus or serve meals as indicated on residents' meal tickets, resulting in multiple residents not receiving the correct foods or portion sizes, including those on specialized diets such as heart healthy and diabetic diets. Substitutions were made without documentation, and beverages were inconsistently provided. Dietary staff and management were aware of ongoing resident complaints, and facility records confirmed repeated issues with menu adherence and lack of proper dietary accommodations.
Staff did not provide milk and other beverages as listed on meal tickets, resulting in multiple residents receiving insufficient liquids with meals. Observations and interviews confirmed that milk was routinely omitted, and the hydration station meant to supply beverages was often not set up, leaving residents with only one cup of juice or coffee and no milk, despite its availability in the kitchen.
Facility staff did not consistently prepare or serve meals according to physician-ordered therapeutic and mechanically altered diets, resulting in residents on diabetic and heart healthy diets receiving incorrect foods and portions, and a resident requiring a mechanically altered diet being served improperly prepared food. Ongoing complaints from residents and documentation review confirmed repeated failures to follow prescribed dietary orders.
Facility staff did not maintain the walk-in freezer and pellet warmer in safe, working condition, resulting in a damaged freezer door with significant ice buildup and a non-functional pellet warmer. Staff and maintenance confirmed both issues had persisted for an extended period, with ongoing resident complaints about cold food and visible evidence of equipment disrepair. Documentation showed attempts to contact vendors and repair the equipment, but both remained out of service, affecting food storage and meal temperature.
Staff failed to provide two residents with meals and items according to their documented preferences, including specific entrée choices and the use of a lidded cup, despite these preferences being recorded in care plans and meal tickets. Ongoing dietary concerns were also noted in resident council meeting minutes.
A resident with severe cognitive impairment experienced a fall resulting in a skin tear, but the facility failed to notify the responsible party due to incorrect documentation. An LPN and the DON acknowledged the error, confirming the deficiency in the notification process.
The facility failed to secure a sufficient surety bond to cover the personal funds of 72 residents, with a bond amount of $165,000 against a total balance of $180,783.50. The administrator was informed, and the new business office manager identified accounts needing closure, which had not been done.
The facility staff failed to adhere to food safety and sanitation standards, including improper storage temperatures, lack of labeling and dating of food items, and inadequate dishwashing practices. The walk-in cooler was not maintaining safe temperatures, and there were no temperature logs available. Food items were not labeled or dated, and dishes were stacked while wet. Additionally, staff did not wear proper hair restraints, and sanitizer solutions were ineffective.
The facility failed to maintain adequate nurse staffing, leading to long call bell wait times and unmet resident needs. Residents and staff reported significant understaffing, particularly on weekends, with CNAs often responsible for over 20 residents each. The Director of Nursing acknowledged the staffing challenges, citing reliance on a single staffing agency and frequent call-outs due to staff fatigue.
A resident had multiple medications at their bedside without an assessment to determine their ability to self-administer. The facility's LPN was unaware of any approval for self-administration, and medications were typically kept in a locked cart. The DON stated that eligible residents are provided with a lock box, but the required assessment and interdisciplinary review were not initially conducted for this resident.
A resident with multiple health issues was moved to a different room without advance written notice to the resident or their responsible party. The admissions coordinator verbally notified the resident and left a voice message for the responsible party on the day of the move, but no written notice was provided, contrary to the facility's policy. This deficiency was acknowledged by the facility staff during the survey.
A resident with multiple mental health diagnoses was admitted to a facility without the staff incorporating the Level II PASARR recommendations into their care plan. The staff were unaware of the Level II PASARR until requested by surveyors, and the care plan lacked necessary information. The discharge planner incorrectly completed a Level I PASARR, stating no Level II evaluation was needed due to severe physical illness, despite the resident being alert and communicative.
A resident with a history of falls did not receive prescribed fall prevention devices, such as a fall mat and concave mattress, as outlined in their care plan. Despite the facility's policy on fall management, observations and staff interviews revealed these interventions were not in place, leading to a deficiency in providing a safe environment.
A resident in a LTC facility had a PRN order for lorazepam that was not limited to 14 days, as required for psychotropic medications. The order remained active without an end date, and the medication was administered on multiple occasions without proper documentation for one instance. The facility lacked a policy on limiting PRN orders for psychotropics, and the issue was confirmed by the corporate nursing consultant.
A resident requested a grilled cheese sandwich during lunch but was served a cold turkey and cheese sandwich instead. Despite repeated requests, the dietary aide did not notify the cook, assuming the cook would not want to make it. The dietary manager stated that the request should have been accommodated, and there were enough staff to prepare the sandwich. The facility administrator and DON were informed of the incident.
A resident's clinical record was incomplete, missing hospice notes and documentation since mid-April. Despite receiving hospice care, the facility failed to maintain accurate records, as required by professional standards. Interviews revealed unclear procedures for uploading hospice notes, leading to missing documentation. The issue was discussed with facility leadership, but no additional information was provided before the survey concluded.
A CNA at the facility did not receive the required 12 hours of in-service training, completing only 4.75 hours in one year without covering dementia management or care for the cognitively impaired. The facility's assessment mandates such training, but the deficiency was confirmed with no additional information provided by the administration.
The facility failed to provide necessary respiratory care and services to two residents. One resident received oxygen without a physician's order, and the equipment was not labeled with the date. Another resident's respiratory equipment was not stored properly, and the tubing was not changed routinely. Observations and interviews confirmed these deficiencies, which were contrary to the facility's policy requiring weekly changes and proper storage of equipment.
A resident with a physician order for nectar thickened liquids was served thin liquids, contrary to the prescribed diet. Staff interviews revealed that some CNAs provided regular consistency liquids based on the resident's preference and family wishes, despite the risk of aspiration. The facility's therapy director confirmed the resident was not on speech therapy caseload, and the facility administrator and DON were informed of the findings.
Facility staff failed to follow infection control practices for a resident on enhanced barrier precautions. Despite clear signage and care plan instructions, CNAs provided direct care without PPE, indicating a lack of understanding and training. Observations confirmed ongoing non-compliance with infection control protocols, as outlined by facility policy and CDC guidelines.
Facility staff did not follow posted menus for six out of ten residents, leading to discrepancies between served food items and those listed on menus and meal tickets. Issues included serving 1% milk instead of whole milk, missing items like bran muffins and oatmeal, and not providing listed items such as mixed Italian vegetables. The dietary manager cited supply issues, resident preferences, and unavailability of specific items as reasons for these discrepancies, despite the facility's policy on matching meals to individualized diet orders and preferences.
During a facility survey, it was observed that food on Unit 1 was not served at an appetizing temperature. Resident interviews and meeting minutes documented dissatisfaction with cold meals. On the day of observation, food items like spaghetti with meatballs and corn showed significant temperature loss when served. The dietary manager confirmed the lukewarm temperature, citing delays in meal service. Staff interviews revealed issues with beverage shortages and delays, with a CNA reporting running out of tea and an LPN unit manager acknowledging lengthy meal service and cold food. The facility's policy emphasized maintaining proper food temperatures and timely delivery.
A facility did not notify the responsible party of medication changes for a resident with severe cognitive impairment and a complex medical history, including Alzheimer's and hip fracture. Medication adjustments involved Celexa, Zoloft, cephalexin, Namenda, and Buspar, with no documented notifications to the family or responsible party. The DON and an LPN unit manager confirmed that notifications should have been made and documented, highlighting a communication gap regarding medication changes.
Failure to Accommodate Resident Shower Preferences Due to Low Weekend Staffing
Penalty
Summary
The facility failed to accommodate resident preferences for showers on one of its units due to low weekend staffing. Payroll Based Journal (PBJ) records and weekend schedules for March 2025 showed that only two certified nursing assistants (CNAs) were scheduled for a unit with a census of 59 residents, instead of the usual four to five CNAs per shift. Staff interviews confirmed that, as a result, showers were not provided to residents on those days. Instead, CNAs prioritized essential care, providing hygiene and shortened bed baths, and ensured residents were fed and kept safe with assistance from other nursing staff. The Director of Nursing (DON) acknowledged the staffing shortage and the absence of a staff coordinator at the time. Both the DON and a unit manager LPN confirmed that the goal is to have four CNAs per shift, but this was not achieved during the weekend in question. Staff reported that when such shortages occur, non-essential care such as showers is deprioritized. No additional information was provided by the facility prior to the exit conference.
Failure to Follow Discharge Orders Led to Unnecessary Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to ensure that unnecessary psychotropic medications were not administered to a resident by using the at-home medication list for admission orders instead of following the physician-verified hospital discharge summary. As a result, the resident received Amitriptyline 10 mg and Trazodone 100 mg at bedtime, which were not prescribed upon discharge from the hospital. Multiple staff interviews confirmed that the at-home medication list was incorrectly used, and the hospital discharge summary, which should have guided medication administration, was not followed. The clinical record review revealed that the resident had a history of delirium in the hospital, which had resolved by the time of discharge. Despite this, the facility continued to monitor for delirium and administered the unnecessary psychotropic medications. The resident's son repeatedly requested that these medications be discontinued due to concerns about delirium, and the nurse practitioner documented her intent to discontinue them. However, the medications were only held temporarily and then restarted, with no evidence that the discontinuation was completed as requested. Facility documentation and policy reviews indicated that medications are to be administered according to written prescriber orders and that discharge orders from the hospital should be reviewed and approved by the attending physician. Despite these policies, the facility did not have a specific policy related to psychotropic medication use, and the process for verifying and following discharge orders was not properly implemented. This resulted in the resident receiving medications that were not part of the discharge plan, contrary to both facility policy and the expressed wishes of the resident's representative.
Insufficient CNA Staffing on Unit During Weekend Shifts
Penalty
Summary
The facility failed to provide sufficient nursing staff on one of its units during a specific weekend, as evidenced by staffing records and staff interviews. Payroll Based Journal (PBJ) data and as-worked schedules showed that only two certified nursing assistants (CNAs) were scheduled for a unit with a census of 59 residents during the day shift on both Saturday and Sunday. Staff interviews confirmed that the standard staffing expectation was four to five CNAs per shift, and both the DON and CNAs acknowledged that the unit was understaffed on those days. The CNAs reported that, due to the low staffing, they had to prioritize essential care tasks, resulting in showers not being completed, though hygiene and feeding needs were met with assistance from other nursing staff. The deficiency was further supported by statements from the administrator and unit manager, who confirmed that staffing levels did not always meet the facility's assessment, especially on weekends due to turnover and call-outs. Despite the low staffing, there were no documented incidents, grievances, or resident council concerns related to unmet needs or accidents during the period in question. Resident interviews did not reveal significant concerns, except for one resident who requested a change in shower scheduling, which was subsequently addressed. The facility's own assessment indicated that four to five CNAs per shift were needed based on census and acuity, but this standard was not met on the dates reviewed.
Failure to Arrange Home Health Therapy at Discharge
Penalty
Summary
The facility failed to ensure an appropriate discharge for one resident who required home health therapy services after being discharged following spinal fusion surgery. The resident, who had multiple diagnoses including spinal stenosis, diabetes, and scoliosis, was assessed as moderately cognitively impaired and required skilled therapy services for strength training and self-transfers. Discharge instructions indicated that the resident was to receive home health services for physical and occupational therapy upon returning home. However, there was no documentation that the facility initiated these services prior to discharge, and conflicting notes existed regarding whether the resident declined home health services. Staff interviews revealed uncertainty about whether home health was set up, and the social worker could not recall the details or confirm which agency was contacted. Further investigation showed that the resident did not receive home health services immediately upon discharge and only began receiving them after a follow-up appointment with a primary care provider, who then made the referral. The facility's discharge policy required the social service department to coordinate arrangements for home health services, but there was no evidence that this was completed as required. Additionally, there was no documentation that the physician or nurse practitioner was notified if the resident declined therapy services, nor was there evidence that Adult Protective Services was contacted to ensure the resident's safety, as per facility practice.
Failure to Follow Physician Discharge Orders on Admission
Penalty
Summary
Facility staff failed to follow physician discharge orders for one resident upon admission. Instead of adhering strictly to the hospital discharge summary, staff used the resident's at-home medication list to enter admission orders, resulting in the administration of two medications (amitriptyline and trazodone) that were not included in the discharge orders. Interviews with LPNs, the DON, and the Regional Director of Clinical Services confirmed that the at-home medication list was used in addition to the hospital discharge summary, despite facility policy requiring medications to be administered only as per written prescriber orders. The nurse practitioner was unaware of the incorrect medication entries and had intended to discontinue medications at the request of the resident's son, but this was not completed. Facility documentation review showed that the policy required patient information and orders from the discharging physician to be reviewed and approved by the attending physician at admission. However, the staff's unfamiliarity with the hospital's discharge summary format contributed to the error, and the pharmacy was involved in reviewing new medications, but the process did not prevent the addition of non-discharge medications. The deficiency was identified through clinical record review, staff interviews, and policy review, confirming that the admission process was not completed according to physician discharge orders.
Failure to Ensure Proper Physician Review of Medication Orders on Admission
Penalty
Summary
Facility staff failed to ensure that a physician or appropriate practitioner thoroughly reviewed a resident's medication regimen upon admission. Specifically, a resident was prescribed amitriptyline for depression, despite the absence of a documented diagnosis of depression or delirium in the clinical record or hospital discharge summary. The nurse practitioner noted the son's request to discontinue antipsychotic medications, including amitriptyline, trazodone, and Seroquel, and intended to discontinue them, but did not complete the discontinuation process. The medications remained active from admission until the resident's discharge. Interviews with facility staff, including the MDS Coordinator and the nurse practitioner, revealed that the diagnosis of depression was incorrectly assigned based on assumptions rather than documented evidence. The nurse practitioner acknowledged that the diagnosis was not found in the hospital records and that the nursing staff had entered the diagnosis with the medication on admission, which she did not notice when signing off on the paperwork. Facility policy required that admission information and orders be reviewed and approved by the attending physician, and that the medical plan of care be reviewed at each visit, but this process was not properly followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two of six residents reviewed. For one resident, staff did not correctly document admission medications and linked a diagnosis of depression to the use of amitriptyline, despite no documented history of depression or delirium in the resident's records. The nurse practitioner acknowledged that the diagnosis of depression was not found in the hospital records and that the medication was continued without a corresponding diagnosis. Additionally, the resident's son requested discontinuation of antipsychotic medications, which was noted by the nurse practitioner, but the medications were not discontinued as intended. For another resident, there were inconsistencies in the documentation of a stage three pressure ulcer. While the initial skin assessment indicated the presence of the ulcer and treatments were initiated, subsequent daily skilled assessment progress notes and weekly skin assessments inconsistently documented the presence of the pressure ulcer, with some notes indicating 'No' or omitting documentation of the wound. The director of nursing and nurse consultant confirmed discrepancies in the clinical record documentation regarding the pressure ulcer.
Failure to Follow Posted Menus and Serve Prescribed Diets
Penalty
Summary
Facility staff failed to follow posted menus and serve meals as indicated, resulting in residents not receiving the foods listed on their meal tickets. Observations revealed that for both breakfast and lunch, the items served did not match the posted menus or the residents' meal tickets. For example, cranberry muffins listed for breakfast were not prepared or served, and instead, toast was substituted without documentation or use of a substitution log. Beverages, including milk, were not consistently provided with meals, and substitutions were made at the discretion of the cook without guidance or oversight. The cook admitted to making substitutions based on availability and did not maintain or reference a substitution log, as required by facility policy. During lunch service, further discrepancies were observed. The posted menu called for baked ham, carrots, scalloped potatoes, dinner rolls, and chocolate cake with chocolate frosting, but residents were served mixed vegetables, diced red potatoes instead of scalloped potatoes, yellow cake without chocolate frosting, and in some cases, no roll or milk. Residents on specialized diets, such as heart healthy or diabetic diets, did not receive the appropriate menu items or portion-controlled servings. For example, residents requiring a heart healthy diet were supposed to receive baked pork chops but were served ham instead. Diabetic residents received full portions of dessert rather than the required half portions, and when cake ran out, sherbet was substituted without documentation. Chopped meats were not prepared to consistent sizes, and dietary aides did not question discrepancies between meal tickets and what was served. Interviews with dietary staff, the registered dietician, and the activities director confirmed ongoing issues with menu adherence, lack of proper substitutions, and resident complaints about meals not matching posted menus or dietary needs. Resident council minutes and the grievance log documented repeated concerns from residents about these issues over several months. The registered dietician and activities director both acknowledged the lack of a functioning substitution log and ongoing communication problems with the contracted dietary company. Multiple residents were directly affected, including those with specific dietary orders, who did not receive meals as prescribed.
Failure to Provide Beverages Consistent with Resident Needs and Preferences
Penalty
Summary
Facility staff failed to provide beverages, specifically milk and other liquids, in quantities consistent with resident needs and preferences on both units. Observations during breakfast revealed that residents were served food without beverages on their trays, and only one cup of coffee or juice was distributed from the beverage cart. Milk, although listed on residents' meal tickets, was not provided. Staff interviews confirmed that milk was not routinely offered, with one CNA stating that only cream was provided for coffee and another indicating that milk was only given to select residents who requested it. Dietary staff admitted to omitting milk from trays unless specifically asked, despite it being listed on meal tickets. Residents interviewed confirmed they did not receive milk and only received one cup of juice with meals. Further observations during lunch service showed that, despite milk being available in the kitchen and listed on meal tickets, it was not served to residents. The activity director reported that the hydration station in the dining room, intended to provide beverages, was often not set up, resulting in residents receiving food without beverages. Resident grievances had previously been filed regarding the lack of milk with meals, but the issue persisted. The facility did not have a policy regarding beverage service.
Failure to Follow Physician-Ordered Therapeutic and Mechanically Altered Diets
Penalty
Summary
Facility staff failed to prepare and serve foods in accordance with physician-ordered therapeutic diets, affecting multiple residents across both nursing units. Observations revealed that residents on diabetic and heart healthy diets did not receive meals consistent with their prescribed dietary requirements. For example, residents on a heart healthy diet were served baked ham instead of the prescribed baked pork chop, and those on diabetic diets received full portions of cake instead of the required half portions. Additionally, when the kitchen ran out of certain menu items, substitutions were made without regard to the residents' dietary orders, and some residents did not receive all components of their meals, such as dinner rolls. Dietary aides did not question or adjust trays when discrepancies were noted, and the cook admitted to inconsistent portioning, especially in the absence of a manager. Resident council minutes and grievance logs indicated ongoing concerns and complaints from residents regarding the lack of adherence to diabetic diets and discrepancies between posted menus and actual meals served. Residents reported receiving meals with excessive carbohydrates and inappropriate portion sizes, which did not align with their dietary restrictions. The activities director corroborated these concerns, noting frequent mismatches between the menu and what was served, and described efforts to facilitate communication between residents, the dietary company, and the registered dietitian. Despite meetings and discussions, residents continued to express dissatisfaction with the dietary services provided. In a specific instance, a resident with an order for a mechanically altered diet (mechanical advanced chopped baked ham) was served ham cut into long strips rather than chopped, as required. This issue was also reflected in resident council meeting minutes, where concerns about mechanically altered diets not being provided were documented. Facility policy required that therapeutic and mechanically altered diets be prepared according to physician or dietitian orders and individualized care plans, but observations and documentation review confirmed that these standards were not consistently met.
Failure to Maintain Essential Kitchen Equipment in Safe Operating Condition
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment in safe, operating condition, specifically the walk-in freezer and the pellet warmer. During an observation, the walk-in freezer door was found to be damaged and unable to close completely, resulting in significant ice buildup around the door jamb and on the floor, as well as frost accumulation on food packages near the door. The door gasket was detached at the bottom, and the maintenance director confirmed the door had been in poor condition for an extended period, with a new seal unable to resolve the issue due to the door being bent. Communication records showed that the facility had been in contact with a vendor to address the issue, but a replacement had not yet been secured. Additionally, the pellet warmer in the main kitchen was not operational during meal service, leading staff to serve food without using the pellets intended to keep meals warm. Dietary aides reported the pellet warmer had not been working, and the evening cook stated it had been out of service for about two months due to a burning smell and lack of heat. Resident council meeting minutes and grievance logs documented ongoing complaints from residents about cold food, with repeated references to the pellet warmer being out of order. The activities director and maintenance director both confirmed ongoing issues with the pellet warmer, including difficulties in obtaining the correct replacement parts and repeated failed repairs. The facility's documentation included emails and technician notes indicating persistent challenges in identifying and sourcing the necessary parts for the pellet warmer, as well as communication with vendors regarding both the freezer door and the pellet warmer. Despite these efforts, both pieces of essential kitchen equipment remained in disrepair at the time of the survey, directly impacting food storage and meal service.
Failure to Honor Resident Meal Preferences and Dietary Requests
Penalty
Summary
Facility staff failed to provide meals in accordance with resident preferences for two residents out of a sample of eight. One resident was observed receiving a lunch meal that did not match their documented meal ticket, which specified a deli sandwich and tossed salad, but instead received ham, mixed vegetables, diced red potatoes, and a roll. When questioned, the resident confirmed that the meal was not what they wanted. The facility's own policy states that menus are to be served as written unless changed in response to preference, unavailability, or special meal requirements. Another resident was observed receiving a meal that did not match their requested entrée of baked pork chop, instead receiving baked ham, and was not provided with a lidded cup as documented in their care plan. The resident confirmed that they usually receive a pork chop and prefer a lidded cup, which was not provided. Review of resident council meeting minutes revealed ongoing unresolved dietary concerns, including meal tickets not being followed and resident choices not being granted. These findings were discussed with facility leadership during the survey.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility staff failed to notify the responsible party of a change in condition for a resident who experienced a fall with injury. The resident, who had a cognitive score indicating severe cognitive impairment, was involved in a fall incident where they attempted to get up from a wheelchair and landed on their knees, resulting in a skin tear to the left elbow. The clinical record incorrectly documented the resident as their own responsible party (RP), despite having a friend listed as the RP. During an interview, an LPN acknowledged that the physician and RP should be notified in the event of a change in condition or fall with injury. Upon reviewing the documentation, the LPN recognized the error in the notification process, as the resident was not their own RP. The Director of Nursing also reviewed the documentation and concurred that the RP should have been notified, confirming the deficiency in the notification process.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility staff failed to secure a sufficient surety bond to cover the personal funds of residents deposited with the facility, affecting 72 residents. On July 10, 2024, the facility provided a surety bond amounting to $165,000, which was insufficient to cover the total balance of $180,783.50 in the resident trust accounts. During an end-of-day meeting, the facility administrator was informed of this discrepancy. The business office manager, who had recently started at the facility, acknowledged that several accounts needed to be closed, but this had not yet been completed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to store, prepare, and serve food in accordance with professional standards for food safety, which has the potential to affect multiple residents. During a kitchen tour, it was observed that the walk-in cooler was not maintaining an appropriate temperature, with the internal thermometer reading 55 degrees Fahrenheit. The dietary manager acknowledged issues with the cooler and confirmed that the milk stored inside was at 52 degrees, which is above the safe temperature threshold. Additionally, there were no temperature logs available for any of the food storage areas, and staff were unaware of the temperature monitoring responsibilities. The facility staff also failed to label and date foods that had been opened and stored food in a manner that could lead to contamination. Items such as onions were found on the floor, and various food items were not labeled with preparation or use-by dates. Open containers of food were left uncovered, and some items were stored directly on the floor. The dietary manager confirmed that all food items should be labeled and dated to prevent food poisoning, but this practice was not consistently followed. Furthermore, the facility staff did not adhere to proper dishwashing and sanitization procedures. Dishes were observed being stacked while still wet, which could promote bacterial growth. The sanitizer solution used for cleaning food preparation areas was found to be ineffective, with no sanitizer present in the solution. Additionally, the facility staff failed to monitor and record food temperatures to ensure they were cooked and held at safe temperatures. The dietary manager was unaware of the missing temperature logs, and staff were not wearing proper hair restraints while in the kitchen, further compromising food safety.
Chronic Understaffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to maintain sufficient nurse staffing to ensure the safety and well-being of residents across two nursing units. Residents reported waiting over an hour for call bell responses, particularly on weekends, due to inadequate staffing. The Ombudsman and resident council expressed concerns about the dangerous staffing levels, with some residents unable to receive timely assistance for basic needs such as using the bathroom. Staff interviews corroborated these issues, with CNAs reporting that they were often responsible for over 20 residents each, making it impossible to provide necessary care, including regular showers. The facility's staffing records from June to early July 2024 revealed multiple instances where staffing levels were significantly below the required number of CNAs per unit. On several occasions, only two CNAs were available for entire shifts, far below the facility's assessment requirement of five CNAs per shift per unit. This chronic understaffing was particularly acute on weekends and during night shifts, leading to long call bell wait times and unmet resident needs. The Director of Nursing acknowledged the staffing challenges, citing reliance on a single staffing agency and frequent call-outs due to staff fatigue from working extended hours. Despite efforts to cover shifts, including management stepping in, the facility struggled to meet its staffing needs, particularly for the skilled unit with higher acuity residents. The facility's average census of 100 residents further exacerbated the staffing shortfall, impacting the quality of care provided.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility staff failed to assess and determine if a resident was safe to self-administer medications that were at the bedside. Resident #28 had multiple medications, including prescription nasal spray, sterile eye drops, and toothache cream, stored on the over bed table and bedside table in their room. The resident reported using these medications regularly, but there was no evidence in the clinical record or care plan that an assessment had been conducted to evaluate the resident's ability to self-administer these medications. During observations and interviews, it was revealed that the facility's licensed practical nurse (LPN) was unaware of any assessment or approval for the resident to self-administer medications. The LPN mentioned that medications are typically kept in a locked medication cart and administered by nurses. However, the LPN acknowledged that families sometimes bring in medications without the facility's knowledge, and these are removed when discovered. The LPN confirmed that the nasal spray was from the facility's pharmacy and removed it, along with other medications, from the resident's bedside. The facility's director of nursing (DON) stated that residents who can self-administer medications are provided with a lock box to prevent access by other residents. The facility's policy requires a safety screen assessment and interdisciplinary team review to determine eligibility for self-administration. However, this process was not initially followed for Resident #28, leading to the deficiency. The facility later conducted the necessary assessment and obtained physician orders for unsupervised self-administration of certain medications.
Failure to Provide Advance Written Notice of Room Change
Penalty
Summary
The facility staff failed to provide advance written notice of a room change for a resident, identified as Resident #77, who was part of a survey sample. The resident, who had multiple diagnoses including adult failure to thrive, deep vein thrombosis, and major depressive disorder, was assessed with moderately impaired cognitive skills. On July 1, 2024, the resident was moved to a different room without prior written notification to either the resident or the responsible party. The family member of the resident confirmed that no advance notice was given regarding the room change. The admissions coordinator admitted to notifying the resident verbally on the day of the room change and leaving a voice message for the responsible party, but no written notice was provided. The coordinator also acknowledged marking the room change notification form as if a copy had been provided, although no actual copy was given. The facility's admissions/business contract stated that residents had a right to advance notice of room changes, which was not adhered to in this case. This deficiency was discussed with the facility's administrator, director of nursing, and regional nurse consultant, but no further information was provided before the survey concluded.
Failure to Incorporate Level II PASARR Recommendations
Penalty
Summary
The facility staff failed to obtain and incorporate the recommendations from a Level II PASARR into the assessment and care plan for a resident in the survey sample. The resident, who had a Level II PASARR, was admitted to the facility with multiple diagnoses, including hemiplegia, schizoaffective disorder, and major depressive disorder. Despite these conditions, the facility staff were unaware of the Level II PASARR until it was requested by the survey team. The care plan did not address the Level II PASARR or its recommendations, and the facility's documentation did not include the necessary information. During the survey, it was discovered that the discharge planner/social services director had completed a Level I PASARR, which incorrectly indicated that no Level II evaluation was required due to a severe physical illness. However, the resident was alert and communicative, contradicting the justification for not performing a Level II PASARR. The facility's policy required that any Level II PASARR be incorporated into the care plan within five days of admission, but this was not done. The facility administrator was informed of these findings during an end-of-day meeting.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility staff failed to ensure that a resident, identified as R28, received necessary fall prevention devices, leading to a deficiency in providing a safe environment. R28, who had a history of falls, reported having several falls while at the facility and was unaware of any interventions in place to prevent future incidents. Observations confirmed the absence of a fall mat and a concave mattress, which were specified in the resident's care plan as interventions to prevent falls and injuries. The care plan, last revised on 6/7/24, indicated these interventions were necessary due to R28's impaired gait and mobility. Interviews with facility staff, including an LPN who routinely cared for R28, revealed a lack of awareness and implementation of the prescribed interventions. The LPN confirmed the absence of the fall mat and concave mattress in R28's room and expressed concern that a fall mat might pose additional risks, indicating a possible misunderstanding of the care plan requirements. The facility's Fall Management Program policy emphasizes the need for a systematic approach to fall prevention, including discussing risks and interventions with patients and incorporating them into care plans. However, the failure to implement these measures for R28 highlights a deficiency in adhering to this policy.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility staff failed to ensure that a PRN order for the psychotropic medication lorazepam was limited to 14 days for a resident, identified as Resident #82 (R82). The order, dated 5/1/24, was for lorazepam oral concentrate 2 mg/ml to be given 1 ml by mouth every 1 hour as needed for end-of-life anxiety, but it had no end date and remained active. The medication was administered on 5/3/24, 6/30/24, and 7/2/24, but there were no nursing notes explaining the administration on 5/3/24. Notes on 6/30/24 and 7/2/24 indicated the medication was given for agitation and anxiety, respectively, with the medical doctor being aware. The clinical record review revealed that the physician did not reference the PRN lorazepam order during visits on 5/2/24, 5/15/24, and 6/2/24, despite R82 being admitted to hospice services. The corporate nursing consultant confirmed that PRN orders for psychotropics should not exceed 14 days, and the facility lacked a policy regarding this. The facility administrator and director of nursing were informed of these findings, but no additional information was provided.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility staff failed to provide meal substitutions in accordance with resident preferences for one resident in a survey sample of 26 residents. On the specified date, a resident requested a grilled cheese sandwich during lunch but was served a cold turkey and cheese sandwich instead. Despite the resident's repeated requests to the dietary aide, the aide insisted that the resident had ordered the turkey sandwich and did not notify the cook of the resident's preference for a grilled cheese sandwich. The dietary manager, upon being informed of the incident, expressed that the resident's request should have been accommodated and that there were sufficient staff available to prepare the grilled cheese sandwich. The dietary aide admitted to not notifying the cook because she assumed the cook would not want to make it. The facility administrator and director of nursing were informed of these findings, but no further information or facility policy regarding food preferences was provided before the conclusion of the survey.
Incomplete Clinical Record for Hospice Care
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, identified as Resident #77, who was receiving hospice care. The resident's clinical record lacked recent hospice notes and documentation, which is a requirement according to accepted professional standards. Resident #77 was admitted with multiple diagnoses, including adult failure to thrive, deep vein thrombosis, insomnia, severe protein-calorie malnutrition, major depressive disorder, cancer, and gastroesophageal reflux disease. The resident was assessed with moderately impaired cognitive skills. Despite receiving hospice care since January 19, 2024, the clinical record did not include hospice notes or records of services provided since mid-April 2024. Interviews with the Director of Nursing (DON) and the medical records coordinator revealed that hospice was supposed to provide notes after each visit, which were then uploaded to the clinical record. However, the DON was unsure why the notes were missing, and the medical records coordinator indicated that the system for uploading hospice notes was unclear. The coordinator also mentioned that hospice sometimes provided notes in bulk rather than after each visit. Before the survey concluded, the medical records coordinator obtained the missing hospice notes, which included nineteen entries from hospice nurses, social workers, and a spiritual counselor, dated from April 15, 2024, to June 21, 2024. This deficiency was discussed with the administrator, DON, and regional nurse consultant, but no further information was provided before the survey ended.
Inadequate In-Service Training for CNA
Penalty
Summary
The facility staff failed to ensure that a certified nursing assistant (CNA) received the required 12 hours of in-service training per year. Specifically, CNA #8, who was hired on August 30, 2022, only completed 4.75 hours of training from August 30, 2022, to August 30, 2023. The training did not include essential topics such as dementia management or care for the cognitively impaired. Additionally, for the year 2024, CNA #8 had only completed 1.5 hours of training, which covered HIPAA, infection control, and bloodborne pathogens. The facility's assessment indicated that it provides care for residents with cognitive impairments and requires in-service training for nurse aides to include dementia management and resident abuse prevention. The facility's failure to provide the necessary training was confirmed during a review with the facility administrator and corporate nurse consultant, who did not provide any additional information to address the deficiency.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility staff failed to provide necessary respiratory care and services to two residents, leading to deficiencies in their care. For Resident #84, the staff administered oxygen without obtaining a physician's order and failed to label the oxygen tubing with the date. The resident, who was admitted with diagnoses including congestive heart failure and pressure ulcers, was observed receiving oxygen therapy without a corresponding physician order. Interviews with the LPN and the Director of Nursing confirmed the absence of a physician order for the oxygen therapy being administered to Resident #84. In the case of Resident #28, the facility staff did not store respiratory equipment properly to prevent contamination and failed to change the tubing on a routine basis. Observations revealed that the nebulizer mask and tubing had not been changed since 6/25/24, and the oxygen tubing was dated 6/1/24. The oxygen nasal cannula was found hanging open to air, contrary to the facility's policy that requires such equipment to be stored in a labeled, dated bag. Interviews with an LPN confirmed these findings and highlighted that the equipment was not being changed weekly as required by the facility's policy. The facility's policy titled 'Patient Care Equipment' mandates that oxygen humidifier bottles, cannulas/masks, and tubing are changed weekly, and that tubing not in use should be kept in a labeled, dated bag. However, the facility failed to adhere to these standards, as evidenced by the observations and interviews conducted during the survey. The Director of Nursing confirmed that the respiratory equipment setup is supposed to be changed weekly, yet the facility did not provide any additional information or corrective actions during the exit conference.
Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
The facility staff failed to provide a therapeutic diet in accordance with physician orders for a resident who had a physician order for nectar thickened liquids (NTL). During observations, the resident was served thin liquids, including apple juice and water, which were not in compliance with the prescribed NTL. The meal ticket on the resident's tray indicated the requirement for NTL, but the staff, including a CNA, provided regular consistency liquids, citing the resident's preference and family wishes as reasons for the deviation. Interviews with staff revealed a lack of adherence to the physician's orders, with some staff members believing the resident could handle thin liquids despite the risk of aspiration. The therapy director confirmed that the resident had not been on speech therapy caseload and acknowledged the risk of aspiration from serving thin liquids. The facility administrator and director of nursing were informed of these findings, but no additional information was provided regarding corrective actions.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to infection control practices for a resident on enhanced barrier precautions. The resident, who had been admitted with diagnoses including Stage 3 pressure ulcers and a cutaneous abscess, was observed receiving direct care from two certified nursing assistants (CNAs) without the required personal protective equipment (PPE). Despite signage indicating the need for enhanced barrier precautions, the CNAs assisted the resident with bathing, dressing, transferring, and changing bed linens without wearing PPE. Interviews with the CNAs revealed confusion about the signage and the requirements for wearing protective clothing, indicating a lack of understanding and training regarding infection control protocols. Further observations confirmed that the CNAs continued to provide direct care without PPE, even after the issue was initially identified. The facility's documentation and the resident's care plan both specified the need for enhanced barrier precautions, which were not followed. The Director of Nursing confirmed the oversight during a subsequent observation. The facility's policy and CDC guidelines clearly outlined the necessity of gown and gloves during high-contact care activities, especially for residents with wounds, yet these protocols were not implemented, leading to the deficiency.
Menu Compliance Issues Due to Supply and Preference Discrepancies
Penalty
Summary
The facility staff failed to follow posted menus for six out of ten residents in the survey sample, resulting in discrepancies between the food items served and those listed on the menus and meal tickets. Residents #1, #2, #3, #5, #6, and #10 were not provided with the correct food items as per the posted menu and meal tickets. Examples of discrepancies included serving 1% milk instead of whole milk, missing food items like bran muffins and oatmeal, and not providing items listed on the menu such as mixed Italian vegetables and whole milk during lunch service on 4/9/24. During interviews with residents and staff, concerns were raised about the inconsistency between the food served and the menu listings. The dietary manager explained reasons for the discrepancies, such as issues with milk supply, resident preferences for certain food items like sausage, and unavailability of specific food items like mixed Italian vegetables. Despite the facility's policy emphasizing the importance of meals matching individualized diet orders and preferences, the observations revealed a failure to adhere to the posted menus and meal tickets, leading to the deficiency in menu compliance.
Temperature and Timeliness Issues in Meal Service on Unit 1
Penalty
Summary
During a facility survey, it was observed that food was not served at an appetizing temperature on Unit 1. Resident interviews revealed concerns about cold meals, with the resident council president stating that food served in rooms was usually cold. Meeting minutes from January to March documented residents expressing dissatisfaction with the taste and temperature of the food. On the day of observation, food temperatures on the steam table were recorded, with items like spaghetti with meatballs and corn showing significant temperature loss when served to residents. The dietary manager confirmed the lukewarm temperature of the food, noting delays in serving meals after delivery to the floor. Further interviews with staff revealed issues with beverage shortages and delays in meal service. A certified nurses' aide reported running out of tea and having to fetch more from the kitchen, while the licensed practical nurse unit manager acknowledged the lengthy meal service and cold food served during lunch. The facility's policy on meal distribution emphasized the importance of maintaining proper food temperatures, preventing contamination, and ensuring timely delivery to residents.
Communication Lapse in Medication Changes for Cognitively Impaired Resident
Penalty
Summary
The facility failed to notify the responsible party of medication changes for Resident #7, who had multiple medication adjustments without any communication to their family or responsible party. Resident #7 had a complex medical history including diagnoses of hip fracture, Alzheimer's, traumatic brain dysfunction, hypothyroidism, anemia, osteoporosis, anxiety, depression, seizures, and protein-calorie malnutrition. Despite being assessed with severely impaired cognitive skills for daily decision making, Resident #7 experienced medication changes including Celexa being increased and then discontinued, Zoloft being initiated and dose-adjusted, antibiotic cephalexin prescribed, Namenda and Buspar doses increased, with no documented notifications to the responsible party in the clinical record. The Director of Nursing (DON) and a Licensed Practical Nurse unit manager acknowledged during interviews that notifications regarding medication changes should have been made to Resident #7's family or responsible party. The DON confirmed the lack of notifications in the clinical record and emphasized the expectation for staff to inform families about changes in condition or treatment, including medication adjustments. LPN #2 also acknowledged that any notifications should have been documented in Resident #7's clinical notes, highlighting a gap in communication regarding medication changes for the resident.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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