Colonnades Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlottesville, Virginia.
- Location
- 100 Colonnades Hill Drive, Charlottesville, Virginia 22901
- CMS Provider Number
- 495254
- Inspections on file
- 13
- Latest survey
- November 5, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Colonnades Health Care Center during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment regarding hot liquids, leading to incidents where two residents spilled hot coffee, with one requiring first aid. The facility did not consistently monitor coffee temperatures or assess residents' abilities to manage hot liquids safely. Staff interviews and records indicated a lack of proper monitoring and assessment, contributing to the deficiency.
The facility failed to protect residents from abuse, with incidents involving rough treatment by a CNA leading to psychosocial harm for a resident. Reports of abuse were inadequately documented and investigated, with the facility's policies on abuse prevention and reporting not followed. The lack of proper documentation and follow-up on reported incidents resulted in immediate jeopardy and substandard quality of care.
The facility failed to protect residents from abuse, resulting in immediate jeopardy and substandard care. A resident reported rough treatment by a CNA, but the facility did not document or investigate the allegations promptly. The CNA continued to work with residents, and another resident also reported rough treatment, which was not adequately followed up. The facility's abuse prevention policy was not followed, leading to serious deficiencies.
A resident experienced a significant medication error when an antibiotic order was delayed due to a system error that sent the prescription to the wrong pharmacy. The resident, with a complex medical history, missed multiple doses of Cephalexin, which was critical for their treatment. The facility's process for handling medication orders from the hospital was flawed, leading to a delay in delivery and administration.
A resident had unsecured eye drops at the bedside without authorization for self-administration, and a medication cart containing various medications was left unlocked and unattended in a hallway. Additionally, expired Tuberculin Purified Protein vials were found in the medication storage room, not discarded according to FDA guidelines. These deficiencies were noted during a survey and reported to the facility's administration.
The facility was found to have deficiencies in food storage and handling, with expired food bins accessible for distribution and improper glove use by a CNA in the dining room. The dietary manager acknowledged the oversight, and the CNA admitted to not changing gloves, contrary to the facility's infection control policy.
The facility failed to involve direct care staff, residents, and families in the development of its facility assessment. The assessment, updated in May 2024, was completed by administrative and management staff without input from these groups. The facility's policy did not address their involvement, and the administrator confirmed that residents and families were not included due to cognitive impairments. This deficiency was highlighted during a meeting where regulatory changes were discussed.
The facility failed to maintain accurate clinical records for residents, leading to deficiencies in documenting falls and injuries. A resident experienced multiple falls with significant injuries, but the records lacked detailed descriptions and interventions. Another resident had several falls requiring emergency care, yet the records were insufficient. Additionally, an injury of unknown origin was not documented for a resident, despite being reported. These issues indicate a pattern of inadequate documentation affecting resident care.
The facility failed to provide COVID-19 vaccination and education to four residents and three staff members. Residents had signed consent forms, but vaccines were not administered, and there was no documentation of education for staff. The DON admitted to oversight in the immunization process, and the facility lacked evidence of staff education, violating regulatory requirements.
The facility failed to provide mandatory QAPI training to five staff members, including CNAs, an LPN, and an RN. Despite using computer-based training and maintaining a training calendar, none of the employees received QAPI training in 2023 or 2024. Additionally, QAPI meetings were held only with management-level staff, excluding broader staff participation. The deficiency was identified during a survey, and the facility was informed of the findings.
The facility failed to implement its QAPI policy and abuse policy regarding an allegation of abuse and injury of unknown origin for a resident. The facility did not monitor abuse allegations during QAPI meetings, and staff failed to report and investigate a resident's abuse allegation timely. The resident reported rough handling by staff, resulting in bruising, but the incident was not documented or reported to the required agencies until after surveyor intervention.
A resident with dementia receiving psychotropic medication lacked a comprehensive care plan addressing their behavioral health needs. The plan did not specify targeted behaviors, measurable goals, or non-pharmacological interventions. The acting DON noted behaviors such as agitation and hallucinations, but the care plan only addressed elopement risk, failing to meet the facility's policy requirements.
A resident received an incorrect insulin dosage due to a failure to clarify a physician's order. The resident was supposed to receive 86 units of Tresiba, but the MAR indicated 88 units of Lantus Solostar were administered. The discrepancy was not questioned by staff, and the error was confirmed as a typographical mistake by the pharmacy. The attending physician noted no adverse effects on the resident's blood sugar levels.
A facility failed to implement non-pharmacological interventions for pain management for a resident with chronic pain and other medical conditions. Despite being prescribed Oxycodone, there was no documentation of alternative pain management strategies being used prior to medication administration. The DON confirmed that staff should document such interventions, as outlined in the facility's Pain Management Program.
A resident with dementia did not receive individualized care at the facility, as her care plan lacked specific goals and interventions tailored to her needs. Despite experiencing multiple falls and displaying behaviors such as hallucinations, the facility did not implement non-pharmacological interventions or monitor her condition effectively. Interviews with staff revealed a lack of monitoring and absence of a dementia care policy.
A resident receiving psychotropic medications showed symptoms of tardive dyskinesia, yet the facility failed to act on pharmacy recommendations for a gradual dose reduction. Despite multiple recommendations, there was no documented response from the medical provider, and the facility's policy requiring timely action on such recommendations was not followed.
The facility failed to ensure gradual dose reductions and proper documentation for psychotropic medications in several residents. One resident was on a psychotropic medication for 22 months without dose reduction attempts, another received Haldol beyond the 14-day PRN limit without proper documentation, and a third resident's antidepressant use was not monitored as required. These deficiencies highlight lapses in medication management and documentation.
The facility failed to provide timely physician-ordered rehabilitative therapy services to three residents with cognitive impairment. Despite having active orders for therapy evaluations, these residents were not assessed due to the therapy department prioritizing outpatient cases. An LPN indicated that therapy orders should be executed the same day, but the therapy director admitted to delays, placing skilled care residents lower on the priority list.
A resident's power of attorney requested copies of the resident's clinical record, but the facility staff delayed fulfilling the request for over six weeks. The medical records employee was unaware of the request, and the social worker confirmed the delay. The facility's policy requires records to be provided within two business days, but this was not followed.
The facility failed to report allegations of abuse and injuries of unknown origin involving two residents. A resident reported staff being rough, resulting in bruising, but the facility did not document or report it promptly. Another resident's skin tear was not investigated or reported as an injury of unknown origin. The facility's policy mandates reporting such incidents, but it was not followed in these cases.
The facility failed to thoroughly investigate abuse allegations involving a CNA and three residents, as well as an injury of unknown origin for another resident. Despite reports of rough treatment and skin tears, the investigation was incomplete, lacking interviews with other potentially affected residents and documentation of findings. The facility's response to the incidents was inconsistent and did not adhere to their policies on abuse prevention and investigation.
The facility staff failed to follow physician orders for two residents, resulting in medication administration errors. An LPN administered an incorrect dosage of vitamin D3 to one resident, while another resident's medication orders, including Tramadol and KDur, were not implemented as prescribed. The DON suggested a possible delay due to lab work, but no documentation supported this. The facility lacked a policy on physician orders.
Failure to Ensure Safe Management of Hot Liquids
Penalty
Summary
The facility staff failed to ensure the environment was free of accident hazards, specifically regarding the management of hot liquids, which affected multiple residents. Two residents, identified as Resident #105 and Resident #109, experienced incidents where they spilled hot coffee onto their laps. Resident #105 required first aid intervention due to redness on the thighs, while Resident #109 spilled lukewarm coffee and sustained no injury. The facility did not have a consistent system in place to monitor the temperatures of hot liquids being served, and residents' abilities to manage hot liquids were not assessed. Observations revealed that the coffee temperature was not consistently monitored, and the facility's dietary staff did not record or monitor the temperature of hot liquids during each meal. The coffee machine's temperature was initially set too high, and the dietary staff confirmed that they did not cool down the coffee before placing it in the lobby. The facility's documentation showed multiple omissions in the meal service temperature logs, indicating a lack of proper monitoring. Interviews with staff and review of clinical records indicated that Resident #105 had previously been identified with self-feeding issues, prompting a physician order for lightweight mugs. However, the facility failed to assess residents for their ability to manage hot liquids safely, particularly those with cognitive or visual impairments. The facility's interim administrator and DON acknowledged the deficiency and initiated a performance improvement plan, but the plan was still in process and had not been completed at the time of the survey.
Removal Plan
- Residents were assessed for hot liquid safety and referred to Occupational Therapy.
- Director of Nursing will conduct an assessment of all current residents for accident hazards such as risk of burns from hot liquids.
- Residents identified at risk; nursing will initiate a care plan with interventions to mitigate hazards such as risk of burns from hot liquids.
- Residents identified at risk will be evaluated by occupational therapy.
- Director of Nursing will educate all team members on hazards such as the risk of burns from hot liquids and appropriate serving temperature prior to being permitted to work.
- Dietary manager will educate dietary team members on the importance of completing and documenting temperatures on hot liquids during each meal prior to being permitted to work.
- New admissions will be assessed for hazards such as risk of burns from hot liquids, with interventions initiated and a referral to occupational therapy.
- Hot beverage station located at the concierge's desk will be removed.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility staff failed to protect residents from abuse, resulting in multiple incidents involving four residents. Resident #5 and Resident #20 reported physical and verbal abuse by a certified nursing assistant (CNA1), who was described as rough during care. Resident #20 experienced psychosocial harm and reported feeling intimidated and dehumanized by the CNA's actions. Despite these reports, the facility's documentation was inadequate, with no records of the abuse allegations or interviews in the residents' clinical records. The facility administrator and social service director failed to conduct a thorough investigation, and the allegations were initially deemed unsubstantiated. Resident #7 reported rough treatment by staff, which was not properly documented or reported to the required agencies. The acting director of nursing (DON) was informed of the allegation by a surveyor but failed to follow up appropriately. The administrator was aware of the situation but did not ensure that the allegation was reported or investigated. Additionally, Resident #177 sustained a skin tear, and a staff member reported rough treatment by CNA1, but the incident was not investigated or documented properly. The anonymous staff member who reported the incident received a dismissive response from the administrator. The facility's failure to report and investigate these allegations of abuse led to the identification of immediate jeopardy and substandard quality of care. The facility's policies on abuse prevention, reporting, and investigation were not followed, and staff members were not adequately trained or informed about their responsibilities as mandated reporters. The lack of documentation and follow-up on reported incidents contributed to the facility's inability to protect residents from abuse and neglect.
Removal Plan
- The administrator and current on shift skilled team members will be educated by the regional director of resident care/designee to prevent, protect, respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy.
- The administrator will complete a facility reportable incident for an allegation of abuse of Resident #7 to required agencies.
- The administrator and/or designee will interview resident #7 and have a nurse complete a physical assessment.
- An assessment will be conducted for current residents in skilled nursing by the administrator and/or designee who are alert and oriented for safety and care concerns in the community to include abuse.
- The administrator and/or designee will place additional signage around the community advising of the abuse coordinator and grievance coordinator.
- The regional director of resident care and/or the acting director of nursing will re-educate all skilled team members on how to prevent, protect, and how to respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy. All skilled team members will be trained prior to them being able to work.
- Any concerns identified will be addressed as per our policy and procedures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to effectively administer its resources to ensure residents were free from abuse, leading to immediate jeopardy and substandard quality of care. Resident #20 reported being treated roughly by a certified nursing assistant (CNA1), which was communicated to the social worker. Despite the report, there was no documentation of the abuse allegation in the resident's clinical record. The social service director confirmed the rough treatment allegations from both Resident #20 and her roommate, Resident #5. However, the facility administrator did not take immediate action to protect the residents or initiate an investigation, allowing CNA1 to continue working with the residents. The facility's administration was further questioned about the lack of documentation and timely reporting of the abuse allegations to regulatory agencies. The administrator admitted that not all nursing staff had received the necessary education on abuse prevention. The MDS coordinator had reported the abuse allegations to the administrator, but CNA1 continued to provide care until the following day. The facility's failure to remove CNA1 immediately after the initial report allowed the potential for further abuse. Additionally, Resident #7 reported rough treatment by staff, which was not documented in her clinical record. The director of nursing was informed of the allegation but did not follow up adequately. The administrator, who was also the abuse coordinator, failed to report the incident as an abuse allegation, instead reporting it as an injury of unknown origin only after being questioned by the surveyor. The facility's policy on abuse prevention and reporting was not followed, contributing to the identification of immediate jeopardy and substandard quality of care.
Medication Error Due to Pharmacy Order Miscommunication
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically involving the administration of an antibiotic. The resident, who had a history of Parkinson's, recurrent falls, and other medical conditions, returned to the facility from the hospital with a prescription for Cephalexin to be taken four times daily. However, the medication was not administered as prescribed, resulting in a two-day delay and multiple missed doses. The medication administration record (MAR) indicated that the antibiotic was pending delivery, and the order was discontinued before the full course was completed. The deficiency was further compounded by a system error where the order was mistakenly sent to a local retail pharmacy instead of the facility's contracted pharmacy. This error was not immediately identified, leading to a delay in the delivery of the medication. Interviews with the nursing staff revealed that the facility's process for handling medication orders from the hospital involved entering the orders into the computer system, which then sent them to the pharmacy. However, due to the system defaulting to the wrong pharmacy, the order was not filled in a timely manner. The facility's Director of Nursing (DON) acknowledged the issue and noted that the system sometimes defaults to the retail pharmacy, which contributed to the delay. The DON also confirmed that there was no specific policy regarding physician orders, although the expectation was that orders be carried out as given by the doctor. The attending physician was informed of the delay and indicated that the duration of the antibiotic course would need to be extended to ensure the resident received all prescribed doses.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility staff failed to ensure the secure storage of medications for one resident, identified as R128, who had eye drops at the bedside that were not secured. The eye drops, labeled as Carboxymethylcellulose Refresh 1%, were obtained from a hospital and were not authorized for self-administration by the resident, as there was no documentation in the resident's care plan indicating the ability to self-administer medications. Interviews with the nursing staff revealed a lack of clarity regarding the process for evaluating a resident's capability to self-administer medications and the proper storage of such medications. Additionally, the facility staff did not secure a medication cart containing over 75 cards of medications, which was left unattended and unlocked in a hallway. The cart contained various medications, including pain medications, vitamins, and syringes with needles. The surveyor observed multiple staff and residents passing by the cart, posing a risk of unauthorized access to the medications. The nurse responsible for the cart was unaware of how it became unlocked and confirmed that no one else had keys to access it. Furthermore, the facility staff failed to discard expired medications in the medication storage room. Two multi-dose vials of Tuberculin Purified Protein were found in the refrigerator, both past their open dates, with one vial being expired for over 30 days. The facility's policy on medication storage did not address the specific expiration guidelines for these vials, and the staff did not adhere to the FDA's recommendation to discard the vials after 30 days of being opened. These deficiencies were brought to the attention of the facility administrator and director of nursing during an end-of-day meeting.
Deficiencies in Food Storage and Sanitary Practices
Penalty
Summary
The facility was found to have deficiencies in food storage and handling practices. During an inspection of the main kitchen, four large food bins containing rice, flour, sugar, and bread crumbs were labeled with expired dates and were accessible for distribution. The dietary manager acknowledged the oversight, indicating that either the bins were not relabeled when new food was added or the food was indeed expired. The facility's policy on food storage mandates that all food items be labeled, dated, and rotated to maintain a First In First Out system, and expired food should be discarded. This policy was not adhered to, leading to the potential distribution of expired food items. Additionally, the facility staff failed to maintain sanitary practices in the dining room. A certified nursing assistant (CNA) was observed wearing the same pair of gloves while performing various tasks, including repositioning residents, rearranging chairs, touching cabinets, and serving food, without changing gloves or performing hand hygiene. The CNA admitted to not changing gloves but acknowledged the need to do so. The facility's infection prevention and control program emphasizes the importance of hand hygiene and the proper use of gloves, stating that gloves are not a substitute for hand hygiene and should be changed after contact with a resident or the surrounding environment. This failure to follow proper glove use and hand hygiene protocols could lead to the spread of infection among residents.
Lack of Involvement in Facility Assessment Process
Penalty
Summary
The facility staff failed to ensure the active involvement of direct care staff, residents, resident representatives, and family members in the development of the facility assessment. The assessment, updated on May 23, 2024, and reviewed with the governing body on May 16, 2024, did not include input from these groups. The individuals involved in completing the assessment were the administrator, director of nursing, governing body representative, medical director, social services coordinator, resident assessment coordinator, and dietary services manager. This lack of involvement was confirmed during an interview with the facility administrator, who stated that the process primarily involved the DON and assistant director of nursing, and that residents and families were not involved due to the cognitive impairment of most long-term residents. The facility's policy titled "Facility Assessment Process" was reviewed and indicated that the facility uses an assessment tool to collect necessary information about residents' needs and the resources available to meet those needs. However, the policy did not address the involvement of direct care staff, residents, or families in the assessment process. During an end-of-day meeting on November 1, 2024, the facility administrator, management team, and corporate staff were informed of recent regulatory changes requiring such involvement, highlighting the deficiency in the current assessment process.
Inadequate Documentation of Falls and Injuries
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for several residents, leading to deficiencies in documenting falls and injuries. Resident R12 experienced multiple falls, some resulting in significant injuries, including a subarachnoid hemorrhage and parietal fracture. The clinical records for R12 did not include detailed descriptions of the falls, the resident's condition following the falls, or the facility's response and interventions. Despite requests from the survey team, the facility was unable to provide adequate documentation from the clinical records, and the details were only provided later in a separate document prepared by the resident assessment coordinator. Similarly, Resident R7 had eleven falls, some resulting in injuries that required emergency room visits. The clinical records for R7 also lacked detailed documentation of the falls, including contributing factors and interventions implemented to prevent recurrence. The survey team requested a timeline of R7's falls and interventions, but the initial documentation provided was insufficient. The resident assessment coordinator later provided a more detailed timeline, but these details were not found in the original clinical records. Additionally, the facility failed to document an injury of unknown origin for Resident R177. The resident had two skin tears that were not documented in the clinical record, despite being reported by a licensed practical nurse. The facility's documentation did not include an incident report or details of the injury, and the acting director of nursing acknowledged that such incidents should have been charted. These deficiencies highlight a pattern of inadequate documentation and record-keeping within the facility, affecting the care and safety of the residents.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility staff failed to provide education and offer COVID-19 immunizations to four out of five residents sampled for immunizations. Specifically, residents R7, R17, R76, and R20 did not have proper documentation or evidence of being offered education or the COVID-19 vaccine. R7 had a signed consent form dated 10/18/24, but the vaccine had not been administered by 10/31/24. R17 had a signed consent form dated 10/17/24, but the resident had not been immunized, and the form was incomplete regarding other vaccines. R76's records showed no information on COVID-19 immunization status, and R20 had a signed consent form dated 10/17/24, but the vaccine had not been given by 10/31/24. The Director of Nursing (DON) confirmed the oversight in the immunization process, stating that it was her first time managing this responsibility and that it was a work in progress. The DON explained that the social worker typically initiates the process by obtaining consents and that the facility had recently conducted a flu clinic. However, there was a lack of follow-up and documentation for COVID-19 vaccinations. The DON also admitted to not being familiar with the Virginia Immunization Information System (VIIS) portal, which could have been used to verify residents' immunization statuses. Additionally, the facility failed to provide evidence of COVID-19 immunization education for three staff members sampled, including an LPN, a CNA, and another employee. The general manager stated that Costco provided education, but there was no documentation to confirm that staff received this education. The facility's policy requires documentation of education regarding the benefits and potential risks of the COVID-19 vaccine, but this was not adhered to, leading to a deficiency in compliance with regulatory requirements.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five staff members, including certified nursing assistants, a licensed practical nurse, and a registered nurse. This deficiency was identified during a survey where the education and training records of these staff members were reviewed. The facility's general manager confirmed that all staff education was conducted through computer-based training using Relias, and a training calendar was maintained. However, the review of the training records revealed that none of the five employees had received QAPI training in 2023 or 2024, despite it being listed as mandatory in the 2023 training outline. Further investigation revealed that the facility's QAPI meetings were held monthly but only included management-level staff and the medical director, excluding other staff members. The facility administrator confirmed this practice and described the meetings as opportunities to discuss pertinent topics like fall prevention. However, the administrator did not provide evidence of QAPI training for the broader staff, which is a regulatory requirement. The surveyor informed the facility administrator and management staff of these findings, but no additional information was provided to demonstrate compliance with the mandatory training requirement.
Failure to Implement Abuse Policy and QAPI Procedures
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policy regarding abuse, as well as its abuse policy concerning an allegation of abuse and an injury of unknown origin for one resident. The facility did not communicate or monitor feedback of allegations of abuse during QAPI meetings as directed in their policy. Specifically, the QAPI meeting minutes from October 23, 2024, did not indicate that abuse allegations were monitored or discussed, which was confirmed by the facility administrator. For one resident, identified as Resident #7, the facility staff failed to implement their abuse policy by not reporting the allegation of abuse timely to the required regulatory agencies and failing to initiate an investigation. The resident reported that staff were rough when assisting her, which was corroborated by bruising on her wrist. Despite this, there was no documentation regarding the bruising, and the acting director of nursing (DON) did not follow up adequately on the resident's statement. The DON's interview revealed a lack of proper investigation and documentation of the incident. The facility's administrator was unaware of any abuse reports in process and acknowledged that the resident's allegation had not been reported to the required agencies. The facility's policy mandates that all team members report known or suspected abuse to local and state authorities, but this was not adhered to in the case of Resident #7. The failure to report and investigate the allegation was only addressed after the surveyor's intervention, highlighting a significant lapse in the facility's adherence to its abuse prevention and reporting policies.
Inadequate Care Plan for Resident's Behavioral Health Needs
Penalty
Summary
The facility staff failed to develop a comprehensive care plan for a resident with dementia, who was receiving psychotropic medication for behavioral health needs. The care plan did not specify the targeted behaviors being treated with the medication, nor did it include measurable goals or a projected reduction/endpoint for the medication. Additionally, the care plan lacked documentation of the resident's behaviors that required management by psychotropic medication and did not list any non-pharmacological interventions for staff to use when providing care in the presence of these behaviors. During interviews, the acting Director of Nursing (DON) acknowledged that staff should be monitoring and documenting the resident's behaviors. The DON described the resident's behaviors as including agitation, aggression, hallucinations, delusions, and unusual behavior such as pushing away aides. Despite these observations, the care plan only noted the resident as an elopement risk and wanderer, with interventions that did not address the specific behaviors or the use of psychotropic medication. The facility's policy on individualized care plans requires the interdisciplinary team to develop comprehensive plans addressing the resident's most acute problems, including behavioral health care needs, which was not adequately done in this case.
Failure to Clarify Insulin Dosage Order
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice for a resident, identified as R102, by not clarifying a physician's order for insulin administration. The resident was admitted to the facility following an acute care hospitalization with discharge orders to receive Tresiba FlexTouch insulin at 86 units nightly. However, the facility's medication administration record (MAR) indicated that Lantus Solostar was being administered at 88 units nightly. A fax from the pharmacy recommended a therapeutic interchange to Lantus Solostar at 86 units, but the MAR showed a discrepancy with 88 units being administered. This inconsistency was not questioned by the nursing staff, and the Assistant Director of Nursing Services (ADNS) acknowledged that the pharmacy enters therapeutic interchange orders into the electronic health record. Interviews with the attending physician and the facility's contracted pharmacy confirmed that the correct dosage should have been 86 units, and the 88 units was a typographical error. The attending physician noted that the difference in dosage did not pose a significant risk to the resident, as their blood sugars were not adversely affected. However, the failure to clarify the insulin order was acknowledged by the facility's interim administrator and director of nursing, who confirmed that the nurses should have followed professional standards by seeking clarification. The report highlights a lapse in following proper procedures for medication administration, as outlined in the Lippincott Manual of Nursing Practice, which emphasizes the importance of questioning incomplete or incorrect medical orders.
Failure to Implement Non-Pharmacological Pain Management
Penalty
Summary
The facility staff failed to implement non-pharmacological interventions for pain management for a resident who required such services. The resident, who had diagnoses including post-surgical hip repair, chronic kidney disease, major depression, and chronic pain, was assessed as cognitively intact with a score of 12 out of 15 on the MDS. Physician orders indicated that the resident was prescribed Oxycodone for severe pain, and the medication administration record showed that the resident received Oxycodone on three occasions. However, there was no documentation of non-pharmacological interventions being used prior to administering the medication. During an interview, the DON acknowledged that staff should be using and documenting non-pharmacological interventions before administering pain medication, but the progress notes did not reflect this practice. The facility's Pain Management Program also emphasized the use of multiple non-drug therapies to meet residents' individual needs, with all interventions to be evaluated and documented similarly to medication therapy. The deficiency was presented to the administrator and general manager, but no additional information was provided before the exit conference.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility staff failed to provide appropriate dementia care with individualized interventions for a resident diagnosed with unspecified dementia. The resident, who was hard of hearing and had impaired vision, did not have a care plan that included specific goals or approaches tailored to her needs. The care plan lacked guidance on how to address the resident's behaviors, such as verbal aggression and hallucinations, and did not consider internal or external triggers related to her sensory impairments. Additionally, the care plan did not include non-pharmacological interventions or meaningful activities based on the resident's preferences and routine. The resident experienced 11 falls in 2024, some resulting in significant head injuries requiring hospital visits, yet there were no interventions in place to address these incidents. Interviews with facility staff revealed a lack of monitoring for behaviors and side effects related to the resident's dementia care. The facility also did not have a policy regarding dementia care, as confirmed by the facility administrator. The acting director of nursing acknowledged the need for routine monitoring of behaviors and resident-specific approaches, but no evidence of such practices was found in the resident's records.
Failure to Respond to Pharmacy Recommendations for Medication Dose Reduction
Penalty
Summary
The facility staff failed to respond to a medication regimen review and recommendations from the pharmacy for a resident receiving two psychotropic medications. The resident, who was observed to have symptoms indicative of tardive dyskinesia, was receiving Buspirone for anxiety and Remeron for major depressive disorder. Despite pharmacy recommendations for a gradual dose reduction (GDR) of these medications, there was no documented response or action taken by the facility's medical provider. The pharmacy had made recommendations on two occasions, suggesting a dose reduction or documentation of contraindications, but the forms remained blank with no physician response. Interviews with the acting Director of Nursing (DON) and the physician revealed a lack of communication and documentation regarding the pharmacy's recommendations. The DON indicated that the process of handling pharmacy recommendations was still being worked out, and the physician admitted to not having documented any rationale for not attempting a dose reduction. The facility's policy requires that medication regimen review recommendations be acted upon within 30 days, but this was not adhered to in this case. The deficiency was discussed with the facility administrator and management staff, but no additional information was provided to address the issue.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure a gradual dose reduction for a resident who was on a psychotropic medication for 22 consecutive months. The resident was observed to have symptoms indicative of tardive dyskinesia, prompting further investigation into their medication regimen. Despite pharmacy recommendations for a dose reduction, there was no evidence that these were reviewed or addressed by the physician. The physician admitted to not documenting the rationale for not attempting a dose reduction, which is required by the facility's policy. Another resident was found to be receiving an antipsychotic medication, Haldol, beyond the 14-day limit for PRN orders without appropriate clinical indication documented. The facility staff also failed to monitor and document the resident's behaviors and side effects associated with the use of Haldol. Interviews with hospice and facility staff revealed a lack of communication and documentation regarding the necessity and monitoring of the medication, despite the resident experiencing multiple falls and injuries. Additionally, the facility failed to document the assessment and monitoring of an antidepressant medication for a third resident. The physician's order required monitoring for side effects, mood, and behavior, but the necessary scheduling details were not completed, resulting in a lack of documentation. The DON acknowledged the oversight, which led to the resident not being properly assessed as required by the facility's policy.
Failure to Provide Timely Rehabilitative Services
Penalty
Summary
The facility staff failed to provide physician-ordered rehabilitative therapy services to three residents with a BIMS score of 12 or less, indicating cognitive impairment. These residents had active physician orders for therapy evaluations dating back to December 23, 2024, but had not been evaluated by the therapy department as of January 8, 2025. The delay in providing these services was attributed to the therapy department's focus on a large outpatient caseload, which took precedence over the skilled care residents. Interviews with facility staff revealed a breakdown in the process of executing physician orders. A Licensed Practical Nurse (LPN) stated that therapy orders should be communicated to the therapy department and carried out the same day they are given. However, the therapy director admitted that the skilled care residents were not prioritized and were placed on a list based on the order date, leading to the delay. This oversight was acknowledged by the facility's interim administration, who were informed of the issue on the evening of January 8, 2025.
Delayed Response to Clinical Record Request
Penalty
Summary
The facility staff failed to respond timely to a clinical record request for a resident whose power of attorney requested copies of the resident's clinical record. The request was made on December 21, 2023, but the records were not received until February 3, 2024, resulting in a delay of over six weeks. During a closed clinical record review, no information was found regarding the request for clinical records being made. The medical records employee, who had been in the role for about two months, was unaware of the request and reported that the social worker had handled it. The social worker confirmed the request and provided documentation showing that the records were eventually shipped and received. The facility's policy, in accordance with 42 CFR 483.10(b)(2), requires that access to records be provided within 24 hours and copies within two business days, excluding weekends and holidays. However, the facility did not adhere to this policy, resulting in a significant delay. The findings were reviewed with the facility administrator, acting director of nursing, and corporate staff, but no additional information was provided.
Failure to Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility staff failed to report an allegation of abuse involving Resident #7 (R7) in a timely manner. R7 reported to a surveyor that staff were rough when assisting her, which was corroborated by bruising on her right wrist. Despite this, the facility did not document the bruising or report the allegation to the required agencies promptly. The acting director of nursing (DON) was informed of the allegation but did not take immediate action to report it, and the facility administrator was not initially aware of the situation. Additionally, the facility failed to report a skin tear on Resident #177 (R177) as an injury of unknown origin. An anonymous staff member reported the incident to the administrator, but no investigation was conducted, and the incident was not reported to the appropriate authorities. The administrator claimed to be unaware of the allegation, and no documentation was provided to show that an investigation had been conducted. The facility's policy requires all team members to report known or suspected abuse, neglect, or exploitation to local and state authorities. However, in both cases involving R7 and R177, the facility did not adhere to this policy, resulting in a failure to report and investigate the allegations of abuse and injuries of unknown origin in a timely and appropriate manner.
Inadequate Investigation of Abuse Allegations and Injury
Penalty
Summary
The facility staff failed to conduct a thorough investigation into allegations of abuse involving three residents. Two residents reported that a certified nursing assistant (CNA1) was rough during care, with one resident describing the treatment as being slapped with a washcloth. Despite these reports, the facility's investigation was inadequate, as it did not include interviews with other residents who might have been affected. The acting director of nursing only performed skin checks on the two residents who reported the abuse, and the social service director was unable to provide documentation of interviews with other residents who had previously complained about the CNA. The facility's documentation and interviews revealed inconsistencies and a lack of follow-through in addressing the abuse allegations. The administrator and other staff members were aware of the complaints, but the investigation was not comprehensive. The social service director documented interviews with the two residents but could not locate the documentation or recall the names of other residents who had complained. Additionally, the administrator's actions were inconsistent, as she initially stated that the abuse allegations were unsubstantiated, yet the CNA was terminated for her behavior. In a separate incident, the facility staff failed to investigate an injury of unknown origin for another resident who suffered a skin tear. A staff member reported the incident to the administrator, but there was no evidence of an investigation or determination of the cause of the injury. The facility's documentation did not mention the skin tear, and the administrator's response to the report was dismissive. Despite requests for evidence of an investigation, the facility did not provide any documentation, indicating a failure to adhere to their own policies on abuse, neglect, and exploitation prevention and investigation.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility staff failed to follow physician orders for two residents, leading to deficiencies in medication administration. For one resident, an LPN administered only one tablet of vitamin D3 25 mcg instead of the prescribed two tablets. This error was observed during a medication pass, and the LPN acknowledged the mistake upon review of the physician's order. The resident's clinical record confirmed the order for two tablets daily, and this issue was discussed with the facility's administration and nursing staff without further information provided. For another resident, the facility staff did not carry out physician orders for several medications, including Tramadol, KDur, and Fibercon. The physician had documented a plan to restart these medications, but the orders were not implemented as intended. The Tramadol order was never executed, and substitutions for KDur and Fibercon were delayed. The DON, who signed the order, suggested that the physician might have instructed her to wait for lab results, but no documentation of such a conversation or lab work was available. The facility lacked a policy regarding physician orders, and no additional information was provided before the survey concluded.
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Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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