Cherrydale Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Virginia.
- Location
- 3710 Lee Highway, Arlington, Virginia 22207
- CMS Provider Number
- 495121
- Inspections on file
- 17
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Cherrydale Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow transmission-based precautions and PPE protocols on two nursing units, including not wearing required isolation gowns when providing care to residents on enhanced barrier or contact precautions, handling medications with bare hands, and not performing hand hygiene after glove removal. Staff interviews revealed confusion about PPE requirements, and the DON confirmed that established infection control policies were not followed.
A resident who was cognitively intact did not receive timely incontinence care when a CNA failed to respond to their call light, leaving the resident in feces for hours. The resident reported feeling threatened by the CNA's aggressive behavior and called the police for assistance. Facility records and staff interviews confirmed the CNA's lack of responsiveness and the incident was substantiated as neglect, resulting in the CNA's termination.
Facility staff did not follow abuse and neglect prevention policies when a CNA neglected a cognitively intact resident, failing to respond to call lights and displaying aggressive behavior. The incident was substantiated as neglect, and it was also found that the CNA's certification and criminal background were not properly verified prior to employment, in violation of facility policy.
Facility staff did not remove alleged perpetrators from duty following reports of abuse and neglect involving two residents. In both cases, the accused employees continued to work their shifts and had access to other residents while investigations were ongoing. Facility policies lacked guidance on protecting residents during such investigations, and supervisory staff did not take steps to restrict the accused staff members' access.
Staff failed to transcribe and administer a physician-ordered antifungal medication to a resident for two days after admission, despite clear discharge instructions. Additionally, two residents with PEG tubes did not have the required anchor devices in place as ordered by their physicians, even though staff documented otherwise. Nursing staff were unaware of the specific orders, and facility policies did not address the use of anchor devices for PEG tubes.
A resident admitted with a candida UTI did not receive a prescribed antifungal medication for three days because staff failed to transcribe the physician's order at admission. The medication was only started after the delay was identified during a chart check, despite facility policy requiring prompt recording of all admission orders by nursing staff.
Staff did not maintain accurate clinical records for three residents. Two residents with PEG tubes had physician orders for anchor devices, but staff signed off that anchors were in place when they were not, and staff were unaware of the orders. Another resident who attended off-site dialysis had no documentation of departures, returns, or dialysis communication forms in the clinical record, contrary to facility policy.
During a lunch meal service, staff did not prepare or serve the apple crisp dessert listed on the menu and meal tickets, instead providing mixed fruit to all residents on four units. The dietary manager allowed the substitution without proper justification, citing a staff call out and time constraints as reasons for the omission.
Staff did not ensure that food was served at appetizing and safe temperatures on one unit. Food was transferred from the kitchen to the dining room and resident rooms, but temperatures of several items were found to be below recommended levels, resulting in lukewarm or barely warm meals. Multiple residents reported that their food was not usually warm, and the dietary manager confirmed the food was not palatable.
Staff did not consistently serve meals and beverages according to residents' documented preferences and meal tickets. Several residents did not receive requested items such as milk, specific salads, or oatmeal, despite these being listed on their meal tickets and preference forms. Dietary and nursing staff confirmed that the correct items should have been provided, but errors occurred and were not explained.
Staff did not provide beverages, including milk, as indicated on meal tickets for multiple residents during meal service on two units. Several residents expressed their preferences and needs for specific beverages, but were not served accordingly, even when beverages were available. Staff interviews confirmed that meal tickets were not consistently followed, and facility policy requiring individualized beverage service was not adhered to.
Staff failed to store, prepare, and distribute food in a sanitary manner, including leaving opened and unlabeled food items exposed in coolers and freezers, and stacking wet, unclean pans and trays, contrary to facility policy and federal food safety standards. The dietary manager acknowledged these lapses during surveyor observations.
Staff failed to follow infection control protocols during meal service by not changing gloves between tasks, not performing hand hygiene, and placing clean table linens on the floor before use. Additionally, a staff member did not wear the required gown and gloves while providing direct care to a resident on enhanced barrier precautions, despite clear signage and physician orders.
The facility did not maintain an effective pest control program, as evidenced by direct observations of cockroaches in resident areas, repeated pest sightings documented in logs, and multiple reports from residents and staff of ongoing infestations. Despite regular pest control services and established policies, pests continued to be present throughout the facility.
A resident with a designated power of attorney was prescribed a muscle relaxer, and the order was later revised, but there was no documentation that the resident or responsible party was notified of the medication change. Staff interviews confirmed the lack of notification, and facility policies did not specifically address the requirement to inform responsible parties of new or changed medication orders.
A resident was moved between rooms multiple times without being provided written notice or documented reasons for the changes, as required. Staff interviews and record reviews confirmed that only verbal notification was given in one instance, and facility policy on room transfers was not followed.
A resident's full beard was shaved off by a CNA without obtaining the resident's consent, despite the resident's attempts to stop the action and his limited mobility. The resident became upset and developed facial redness and razor burn. Staff incorrectly believed the family requested the beard removal, but the resident's sister clarified she only wanted the beard kept clean. There was no documentation of consent or grooming preferences in the care plan.
A resident did not receive scheduled doses of Atorvastatin and Apixaban, with no documentation or explanation for the missed medications. Facility staff confirmed the omission, and the MAR was left blank despite the resident being present. Policy requiring immediate documentation was not followed.
A resident did not receive a prescribed medication due to it being unavailable, as confirmed by review of the MAR and staff interviews. The facility's policy requires staff to notify the provider and responsible party when medications are not available, but the medication was not administered as ordered, and the issue was confirmed by the DON and unit manager.
Staff failed to properly disinfect multi-use glucometers between residents, used unapproved cleaning methods, and did not allow for required drying times. In addition, a CNA did not wear required PPE or use soap during catheter care for a resident on Enhanced Barrier Precautions, and did not change gloves appropriately. A urinary catheter bag was also repeatedly observed resting on the floor, contrary to infection control policy.
The facility did not employ a qualified dietitian or other clinically qualified nutrition professional for several weeks, with only intermittent assistance from a dietitian at a sister facility. During this period, food was not consistently served at palatable temperatures, residents were not always offered sufficient drinks to maintain hydration, and bread products in the kitchen were improperly stored without proper dating, labeling, or covering.
Surveyors found that food products, including bread and rice, were not properly dated, labeled, or stored according to facility policy and professional standards. Items were observed in open or unlabeled packaging, and there was no schedule for checking food for expiration, as confirmed by the RD.
Staff served all residents meals on trays without removing plates, cups, or silverware to the dining tables, contrary to facility policy and expectations for a homelike environment. Additionally, a CNA referred to a resident as a "feeder" in her presence, which was acknowledged as inappropriate by both the CNA and the DON.
Several residents reported receiving cold meals, and food temperature checks confirmed that food served last on the unit was cold. The RD acknowledged complaints but had not conducted test trays or implemented interventions, and there was no policy on food palatability.
Multiple residents did not receive milk with their meals as specified on their meal slips and the facility menu, despite milk being available. A resident with diabetes and chronic kidney failure also reported missing milk on their tray during two observed meals, and staff confirmed the omission. These deficiencies were confirmed through observation, resident interviews, and staff review.
The facility did not document the administration or refusal of influenza, pneumococcal, and COVID-19 vaccines for several residents with type two diabetes, as required by policy. Immunization records for these residents were incomplete, and the Infection Preventionist confirmed the absence of documentation for both vaccine administration and refusals.
A resident admitted with Guillain-Barre Syndrome did not have their food preferences obtained or documented upon admission, despite facility policy requiring this within 48 hours. The care plan lacked dietary preference information, and the resident reported being unable to eat the provided food, believing this led to weight loss. The RD confirmed that no preferences were in place and that nursing had not communicated any dietary needs.
A resident with multiple diagnoses, including dementia and diabetes, was not given the opportunity to participate in their care planning, despite being assessed as cognitively intact. Staff interviews confirmed that documentation of the resident's involvement was missing, and no evidence was found in the clinical record to show the resident was invited to participate in treatment planning.
A resident with multiple medical conditions and a recent fracture did not receive showers twice weekly as scheduled, despite expressing this preference and being aware of state requirements. Documentation showed missed showers on two scheduled dates, and staff interviews could not account for the lapses. The resident required assistance with ADLs, and the deficiency was confirmed through record review and staff interviews.
A resident admitted with Guillain-Barre Syndrome did not have a Food Preference Interview completed as required by facility policy, resulting in no documented dietary preferences. The resident, who was cognitively intact and at risk for weight loss, reported not eating due to disliking the food, and the RD confirmed no preferences were in place.
A resident with multiple medical conditions did not have a personal property inventory completed upon admission, as required by facility policy. The resident later reported missing ear pods and stated that no inventory list was ever filled out. Staff interviews and review of records confirmed the absence of the required inventory documentation.
The facility did not notify the Department of Health Professions after receiving an allegation that a registered nurse engaged in excessive and unwanted touching of a resident during wound care. Although the incident was documented and other notifications were made, the required report to DHP was not completed as per facility policy.
Two residents experienced deficiencies in the facility's response to alleged abuse and neglect. In one case, a cognitively intact resident reported inappropriate sexual contact by a nurse, but the facility did not interview the alleged perpetrator or document staff interviews. In another case, a severely cognitively impaired, Spanish-speaking resident fell during care, and the post-fall investigation did not adequately address language barriers or adherence to care plan interventions. Staff interviews revealed gaps in awareness and investigation, contrary to facility policy.
A resident's MDS assessment did not reflect significant weight loss documented by the registered dietician in progress notes, despite the expectation that staff obtain and validate such information through regular meetings and reports. The MDS coordinator was unaware of the weight loss at the time of assessment, resulting in inaccurate completion of the MDS.
A resident with bipolar and major depressive disorder was readmitted without a completed PASARR Level I assessment. The absence of this required screening was confirmed through record review and staff interviews, with facility staff acknowledging the oversight and lack of identification at admission.
Two residents did not receive care in accordance with their comprehensive care plans. One resident's care plan failed to include food preferences, leading to dissatisfaction with meals and reported weight loss, while another resident's fall prevention intervention of keeping the bed in a low position was not consistently implemented. Staff interviews confirmed lack of awareness and adherence to these care-planned interventions.
A resident with spinal stenosis and no cognitive impairment had a Durable Do Not Resuscitate (DNR) form that was not fully completed, missing documentation of the resident's capacity to make the decision. Although both the resident and physician had signed the form, facility policy required all sections to be filled out for the DNR to be valid. The DON confirmed the incomplete form would result in the resident being treated as a full code.
A nurse administered a 50 mg dose of Lyrica to a resident instead of the prescribed 25 mg dose, after selecting the wrong medication supply card during a medication pass. The error was identified when the nurse reviewed the resident's updated physician order and realized the previous higher-dose supply was mistakenly used.
A resident with severe cognitive impairment and physical disabilities was not provided with the care-planned fall intervention of a low bed position, as observations showed the bed was not kept low. After the resident fell during personal care, staff did not conduct a thorough post-fall investigation or adequately address potential language barriers, and documentation was insufficient to determine the cause of the fall.
A resident with multiple health conditions reported that a bathroom hand assist bar was not securely anchored, and this concern had not been addressed despite being reported. Observation confirmed the bar was loose and unsafe, and facility staff acknowledged that no work order had been placed for repair. The issue was confirmed during a joint inspection with facility leadership.
Failure to Implement Transmission-Based Precautions and Proper PPE Use
Penalty
Summary
Facility staff failed to implement proper transmission-based precautions on two of four nursing units, specifically the fourth and fifth floors. Multiple staff members, including nursing students and a certified nursing assistant, entered rooms of residents on enhanced barrier or contact precautions without wearing required personal protective equipment (PPE) such as isolation gowns, despite clear signage and available supplies. In one instance, two staff members assisted a resident with a g-tube and tracheostomy while only wearing masks and gloves, contrary to the posted instructions and physician orders. Another staff member adjusted bed linens for a resident with ESBL in the urine while not wearing an isolation gown, and later exited the room carrying soiled items without removing PPE or performing hand hygiene. Additional deficiencies were observed in medication administration and PPE use. A nurse was seen handling medications with bare hands, and another administered eye drops in the hallway, removed gloves without performing hand hygiene, and then touched shared equipment and medication cards before using hand sanitizer. A respiratory therapist was observed leaving a resident's room in full PPE, accessing a supply cart in the hallway with gloved hands, and then re-entering the room, which was inconsistent with facility policy and infection control practices. Interviews with staff and the Director of Nursing confirmed a lack of adherence to established policies regarding PPE use for enhanced barrier and contact precautions. Staff demonstrated confusion or lack of awareness about the requirements indicated on precaution signage, and the DON acknowledged that proper procedures were not followed in the observed situations. Facility policies reviewed required the use of gowns and gloves for high-contact care activities and specified the need for PPE and hand hygiene to prevent the spread of infection, but these were not consistently implemented.
Failure to Protect Resident from Neglect and Aggressive Staff Behavior
Penalty
Summary
Facility staff failed to protect a resident's right to be free from neglect when a certified nursing assistant (CNA) did not respond to the resident's call light for incontinence care, resulting in the resident remaining in feces for hours. The resident, who was cognitively intact and had no behavioral issues, reported the incident to both their child and the director of nursing via text messages. The resident also felt threatened by the CNA's aggressive and erratic behavior, which escalated to the point where the resident called the police for assistance. The police responded, and the CNA was subsequently removed from the situation. Facility documentation and staff interviews confirmed that the CNA had a history of not responding to resident requests and was difficult to awaken for duty. The facility's investigation substantiated the allegation of neglect, noting that the CNA's actions constituted a willful failure to provide timely and consistent care necessary for the resident's health, safety, and comfort. The CNA's employment was terminated following the incident.
Failure to Implement Abuse Policy and Pre-Employment Screening
Penalty
Summary
Facility staff failed to implement their abuse and neglect prevention policy for a certified nursing assistant (CNA) who neglected a cognitively intact resident. The resident reported that staff did not respond to call lights for incontinence care, resulting in the resident remaining in feces for hours. The resident felt threatened by the CNA's aggressive behavior and called the police. Text messages sent to the DON and the resident's child documented the incident, and the facility's own investigation substantiated the allegation of neglect. The charge nurse was aware of the CNA's lack of response to resident needs, and the CNA was found sleeping during the shift, requiring a nurse to wake her to provide care. Further review revealed that the facility failed to verify the CNA's active certification and did not obtain a criminal background check prior to employment. The CNA had previously worked at the facility, but upon rehire, the required checks were not repeated, contrary to facility policy. The human resources director confirmed that neither a current background check nor license verification was present in the personnel file at the time of the incident. The facility's policy required criminal background and reference checks for all employees, but these procedures were not followed for this CNA.
Failure to Protect Residents During Abuse and Neglect Investigations
Penalty
Summary
Facility staff failed to take immediate protective measures following allegations of abuse and neglect involving two residents. In the first instance, a resident reported to the facility administrator that a housekeeper threatened to beat him up. Although the administrator documented the incident and reported it to the state regulatory agency, the alleged perpetrator was allowed to work the remainder of the shift, as confirmed by timecard records. This action provided the employee continued access to other residents during the ongoing investigation. In the second case, a cognitively intact resident reported neglect and intimidation by a CNA, including delayed incontinence care and aggressive behavior, which led the resident to contact the police. Despite the substantiated allegation of neglect, the CNA was permitted to work a full shift the following day, providing direct care to other residents. Facility policies reviewed did not address the need to protect residents from alleged perpetrators during investigations, and supervisory staff did not take measures to restrict the accused staff members' access to residents during the investigation period.
Failure to Follow Physician Orders for Medication and PEG Tube Anchoring
Penalty
Summary
Facility staff failed to follow physician orders for three residents in a sample of eight, resulting in deficiencies related to medication administration and treatment implementation. For one resident, staff did not transcribe an order for antifungal medication (fluconazole) upon admission, despite the hospital discharge summary and medication list indicating it should be started immediately for a diagnosed candida urinary tract infection. The medication order was not entered until two days after admission, and the resident did not receive the prescribed medication during that period. Interviews with nursing staff confirmed that there was no reason for such a delay, as medications are typically available promptly through the facility's pharmacy and automated dispensing system. The Director of Nursing (DON) acknowledged that the medication should have been started on admission and confirmed the order was not present until two days later. For two other residents, staff failed to implement physician orders for the use of an anchor device to secure PEG (percutaneous endoscopic gastrostomy) feeding tubes. Observations revealed that neither resident had an anchor device in place, despite active physician orders specifying that the feeding tube should be anchored every shift. Treatment administration records indicated that staff had documented the presence of the anchor device each shift, but direct observation contradicted these records. Interviews with nursing staff revealed a lack of awareness regarding the physician orders for anchor devices, and staff reported using tape and gauze instead of the ordered device. The DON was not aware of the specific orders and stated that the facility did not use anchor devices for PEG tubes at the time of the survey. Facility policies regarding physician orders and enteral feeding tubes were reviewed. The policy on physician orders required that all medication and treatment orders be recorded upon admission, but the process was not followed in these cases. The enteral feeding tube policy did not address the use of anchor devices. The deficiencies were discussed with facility leadership, and no additional information or documentation was provided to explain the failures to follow physician orders.
Delayed Initiation of Antifungal Medication Due to Failure to Transcribe Admission Order
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not transcribing a physician's order for an antifungal medication upon admission. The resident, who had been diagnosed with a candida urinary tract infection during a recent hospitalization, was discharged with an order to begin fluconazole 200 mg daily for thirteen days. Upon review, it was found that the order for fluconazole was not entered into the facility's system at the time of admission, resulting in a three-day delay before the medication was started. The medication was eventually initiated, but only after the delay was identified during a chart check by the unit manager. Interviews with nursing staff confirmed that there was no reason for such a delay, as medications are typically available in the facility's automated dispensing system or can be delivered by the pharmacy multiple times a day. The facility's policy requires that all admission physician orders, including medications, be recorded by a licensed nurse upon admission, but this process was not followed in this instance. The Director of Nursing confirmed that the medication should have been started as ordered and acknowledged the lapse in following the established procedure.
Failure to Maintain Accurate Clinical Records and Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three residents. For two residents with PEG tubes, staff signed off in the treatment administration record (TAR) that an anchor device was in place each shift, as required by active physician orders. However, direct observation revealed that no anchor or securing device was present for either resident. Interviews with nursing staff and the DON confirmed that anchors were not being used for PEG tubes, and staff were unaware of the physician orders requiring them. One LPN stated she believed she was signing off on the presence of a different device, not the anchor. The DON was not aware of the physician orders and acknowledged that orders should be followed if present. For a third resident who attended off-site dialysis three times weekly, the facility failed to document the resident's departures and returns for dialysis sessions in the clinical record. There was also no documentation of dialysis communication forms being uploaded into the clinical record, as required by facility policy. Review of the sign-out book and the dialysis communication book revealed no entries regarding the resident's dialysis appointments or communication with the dialysis center.
Failure to Serve Menu-Listed Dessert During Meal Service
Penalty
Summary
Facility staff failed to prepare and serve meals in accordance with the posted menu, as observed during the lunch meal service on 6/24/25. Specifically, the dessert item, apple crisp, listed on both the menu and individual meal tickets, was not prepared or served to residents on all four units. Instead, residents received mixed fruit as dessert. The dietary manager was present during meal service and allowed the substitution without verifying or correcting the omission at the time. Upon inquiry, the dietary manager confirmed that the apple crisp was not prepared because the cook was absent due to a call out and ran out of time. Facility policy requires that menus be served as written unless changes are made in response to resident preference, unavailability of an item, or for special meals. No such justification was documented for this substitution. The deficiency was brought to the attention of the facility administrator and DON during an end-of-day meeting.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
Facility staff failed to prepare and serve food at an appetizing and palatable temperature on one of four units, specifically the fifth floor. Observations revealed that food was transferred from the main kitchen to insulated transport boxes and then to the fifth-floor dining room, where it was placed in a steam table. Initial food temperatures were recorded upon arrival, but salads were not checked for temperature. Residents in the dining room received their meals, and trays were also prepared for distribution to resident rooms. Multiple residents expressed concerns that their food was not usually warm when received. When the last meal tray was served, temperatures of the food items on a test tray were taken and found to be below recommended serving temperatures, with items such as chicken, green beans, and macaroni and cheese being lukewarm or barely warm, and cold items like fruit cocktail and tea not being served at a cool temperature. The dietary manager confirmed that the food was not palatable. Facility policy requires prompt transportation of food to maintain appropriate temperatures, but this was not achieved during the observed meal service.
Failure to Provide Meals and Beverages According to Resident Preferences
Penalty
Summary
Facility staff failed to provide meals and beverages in accordance with residents' documented preferences and meal tickets for multiple residents. One resident, who requested a grilled chicken salad and milk for lunch, did not receive the requested items on his tray, and reported that this was a recurring issue. The dietary aide confirmed that meal tickets are supposed to reflect residents' likes and dislikes, and that all items listed should be served. Facility documentation indicated that meal tickets are intended to identify allergies, preferences, and special requests, but these were not consistently followed. Several residents in the dining room did not receive milk as indicated on their meal tickets, with some only being served tea despite specific instructions for milk and other beverages. One resident, who could not drink tea and was supposed to receive milk, did not receive it until prompted by the surveyor. The dietary manager acknowledged the issue and considered changing the process to ensure accuracy. The registered dietician was unable to provide a completed preference form for one resident, and other residents also reported not receiving their preferred beverages as documented in their food preference interviews and meal tracker forms. Another resident, who preferred oatmeal for breakfast, was served cold cereal instead, despite the meal ticket specifying oatmeal. The certified nursing assistant and unit manager confirmed that the resident should have received oatmeal, and the kitchen had it available, but no explanation was given for the error. Facility policy requires that food and beverage preferences be identified, documented, and followed, but these procedures were not adhered to, resulting in residents not receiving their preferred or requested meals and beverages.
Failure to Provide Beverages According to Resident Preferences and Meal Tickets
Penalty
Summary
Facility staff failed to provide beverages, specifically milk, in accordance with residents' meal tickets and preferences during meal service on two units. Observations revealed that multiple residents were not served milk as indicated on their meal tickets, despite milk being available in the dining room. Residents expressed their preferences and needs for milk, with some requesting it directly from staff and not receiving it. One resident required Lactaid milk, which was not available, and another resident stated a need for milk due to dietary restrictions and was not provided with any beverage options other than tea, which she could not consume. Staff interviews confirmed that meal tickets were intended to guide beverage service according to each resident's preferences and needs, including allergies and special requests. However, staff did not consistently follow these instructions, resulting in residents not receiving the beverages listed on their meal tickets. The dietary aide acknowledged that it was the responsibility of aides in the dining room to serve beverages as indicated, but this was not done. The dietary manager was made aware of the issue during the meal service and indicated a desire to change the process to ensure accuracy, but residents continued to go without the appropriate beverages during the observed meals. Facility documentation and policy stated that meal tickets should identify and accommodate residents' beverage preferences and that the registered dietitian or nutritionist would adjust meal plans as needed. Despite these policies, several residents did not receive the fluids specified on their meal tickets, including milk, coffee, or juice, and in some cases, only received tea or a single beverage option. These failures were observed and reported to facility leadership, with no additional information provided prior to the exit conference.
Deficient Food Storage and Dishware Handling Practices
Penalty
Summary
Facility staff failed to store, prepare, and distribute food in a sanitary manner in the main kitchen, as observed during a kitchen tour with the dietary manager. In the walk-in cooler, opened bags of green peas were not labeled with open or use-by dates, and some bags were left open to air. The dietary manager acknowledged that bags should be tied and boxes closed, and that dating is important for rotation. In the walk-in freezer, a pan of turkey meatloaf was inadequately covered with saran wrap, leaving food exposed and with ice build-up, and the dietary manager stated it would be discarded. Additional items, such as a bag of bread dough and fish filets, were found with holes or open to air, lacking labels or dates. Sausage patties and bacon were also found exposed and without identification. In the stand-alone coolers, garden salads and pitchers of juice were not labeled or dated, and the dietary manager confirmed the juice had been prepared for the meal. Facility policy and federal food codes require proper labeling, dating, and storage to prevent contamination, which was not followed in these instances. Additionally, staff were observed stacking stainless steel pans and meal trays while still wet, with standing water and moisture present, and significant food residue noted on some trays. The dietary manager confirmed that wet stacking can promote bacterial growth. Facility policy and federal food codes require that dishware be air-dried and properly stored after cleaning and sanitizing, which was not adhered to in this case. These findings were shared with the facility administrator and DON during an end-of-day meeting.
Infection Control Lapses During Meal Service and Failure to Use PPE for Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow proper infection prevention and control practices during meal service on two units. Observations revealed that certified nursing assistants wore the same gloves throughout the meal service, touching multiple surfaces and distributing food and beverages without changing gloves or performing hand hygiene. Additionally, a staff member placed clean table linens on the floor before placing them on dining tables, resulting in the linens coming into contact with the floor and then being used on tables. The soap dispenser in the dining room was not functioning, and hand sanitizer was not available in the area, further impeding proper hand hygiene. Interviews with staff confirmed awareness that gloves should be changed between tasks and that hand hygiene should be performed, but these practices were not followed. Staff also acknowledged that placing clean linens on the floor could cause cross-contamination. Facility policy documents reviewed stated that gloves should be changed between tasks, hand hygiene should be performed after glove removal, and linens should be handled in a way that prevents contamination. In a separate incident, a staff member from the therapy department failed to wear the required personal protective equipment (PPE) while providing direct care to a resident on enhanced barrier precautions. The staff member provided passive range of motion exercises wearing only gloves, despite signage and a bin of PPE outside the resident's room indicating that both gown and gloves were required. The staff member was unaware of the need for enhanced barrier precautions for this resident, who had physician orders for such precautions due to enteral feeding and wounds. Facility policy required the use of gown and gloves for high-contact care activities under enhanced barrier precautions.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by direct observations of multiple cockroaches in a resident bathroom and corroborated by staff and resident interviews. During a facility tour, a surveyor observed numerous cockroaches crawling on the bathroom floor of a dually occupied resident room, with a maintenance assistant confirming the infestation and noting that cockroaches emerged from the wall when disturbed. Residents reported ongoing issues with cockroaches and mice, describing the situation as an infestation that has worsened over time. Staff interviews further confirmed the presence of pests, and pest sighting logs from multiple units documented repeated sightings of cockroaches in resident rooms over several months. Review of facility documentation, including pest control logs and service reports from the pest control contractor, indicated that the facility was on a cockroach and rodent program, with regular treatments and bait stations in place. Despite these measures, both facility staff and the pest control contractor noted continued observations of cockroaches in resident rooms. The facility's pest control policy required monthly inspections and treatments, but the persistent presence of pests across all resident units demonstrated that the program was not effective in preventing or addressing infestations.
Failure to Notify Resident and Legal Representative of Medication Change
Penalty
Summary
The facility failed to notify a resident and the resident's legal representative of a medication change. The resident, who had a power of attorney appointing his wife as his legal representative and responsible party, was prescribed cyclobenzaprine, a muscle relaxer, on admission. The order was later revised to a 14-day duration. There was no documentation in the clinical record indicating that either the resident or his legal representative was informed of the initial medication order or the subsequent change. Staff interviews confirmed that the process for new medication orders requires nurses to inform the resident and, if applicable, the responsible party. The unit manager and DON both acknowledged that there was no evidence in the electronic health record that the resident or his responsible party were notified about the cyclobenzaprine order. Review of facility policies revealed that existing policies did not specifically address notification requirements for new or changed physician orders unless there was a significant change in condition.
Failure to Provide Written Notice and Reason for Resident Room Changes
Penalty
Summary
Facility staff failed to provide a resident with written notice and the reason for multiple room changes, as required by resident rights regulations. Clinical record review showed that the resident was moved between rooms on several occasions, but there was no documentation of written notification or the reasons for these changes in the nursing progress notes. While there was a note indicating verbal notification and consent for one room change, there was no evidence that written notice was provided for any of the moves. Additionally, staff interviews revealed that nurse managers and the admissions director could not explain the reason for at least one of the room changes, and the social worker confirmed that no written notification was given. The facility's policy on room transfers requires notification and documentation, but the records reviewed did not show compliance with these procedures. The resident was on a leave of absence during the survey and could not be interviewed. The clinical notes indicated that the resident was alert, verbally responsive, and had stable skin condition at the time of the moves. However, the lack of written notice and documentation of reasons for the room changes constituted a failure to honor the resident's rights.
Resident's Beard Shaved Without Consent, Violating Dignity and Choice
Penalty
Summary
Facility staff failed to honor a resident's right to self-determination and dignity by shaving off the resident's full beard without obtaining his consent. The incident occurred during a shower, when a certified nursing assistant began shaving the resident's mustache and beard despite the resident's attempts to stop her. The resident, who only has use of one arm, was unable to physically prevent the action and was observed to be very upset, anxious, and experiencing facial redness and razor burn following the incident. The resident expressed distress about the loss of his beard, which he had maintained for a long time, and reported discomfort from the razor burn. Interviews with staff revealed that the CNA applied aftershave lotion after shaving, and a LPN incorrectly stated that the resident's family had requested the beard be shaved off. However, the resident's sister clarified that she had only asked staff to keep the beard clean, not to remove it. Review of the clinical record showed no documentation of consent or refusal for shaving, and the resident's care plan did not reflect his grooming preferences. The nurse practitioner subsequently ordered hydrocortisone cream for the razor burn. Facility documentation confirmed the resident's right to be treated with respect and dignity, but this was not upheld in this instance.
Failure to Administer and Document Prescribed Medications
Penalty
Summary
Facility staff failed to administer prescribed medications to a resident as ordered by the physician. On the evening of 6/19/25, the resident's medication administration record (MAR) showed that scheduled doses of Atorvastatin Calcium and Apixaban were not documented as given, with the MAR left blank for the 9 p.m. administration. There were no progress notes or documentation in the resident's chart explaining the omission, and the resident was present in the facility at the time. The resident reported frequent issues with medication availability and administration, specifically mentioning pain medication. Interviews with facility staff, including the unit manager (RN) and the DON, confirmed that there was no evidence the medications were administered as ordered. The nurse assigned to the resident that evening was an agency nurse who no longer worked at the facility, and staff acknowledged that if medication administration is not documented, it is considered not done. Facility policy requires immediate documentation of medication administration, and review of the MAR at the end of each pass, but these procedures were not followed in this instance.
Failure to Ensure Timely Availability of Medications for Resident
Penalty
Summary
Facility staff failed to ensure that medications were available for administration to a resident, resulting in the resident not receiving a prescribed medication as ordered. Specifically, a resident reported frequent issues with medication availability, including pain medication. Review of the resident's clinical record and medication administration record (MAR) revealed that a scheduled dose of Fluticasone Propionate Suspension was not administered because it was not available. The MAR indicated the medication was 'on order,' and this was confirmed by both the unit manager (RN) and the director of nursing (DON) during interviews. The staff acknowledged the importance of timely medication administration and described the process for ordering medications when supplies are low. Facility policy requires that when a medication is unavailable, the nurse must notify the provider, discuss alternatives, activate the backup pharmacy process if needed, and document all notifications. The review found that the medication was not available as ordered, and the resident, as well as the provider and responsible party, should have been informed according to policy. The deficiency was confirmed through resident and staff interviews, clinical record review, and facility documentation.
Failure to Follow Infection Control Protocols for Glucometer Disinfection, Catheter Care, and Catheter Bag Positioning
Penalty
Summary
Staff failed to follow infection prevention and control standards in several instances involving multiple residents. During blood glucose monitoring, a registered nurse did not disinfect a multi-use glucometer with an approved EPA disinfectant between residents, instead placing the device back into the caddy without cleaning. On another occasion, the same nurse used the glucometer on a second resident without prior disinfection. When the glucometer was eventually cleaned, the nurse did not allow it to dry before storing it. Other staff members were observed using alcohol wipes, which are not approved by the manufacturer, instead of the required germicidal wipes. The facility's policy and the manufacturer's guidelines both require the use of germicidal wipes and adherence to specified drying times between uses on different residents. In another incident, a certified nursing assistant provided catheter care to a resident on Enhanced Barrier Precautions (EBP) without wearing the required personal protective equipment (PPE), including gown and gloves. The assistant also failed to use soap during catheter care, did not change gloves when moving from a dirty to a clean area, and did not perform appropriate hand hygiene. The assistant admitted to not following the correct procedures, and both a registered nurse and the director of nursing confirmed that the expected protocol was not followed for residents on EBP. Additionally, staff failed to maintain proper positioning of a urinary catheter bag for a resident, with the bag observed resting on the floor on multiple occasions. Facility policy requires that catheter bags be kept below the level of the bladder and off the floor to prevent infection. Interviews with nursing staff confirmed that the observed positioning did not meet infection control standards.
Removal Plan
- Residents who require blood sugar monitoring will have their glucometers cleaned after each use with the appropriate disinfectant that will kill bloodborne pathogens and kept out until the dry time has completed.
- Two glucometers will be placed in each nurses cart to allow for time in-between use to allow for proper disinfection.
- The Interdisciplinary Team will be educated by the Regional Director of Clinical Services on the facility policy for using glucometers to maintain infection control standards. This education will cover how to disinfect the glucometer after use on each patient and the required dry time to prevent the spread of bloodborne infections.
- All licensed nursing staff will be educated by the DON or designee on the glucometer cleaning policy per manufacturer guidelines to include the steps to take to use and disinfect after each patient.
- This education will be provided to agency nurses prior to starting with the facility.
- Any nurse who hasn't completed will be educated before the start of their next shift.
- The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the policy for the use of glucometers.
- DON or designee will monitor the procedure for disinfecting the glucometer between residents by random observations of glucometer usage/use five times per week for four weeks and weekly for four weeks.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Lack of Qualified Dietitian and Food Service Deficiencies
Penalty
Summary
The facility failed to employ a qualified dietitian or other clinically qualified nutrition professional, either full-time, part-time, or on a consultant basis, for a period of approximately three weeks. Observations and interviews confirmed that there was no qualified nutrition professional present during food preparation, and staff, including the head of the department and the corporate registered dietitian, acknowledged the absence. The registered dietitian from a sister facility only visited a couple of times per week to assist, but this did not fulfill the requirement for a qualified nutrition professional to oversee the food and nutrition service. Additionally, the facility did not ensure that food was served at palatable temperatures, as residents attending council meetings reported that their food was cold. The facility also failed to consistently offer drinks, including water and other liquids, to residents in accordance with their needs and preferences to maintain hydration. Furthermore, bread products stored in the kitchen were not properly dated, labeled, or covered, creating a potential environment for food-borne illnesses.
Failure to Properly Date, Label, and Store Food Products
Penalty
Summary
The facility failed to properly date, label, and store food products in accordance with professional standards and its own policy, which requires food to be stored in a manner that maintains quality and safety, including the use of first-in, first-out procedures and proper dating. During an inspection of the kitchen, surveyors observed dinner rolls and crescent rolls stored in the main refrigerator and on bread racks without proper labeling or dating, with some bread products left exposed to air in open packaging. In the dry goods storage room, multiple types of rice were found in large, open bags without dates. The Registered Dietitian confirmed that bread should be kept in closed packaging and dated when removed from refrigeration, and that rice should be stored in closed containers and dated after opening. The RD also acknowledged there was no schedule for checking food for dates or expired items.
Failure to Provide Dignified, Homelike Dining Experience and Use of Inappropriate Language
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and a homelike dining experience during meal service on one of four units. Observations showed that during both lunch and dinner, all residents in the dining room were served meals on trays, and staff did not remove plates, silverware, or cups from the trays to place them directly on the dining tables. This practice was confirmed by staff interviews, where CNAs stated that serving meals on trays and leaving them on the tables was standard practice, and they had not been instructed otherwise. One CNA also referred to a resident as a "feeder" while serving her meal, acknowledging later that this was inappropriate language to use in front of the resident. The Director of Nursing (DON) confirmed that staff should remove meal items from trays and place them in front of residents to create a homelike environment, and that the term "feeder" is not appropriate and staff are aware of this expectation. Review of the facility's meal delivery policy indicated that meal items should be removed from trays in group dining areas to the extent possible. The deficiency was identified based on observations, staff interviews, and policy review, with no additional information provided prior to survey exit.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper and appetizing temperatures for seven out of 46 sampled residents. During a resident council meeting, multiple residents complained that their meals were being served cold. When questioned, the Registered Dietician (RD) confirmed that there was no policy regarding food palatability and acknowledged receiving complaints about cold food. The RD also stated that she had not conducted any test trays at the facility to determine if food was being served hot and had not implemented any interventions to address the complaints. On the day of the survey, food temperatures were measured at the steam table and found to be within appropriate ranges. However, when a test tray was delivered to the unit as the last tray, the food temperatures had dropped significantly, and the food was found to be cold by both corporate dietitians present. The staff present could not explain the delay in food delivery, and no further information was provided before the survey exit.
Failure to Provide Milk with Meals as Indicated on Meal Slips and Menu
Penalty
Summary
The facility failed to provide drinks, specifically milk, with meals as indicated on residents' meal slips and the facility menu for multiple residents. On two consecutive days, twelve residents in the main dining room on Unit 2 did not receive milk with their lunch, despite it being listed on their meal slips and the menu. Residents confirmed that milk was not provided or offered, and this omission had occurred previously. The corporate registered dietician, present during one of the observations, confirmed the absence of milk and directed staff to provide it, noting that milk was available and should have been served according to the established meal plans. Additionally, a resident with multiple medical diagnoses, including diabetes and chronic kidney failure, was not provided milk as indicated on the meal ticket during two observed meals. The resident, who was cognitively intact, expressed concerns that meal items listed on the ticket were sometimes missing, specifically noting the absence of milk. Staff confirmed that milk should have been included and was available at the time. These findings were presented to facility leadership, and no further information was provided prior to the survey exit.
Failure to Document Administration or Refusal of Required Vaccinations
Penalty
Summary
The facility failed to provide required documentation regarding the administration or refusal of influenza, pneumococcal, and COVID-19 vaccinations for four out of five reviewed residents. Facility policies for each vaccine require screening for eligibility, offering the vaccine, and documenting either administration or refusal in the resident's medical record. However, for the residents reviewed, there was no documentation in the electronic medical record of vaccine administration or refusals by the resident or responsible party. Specifically, residents with a diagnosis of type two diabetes were admitted to the facility, but their immunization records lacked any evidence of receiving or refusing the influenza, pneumococcal, and, in some cases, COVID-19 vaccines. During an interview, the Infection Preventionist confirmed that there was no documentation of vaccine administration or refusals for these residents and described a process of checking state vaccination data, but no further information was provided prior to the survey exit.
Failure to Obtain and Document Resident Food Preferences Upon Admission
Penalty
Summary
The facility failed to obtain and document food preferences for one resident upon admission, as required by its own policy. The policy states that the Dining Service Director or designee must complete a Food Preference Interview within 48 hours of admission to identify individual preferences for dining location, mealtimes, and food and beverage choices. For the resident in question, who was admitted with a diagnosis of Guillain-Barre Syndrome and had no cognitive impairment, there was no evidence in the electronic medical record or care plan that food preferences were obtained or included. The care plan only addressed the risk for weight loss, malnutrition, and dehydration, but did not specify any dietary or food preferences. During interviews, the resident reported dissatisfaction with the food, stating he could not eat it and believed he had lost weight as a result. The Registered Dietician confirmed that dietary preferences had not been reviewed or implemented for this resident and that the care plan did not include such information. The RD also indicated that nursing staff had not communicated any dietary preferences to her, and no additional information was provided prior to the survey exit.
Resident Not Afforded Opportunity to Participate in Care Planning
Penalty
Summary
Facility staff failed to ensure that a resident was given the opportunity to participate in their ongoing treatment and care planning. Record review showed no evidence that the resident, who had diagnoses including dementia with behavioral disturbance, diabetes, depression, anxiety, and chronic kidney disease, was invited to participate in care planning discussions. The most recent MDS assessment indicated the resident was cognitively intact, with a score of 15 out of 15. During interviews, both the social worker and the director of social services were unable to provide documentation showing the resident's involvement in care planning, despite facility practice to invite residents to such meetings on admission, quarterly, annually, and upon significant change in status. The resident was not available for interview during the survey as they were on leave with family. No additional information or documentation was provided by staff prior to the exit conference.
Failure to Provide Scheduled Showers According to Resident Preference
Penalty
Summary
Facility staff failed to honor a resident's preference for twice-weekly showers, resulting in the resident receiving only one shower per week on most weeks. The resident, who was cognitively intact and had a medical history including femur fracture, osteoarthritis, chronic kidney disease, irritable bowel syndrome, gastroesophageal reflux disease, osteoporosis, anxiety, and depression, expressed during an interview that she was not receiving the two showers per week she preferred and was aware of the state requirement for this frequency. Clinical records confirmed that the resident was scheduled for showers on Tuesdays and Fridays, but documentation showed that showers were missed on two scheduled dates, with a ten-day gap between showers. Interviews with facility staff, including the CNA responsible for the resident and the RN unit manager, revealed that there was no documentation or explanation for the missed showers. The resident's care plan indicated a need for assistance with activities of daily living due to recent fracture and weakness following hospitalization. The deficiency was confirmed through review of clinical records and staff interviews, with no further information provided by facility leadership during the survey.
Failure to Obtain and Honor Resident Food Preferences Upon Admission
Penalty
Summary
The facility failed to obtain and honor the food preferences of a resident upon admission, as required by its own policy. The policy states that the Dining Service Director or designee must complete a Food Preference Interview with the resident or their representative within 48 hours of admission to identify individual preferences for dining location, mealtimes, and food and beverage choices. Review of the resident's records showed that this interview was not conducted, and no food preferences were documented for the resident. The resident, who was admitted with a diagnosis of Guillain-Barre Syndrome and had no cognitive impairment, reported that he had lost weight because he did not like the food and could not eat it. The Registered Dietician confirmed that no preferences were in place for this resident and that she had not been contacted by nursing staff regarding the resident's dietary needs. The care plan indicated the resident was at risk for weight loss or malnutrition, but the lack of documented food preferences meant his dietary needs and choices were not addressed.
Failure to Complete Personal Property Inventory Upon Admission
Penalty
Summary
The facility failed to ensure reasonable care for the protection of personal property for one resident. Upon admission, no personal property inventory form was completed for the resident, who had diagnoses including acute respiratory failure, diabetes, urine retention, chronic pain, and obstructive uropathy. The resident was assessed as cognitively intact and later reported missing a pair of ear pods, which he believed had been taken by staff approximately six months prior. He stated that he had reported the concern but could not recall to whom, and confirmed that no inventory list was filled out upon his admission. Review of the clinical record and the facility's inventory log book confirmed the absence of a personal property inventory for the resident. Interviews with staff, including an LPN and the director of clinical services, revealed that facility policy requires a belongings list to be created upon admission and maintained in a log book at the nurses' station. However, neither the medical record nor the log book contained an inventory list for the resident, and staff could not locate one despite searching. The facility's policy was reviewed and confirmed the requirement to complete a resident property list after advising the patient to send valuables and money home.
Failure to Notify DHP After Allegation of Sexual Abuse by RN
Penalty
Summary
The facility failed to implement its abuse policy by not notifying the Department of Health Professions (DHP) within 24 hours after receiving an allegation of sexual abuse involving a registered nurse (RN) and a resident. According to the facility's policy, any incident involving licensed or certified staff must be reported to the DHP within the specified timeframe. In this case, a resident reported that an RN engaged in excessive and unwanted touching during a wound care procedure, prompting the resident to verbally object and physically block the RN. The incident was documented, and referrals to psychological and social services were initiated, as well as notification to the police and physician. However, the required notification to the DHP was not made, as confirmed by the facility's Vice President of Operations during an interview.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence of thorough investigations into allegations of abuse and neglect for two residents. For one resident, who was cognitively intact and able to communicate clearly, an allegation of sexual abuse was reported involving a wound nurse. The resident described inappropriate touching during wound care and stated that her requests for the nurse to stop were ignored until she physically intervened. The facility's documentation showed that while the incident was reported to authorities and other residents were interviewed, there was no evidence that staff, including the alleged perpetrator, were interviewed as part of the internal investigation. Both the Director of Nursing and the Vice President of Operations confirmed that no interview with the alleged perpetrator was conducted or documented. In the second case, a resident with severe cognitive impairment and a primary language of Spanish experienced a fall during personal care. The care plan indicated the need for communication support and a low bed position as a fall prevention intervention. Documentation revealed that the resident fell out of bed while being assisted by a CNA, resulting in an abrasion. The nurse's note attributed the fall to noncompliance, but there was no clear evidence that language barriers or the resident's understanding were considered. The post-fall investigation lacked sufficient detail to determine the cause of the fall, and it was unclear if the care plan interventions were followed at the time of the incident. Interviews with staff indicated a lack of awareness of the resident's care plan interventions and insufficient investigation into the circumstances of the fall. The Director of Nursing acknowledged that the documentation did not adequately explain what happened and that more thorough questioning should have occurred. The facility's policies required comprehensive investigations and adherence to care plan interventions, but these were not fully implemented in either case.
Failure to Accurately Complete MDS Assessment for Significant Weight Loss
Penalty
Summary
A comprehensive Minimum Data Set (MDS) assessment was not completed accurately for one resident following their re-admission to the facility. The resident's admission MDS, with an Assessment Reference Date (ARD) of 02/19/25, indicated no cognitive impairment and did not document any weight loss in the nutrition section. However, review of the resident's progress notes written by the registered dietician on two separate occasions prior to the ARD showed significant weight loss over 30, 90, and 180 days, meeting the criteria for significant weight loss. During interviews, the MDS coordinator stated that weight change information is typically obtained through morning and weekly risk meetings, as well as daily review of the 24-hour report and physician orders. When presented with the findings, the MDS coordinator acknowledged being unaware of the significant weight loss and agreed it should have been documented on the MDS assessment. The Director of Nursing confirmed the expectation that staff should be knowledgeable about the MDS process and complete assessments accurately. The RAI Manual was referenced, emphasizing the need for accurate validation of resident status during the observation period.
Failure to Complete PASARR Level I Assessment on Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment for one resident who was readmitted with diagnoses of bipolar and major depressive disorder. Record review showed that there was no PASARR Level I assessment present in either the electronic medical record or the hard chart for this resident. During interviews, the Director of Social Services acknowledged not identifying the missing PASARR Level I at admission, and the Administrator confirmed that it was not completed at the time of admission. The Director of Nursing stated that the admissions director was expected to identify when a PASARR was missing and notify management, but this did not occur in this case. No additional information was provided prior to survey exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. For one resident with Guillian-Barre Syndrome and no cognitive impairment, the care plan did not address food preferences, despite physician orders for a regular diet with large portions and the resident's report of not liking the food and experiencing weight loss. The Registered Dietician confirmed that dietary preferences were not reviewed or included in the care plan as required. For another resident with hemiplegia, muscle weakness, and severe cognitive impairment, the facility did not implement a care-planned intervention to reduce fall risk. The care plan specified that the bed should be in a low position, but observations on multiple occasions found the bed was not in the low position while the resident was in bed. An LPN was unaware of the fall intervention, and the resident confirmed the bed was only lowered on the day of the survey. The Director of Nursing stated that care-planned interventions are expected to be followed every time.
Incomplete DNR Form Results in Invalid Advance Directive
Penalty
Summary
The facility failed to completely fill out a Durable Do Not Resuscitate (DNR) form for one resident. The DNR form, while signed by both the resident and the physician, was missing a required indication that the resident was capable of making the decision. According to the facility's policy, a DNR form that is not fully completed is not considered valid for withholding CPR. The resident involved was admitted with a diagnosis of spinal stenosis and had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating no cognitive impairment. The care plan documented the presence of an advance directive for DNR and stated that the resident's wishes would be honored. During an interview, the DON confirmed that the form was incomplete and that, as a result, the resident would be treated as a full code.
Failure to Follow Physician Order for Medication Dosage
Penalty
Summary
A nurse administered a 50 mg dose of Lyrica to Resident #103, despite a current physician order specifying a 25 mg dose to be given once daily for 30 days for the treatment of myalgia. The error occurred during a medication pass when the nurse selected the 50 mg capsule from an outdated medication supply card, rather than the newly prescribed 25 mg supply. The nurse acknowledged the mistake upon review, noting that the resident's order had been changed from 50 mg to 25 mg four days prior, but the previous supply was still available and mistakenly used. The clinical record did not contain any current order for the 50 mg dose, and the incident was confirmed through observation, staff interview, and record review.
Failure to Maintain Accident-Free Environment and Implement Fall Interventions
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not implement care-planned fall interventions for a resident with significant cognitive and physical impairments. The resident, who was severely cognitively impaired, Spanish-speaking, and had diagnoses including hemiplegia, hemiparalysis, and muscle weakness, was care planned for a low bed position to reduce fall risk. However, multiple observations revealed the resident's bed was not kept in a low position as required. Staff interviews confirmed a lack of awareness regarding the care plan intervention for a low bed, and the resident reported that the bed was only recently placed in a low position, indicating the intervention was not consistently followed. Additionally, after the resident experienced a fall during personal care, the facility did not conduct a thorough post-fall investigation to determine the cause. Documentation of the incident was insufficient, with staff unable to clarify whether language barriers or lack of interpreter support contributed to the fall. The Director of Nursing acknowledged that the incident report lacked adequate detail and that staff did not ask enough questions to identify the root cause. The facility's policy required a comprehensive post-fall investigation and revision of interventions, but this was not completed as outlined.
Failure to Maintain Safe and Functioning Bathroom Equipment
Penalty
Summary
Facility staff failed to maintain safe and functioning equipment, specifically a hand assist bar in a resident's bathroom that was not securely anchored to the wall. The resident, who had diagnoses including difficulty walking, dialysis, diabetes, chronic kidney failure, and peripheral vascular disease, was assessed as cognitively intact. The resident expressed concerns about the loose hand assist bar, stating it had been reported but not repaired. Observation confirmed the bar was loosely anchored and moved approximately two inches when pulled, scraping the wall. The maintenance director stated that a leadership team is responsible for daily room checks and reporting needed repairs, but upon review, there were no work orders pending for the resident's room and the last recorded repair was unrelated. During a joint observation with the administrator and surveyor, the maintenance director confirmed the grab bar was not safe for use and acknowledged that a work order should have been placed. The findings were presented to facility leadership, with no additional information provided before the exit conference.
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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