Culpeper Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Culpeper, Virginia.
- Location
- 602 Madison Road, Culpeper, Virginia 22701
- CMS Provider Number
- 495279
- Inspections on file
- 24
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Culpeper Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to prevent verbal abuse involving three cognitively intact residents. In one case, a dietary staff member yelled, argued, slammed a door, and used profanity toward a resident. In another incident, an LPN yelled at two residents in the smoking courtyard, telling one to "shut up" after he intervened. These actions violated the facility's zero-tolerance policy for abuse.
Staff did not review or revise the care plans for three residents after incidents of verbal abuse by facility staff, despite written statements and investigations documenting the events. Interviews with the director of discharge planning/social services and a unit manager confirmed that care plans were not updated to reflect the abuse or any interventions, contrary to facility policy.
Staff did not provide or document medically related social services for three residents after incidents of verbal abuse by staff. In each case, the affected residents were not assessed for psychosocial needs, and no interventions or trauma-informed screenings were documented, despite facility policy and staff expectations that such follow-up should occur.
Staff did not document incidents of alleged verbal abuse involving three residents in their clinical records, despite collecting written statements and acknowledging that such events should be recorded. Interviews with the DON and other staff confirmed that allegations of abuse were not entered into the clinical records, contrary to facility policy.
A resident who was cognitively intact reported being yelled at, argued with, and subjected to profane language by a dietary staff member during dinner, resulting in feelings of disrespect. The incident was not followed by a documented psychosocial assessment or trauma-informed screening, and the director of social services was unaware of the event.
Facility staff did not fully document grievances or their resolutions, with numerous grievance forms missing key information such as names, room numbers, dates, and outcomes. The administrator confirmed that grievance documentation was incomplete and did not meet policy requirements, resulting in unresolved or untracked concerns.
A resident's family experienced a significant delay in obtaining the resident's medical records, despite providing required documentation and repeated follow-ups. The process was prolonged due to ongoing requests for additional documents and miscommunication between staff and the legal department, resulting in the records being released thirty-two days after the initial request.
The facility failed to provide adequate supervision for residents smoking and leaving the building. A resident requiring supervision for smoking was observed unsupervised in a non-designated area, while another resident with hemiplegia smoked unsupervised, resulting in a potential burn. Additionally, residents left the facility without proper notification or supervision, despite being moderately impaired or requiring assistance for ambulation. These failures led to Immediate Jeopardy and substandard quality of care findings.
The facility failed to address concerns raised by the resident council about missing clothing during meetings in May and June 2024. Despite documentation of these concerns, no grievances were filed, and there was no evidence of resolution. Staff interviews revealed a lack of communication and documentation, with the director of recreation admitting to not documenting grievances or resolutions. The facility's policy requires documentation and immediate notification of the administrator for urgent issues, but these procedures were not followed.
A resident with diabetes had multiple instances of blood sugar levels exceeding 400, as recorded in June and July 2024, without the physician being notified, contrary to the physician's order. The facility's RN confirmed the requirement to notify the physician and document the communication, but the clinical records lacked evidence of such actions, violating the facility's policy on significant changes in condition.
The facility staff failed to maintain a homelike environment and protect residents' property. During meals, trays and lids were left on tables, causing discomfort. Rooms of two residents were in disrepair, with blue tape and separated baseboards. A resident reported missing clothing over a year, with no resolution. The facility lacked policies for dining and maintaining a homelike environment.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in personal hygiene, oxygen therapy, physician notification for high blood sugar, pressure injury care, and use of splints. Observations and staff interviews revealed that care plans were not followed, resulting in unmet care needs for the residents.
The facility failed to administer an IV antibiotic as ordered for a resident, with six doses not evidenced as given, despite medication availability. Additionally, another resident did not receive timely care for a skin tear, as evidenced by dried blood on her Geri sleeve. Staff interviews revealed non-adherence to medication and wound care protocols.
A resident in a LTC facility experienced a significant medication error when Teflaro, an IV antibiotic, was not administered as ordered on six occasions. The MAR showed discrepancies, and some doses were incorrectly marked as unwitnessed self-administration. Interviews with LPNs revealed that the medication should have been administered promptly, and the facility's policy on the 5 Rights of medication administration was not followed.
The facility staff failed to maintain kitchen sanitation and proper temperature logs. Observations revealed food debris on the kitchen floor and missing freezer temperature checks. The food services manager cited staff shortages for incomplete logs and was unsure about the previous evening's cleaning. The facility's policy mandates frozen foods be stored at 10 degrees or below with daily temperature records, which were not adhered to.
Facility staff failed to follow infection control practices during medication administration for several residents, including improper cleaning of glucometers and handling of medications. Additionally, the facility did not communicate with the local health department during outbreaks of communicable diseases, as required by policy.
Two residents in a LTC facility were found with call bells out of reach, despite staff acknowledging the importance of accessibility. One resident, moderately impaired, was unaware of the call bell's location, while another, severely impaired, had the call bell hanging behind their head. Staff interviews confirmed the expectation for call bells to be within reach, but observations showed otherwise. The facility lacked a specific policy on call bell placement.
A facility failed to implement a baseline care plan for a resident with an Aspira drain within 48 hours of admission, as required by policy. The resident, admitted with cancer and other conditions, required maximum assistance for various activities. Despite the comprehensive care plan indicating the need for drain monitoring, the baseline care plan was not executed, as confirmed by staff interviews.
The facility failed to update care plans for two residents, leading to deficiencies in addressing their safety and preferences. One resident required supervision for smoking, but the care plan inaccurately allowed independent smoking, resulting in unsupervised smoking in an unsafe area. Another resident frequently left the facility independently to visit a local drug store, but the care plan did not address this preference or safety concern. Interviews with LPNs confirmed the need for care plan updates, as required by facility policy.
Three residents in an LTC facility were found with deficiencies in ADL care, specifically in personal hygiene and grooming. A resident with paralysis had untrimmed nails, another had dirty fingernails despite needing substantial assistance, and a third with upper extremity impairment had excessively long nails. Staff acknowledged the need for regular grooming, but observations indicated these standards were not met.
A resident with a stage two pressure injury on the sacrum was not properly monitored or documented by the facility staff. Despite treatment orders being in place, the staff failed to consistently document the size and stage of the wound, as required by facility policy. Interviews revealed a lack of proper documentation and tracking, even though the resident was being followed by a wound clinic.
A resident with traumatic brain dysfunction, seizure disorder, and diabetes mellitus was found with excessively long toenails, indicating a failure in providing appropriate toenail care. The resident, dependent on staff for personal hygiene, was supposed to receive toenail care from a podiatrist due to her diabetic condition. However, observations showed that her toenails were not maintained, leading to the deficiency being identified.
A resident with upper extremity impairment was observed without required hand splints on multiple occasions, despite care plan instructions. An LPN indicated that the splints should have been applied by the night shift, but they were not. Administrative staff were informed of the issue.
A resident with an indwelling catheter had their catheter bag improperly maintained, as it was observed touching the floor, contrary to facility policy. Interviews with a CNA and an LPN confirmed the importance of keeping the bag below the bladder and off the floor to prevent infection. The facility's policy also emphasized these practices, and the administrative staff were informed of the deficiency.
The facility staff failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. One resident received less oxygen than prescribed, while another was connected to an empty portable oxygen tank. Despite clear physician orders and facility policies, the staff did not adhere to the required oxygen administration protocols.
A resident continued to receive PRN Zyprexa despite a pharmacy recommendation to discontinue its use. The facility's process for handling pharmacy recommendations was not followed, as the nurse practitioner did not document a response, and the recommendation was not entered into the resident's chart. The facility's policy requires physician review within 30 days, which was not met.
A facility failed to ensure a resident was free from unnecessary psychotropic medication by not documenting the physician's evaluation for the continued use of Olanzapine. The resident, experiencing terminal delirium related to dementia, received the medication as needed, but the facility lacked documentation and a policy for as-needed antipsychotic medications.
Two residents in the facility had unsecured medications in their rooms. A bottle of Nystatin powder labeled for another resident was found in one resident's room, and an inhaler was left unattended in another's. Both medications should have been stored in the medication cart according to facility policy. The incidents were reported to the facility's leadership.
The facility failed to inspect bariatric beds for safety and entrapment risks for two residents. Observations revealed discrepancies between documented and actual beds in use, with no inspections conducted. The director of maintenance could not explain the oversight, despite facility policy requiring regular audits. Facility leadership was informed of the issue.
A floor technician at the facility did not complete the required QAPI training as part of their onboarding process. Although the training was scheduled to be added to their computer-based program, there was no evidence of completion. The facility's assessment and onboarding calendar indicated that QAPI training was part of the general orientation for all staff, but this was not confirmed for the technician.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
Facility staff failed to protect three residents from verbal abuse by staff members. One resident, who was cognitively intact as indicated by a BIMS score of 14, reported that a dietary staff member yelled at him, argued, slammed a door, and used profane language when he requested a sandwich. The staff member admitted to yelling and shutting the door but did not acknowledge wrongdoing. The incident was not initially reported to the unit manager, indicating a lapse in communication and immediate protective measures. Two other residents, both cognitively intact with BIMS scores of 14 and 15, experienced verbal abuse from an LPN in the facility's smoking courtyard. The LPN yelled at one resident to provide a urine sample and, when the other resident intervened, told him to "shut up" and continued to raise her voice. Both residents described the staff member's behavior as verbally abusive and rude, and their statements were consistent and corroborated each other's accounts. The facility's policy states zero tolerance for abuse, including verbal abuse, yet staff members engaged in yelling, use of inappropriate language, and disrespectful interactions with residents. The incidents were substantiated through resident interviews, staff interviews, and review of facility documentation, demonstrating that the facility did not ensure residents were free from verbal abuse as required.
Failure to Update Care Plans After Verbal Abuse Incidents
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for three residents following incidents of verbal abuse by staff members. For one resident, after reporting that a dietary cook yelled, argued, slammed a door, and used profane language, there was no documentation in the care plan reflecting the incident or any related interventions. The resident was cognitively intact, as indicated by a BIMS score of 14, and the incident was reported to the nurse practitioner, responsible party, and local police, with the staff member suspended. However, the care plan remained unchanged, and interviews with facility staff confirmed that care plans were not reviewed or updated after such incidents. Similarly, two other residents experienced verbal abuse from an LPN, including being yelled at and told to "shut up." Written statements documented these events, but reviews of their comprehensive care plans showed no evidence of review or revision following the incidents. Staff interviews further revealed a lack of understanding or adherence to the policy requiring care plan updates when changes in a resident's condition or circumstances occur, such as after abuse allegations. The administrator and director of nursing were made aware of these concerns, but no additional information was provided before the survey exit.
Failure to Provide Medically Related Social Services After Verbal Abuse Incidents
Penalty
Summary
Facility staff failed to provide medically related social services to three residents following incidents of verbal abuse by staff members. In one case, a resident with a high BIMS score, indicating intact cognitive function, reported being verbally abused by a dietary staff member. The resident expressed feeling disrespected and affected by the incident, and stated that no one had previously asked how the event made him feel. The director of discharge planning/social services was not aware of the incident and did not complete a psychosocial assessment or document any trauma-informed screening for the resident. For two additional residents, written statements documented that an LPN yelled at them and used inappropriate language. Despite these reports, there was no evidence in the clinical records that the residents' psychosocial status was assessed or that psychosocial interventions were implemented following the incidents. The director of discharge planning/social services confirmed that she did not complete a formal assessment or follow-up for these residents after the reported verbal abuse. Interviews with facility staff, including the director of nursing and other clinical staff, revealed an expectation that psychosocial assessments and follow-up with psychiatric or psychological services should occur after allegations of abuse. However, documentation and assessments were not completed as required by facility policy, which states that social work and discharge planning staff are responsible for identifying and assisting with patients' psychosocial and medically related social service needs.
Failure to Document Alleged Abuse Incidents in Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three out of five residents reviewed, specifically by not documenting incidents of alleged verbal abuse in the residents' clinical records. For one resident, who was cognitively intact as indicated by a BIMS score of 14, there was no clinical record documentation of an incident where the resident reported being verbally abused by a dietary staff member. Although the event was recorded in a facility synopsis and statements were obtained, the clinical record lacked any reference to the incident. Interviews with the director of nursing and the administrator revealed inconsistent practices and understanding regarding the documentation of such incidents in the clinical record, despite facility policy requiring accurate and complete records for each patient. Similarly, for two other residents, staff failed to document separate incidents of alleged verbal abuse by an LPN in their clinical records, even though written statements about the events were collected by facility staff. Interviews with nursing staff and the director of nursing confirmed that allegations of abuse should be documented in the clinical records, but this was not done. The lack of documentation was acknowledged by administrative staff during the survey, and no additional information was provided before the survey exit.
Failure to Treat Resident with Dignity During Verbal Altercation
Penalty
Summary
Facility staff failed to treat a resident in a dignified manner during a dinner service. The resident, who was cognitively intact as indicated by a BIMS score of 14 out of 15, reported that a dietary cook yelled at him, argued, slammed a door, and used profane language when he requested a sandwich. The incident was reported to the administrator, and the resident expressed that the event made him feel disrespected and affected him for some time. The resident also stated that no one had previously asked him how the incident made him feel. Interviews with staff revealed that the director of discharge planning/social services was not aware of the incident and did not document any psychosocial assessment or trauma-informed screening for the resident involved. The administrator confirmed that yelling at a resident is not treating them in a dignified manner. Facility policy states that residents have the right to be treated with dignity and respect. No documentation was provided to show that the resident's psychosocial needs were assessed or addressed following the incident.
Failure to Document and Resolve Grievances
Penalty
Summary
Facility staff failed to completely document grievances and the resolution of grievances as required by policy. Review of the Grievance/Concern Logs revealed multiple instances where essential information was missing, such as the first name of the person filing the concern, room number, unit, relationship to the resident, time received, staff title, and documentation of resolution. In several cases, there was no indication of who received the grievance, no date or time of the event, and no administrator review or signature. Some entries only noted that a concern was resolved without providing supporting details or outcomes, while others lacked any documentation of resolution or follow-up. During an interview, the administrator acknowledged that the grievance forms should be fully completed and that documentation of resolution is required. The facility's policy outlines that management staff are responsible for promptly responding to and resolving grievances, with specific procedures for documentation and follow-up in the electronic system. Despite these procedures, the logs reviewed showed consistent failures to document grievances and their resolutions, as well as lapses in administrative oversight and record-keeping.
Delayed Release of Medical Records to Resident's Family
Penalty
Summary
Facility staff failed to release the medical records of a deceased resident to the resident's family in a timely manner. The family initially requested the records and provided the necessary authorization and a copy of the death certificate. Despite repeated follow-ups and submission of additional documents, including a power of attorney and an affidavit as requested by the facility's legal department, the process was delayed due to ongoing requests for documentation and miscommunication between facility staff and the legal department. The records were ultimately released thirty-two days after the initial request. Interviews with staff revealed that the standard process involved forwarding requests to the legal department, which would then assign a case number and request any additional documents needed. Staff members were under the impression that records should be released within 30 days, but confusion regarding required documentation for deceased residents contributed to the delay. The family expressed dissatisfaction with the handling of the request, and staff acknowledged the delay was due to the legal department's repeated requests for documents and lack of clarity on the process.
Inadequate Supervision for Smoking and Leave of Absence
Penalty
Summary
The facility staff failed to provide adequate supervision for residents who were smoking and leaving the building, leading to several deficiencies. Resident #148, who was assessed as requiring supervision for smoking, was observed smoking in an outdoor garden area without staff supervision, a safe cigarette disposal receptacle, a fire blanket, or a fire extinguisher. Despite being cognitively intact, the resident's care plan inaccurately allowed for independent smoking, contrary to the Smoking Safety Screen assessment. Similarly, Resident #90, who had hemiplegia and was moderately impaired in decision-making, was observed smoking unsupervised in a non-designated area, with a hole in their t-shirt suggesting a potential burn from a cigarette. The facility also failed to supervise residents leaving the premises. Resident #97, who was moderately impaired in decision-making and required supervision for ambulation, was observed leaving the facility and crossing a busy street without a cane or staff supervision. Despite therapy recommendations for supervision during ambulation, the resident was not adequately assessed for safety during community outings. Resident #120, who was moderately impaired, frequently left the facility without notifying staff or signing out, despite the facility's policy requiring notification and documentation for leave of absence. The resident was able to ambulate safely but did not follow the required procedures for leaving the facility. Additionally, Resident #136, who was not cognitively impaired, was observed leaving the facility daily without signing out, despite being provided with a safety vest for visibility. The resident's care plan noted frequent leave of absence, but there was no evidence of an assessment to determine the resident's safety to leave independently. The facility's failure to implement and enforce its leave of absence policy and smoking supervision requirements resulted in Immediate Jeopardy and substandard quality of care findings.
Failure to Address Resident Council Concerns on Missing Clothing
Penalty
Summary
The facility staff failed to respond to concerns raised by the resident council during their meetings in May and June 2024 regarding missing clothing. Despite the documentation of these concerns in the resident council meeting notes, there was no evidence of any grievances filed or resolutions provided by the facility. The facility's grievance records from May 1, 2024, to the present did not show any grievances related to the missing clothing issue raised by the resident council. Interviews with staff members revealed a lack of communication and documentation regarding the concerns. The environmental service director was unaware of the concerns, and the director of recreation admitted to not documenting grievances or resolutions, although she claimed to have verbally communicated the issue to the director of environmental services and the administrator. The facility's policy requires documentation of council concerns and immediate notification of the administrator for urgent issues, but these procedures were not followed. The regional vice president of operations confirmed the absence of evidence for resolving the concerns.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility staff failed to notify the physician of a change in condition for a resident with diabetes, whose blood sugar levels exceeded 400 on multiple occasions. According to the physician's order dated April 15, 2024, the staff was required to contact the physician if the resident's blood sugar was greater than 400 or less than 60. Despite this directive, the clinical records for June and July 2024 showed several instances where the resident's blood sugar levels were above 400, yet there was no documentation indicating that the physician was notified. Interviews with the facility's registered nurse and administrative staff confirmed the oversight. The registered nurse acknowledged that the protocol required notifying the physician and documenting the communication in the resident's progress notes. However, a review of the resident's clinical records, including medication administration records and progress notes, revealed no evidence of such notifications. The facility's policy on significant changes in condition also mandates that a licensed nurse assess the patient and notify the provider, which was not adhered to in this case.
Deficiencies in Homelike Environment and Property Protection
Penalty
Summary
The facility staff failed to serve lunch in a homelike manner for three residents, as observed on a specific date. During the meal, staff left meal trays and plate lids on the tables, which the residents found uncomfortable due to limited space. Interviews with the residents confirmed their dissatisfaction with the arrangement, and a CNA acknowledged that this practice was not homelike and suggested that the trays and lids could be placed back on the meal carts during meals. The facility lacked a policy regarding dining, which contributed to this deficiency. In another instance, the facility staff failed to maintain the rooms of two residents in good repair. Observations revealed blue tape along the baseboards and electrical outlets, with portions of the baseboard separated from the wall, exposing dried adhesive. Interviews with the residents indicated that these issues had persisted for a long time without resolution. The maintenance technician confirmed the lack of open work orders for these repairs and acknowledged that the rooms did not appear homelike due to the visible tape and disrepair. Additionally, the facility staff failed to protect a resident's property from loss, as the resident reported multiple missing clothing items over the course of a year. Despite reporting the issue to various staff members, the resident's clothing was not found, and they were given lost and found clothing as a replacement. The facility's grievance logs did not document any grievances for the missing items, and interviews with staff revealed a lack of consistent procedures for addressing such issues. The facility's policy on personal belongings outlined steps for marking and storing items but did not ensure the protection of the resident's property.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to implement comprehensive care plans for several residents, leading to deficiencies in care. For Resident #89, the staff did not assist with personal hygiene as outlined in the care plan. The resident was observed multiple times with a brown substance under their fingernails, indicating a lack of proper hygiene care. Despite the care plan indicating the need for staff assistance with personal hygiene, there was no documentation of care refusal, and staff interviews confirmed that fingernails should be cleaned during daily care. Resident #13's care plan for oxygen therapy was not implemented correctly. The resident was observed with a nasal cannula attached to an empty portable oxygen tank, contrary to the physician's order for continuous oxygen at 2L/min. The LPN interviewed was unsure why the resident was on a portable tank in their room and acknowledged that the tank should not have been empty or set to zero. For Resident #106, the facility staff failed to notify the physician of blood sugar levels exceeding 400, as required by the care plan. The resident's medication administration records showed multiple instances of high blood sugar levels without documented physician notification. Additionally, Resident #86's care plan for pressure injury care was not followed, as there was inconsistent documentation of the sacrum pressure injury's measurements and stage. Lastly, Resident #56 was observed without the prescribed splints for their contractures, despite the care plan specifying their use for a set duration each shift.
Failure to Administer Medication and Provide Wound Care
Penalty
Summary
The facility staff failed to administer an IV antibiotic medication, Teflaro, as ordered for Resident #269 on six occasions. The medication was scheduled to be given three times a day, but there were multiple instances where doses were not administered, as evidenced by the Medication Administration Record (MAR). The facility's Regional Director of Clinical Services confirmed that a coding error in the system marked some doses as 'Unwitnessed self-administration,' which was not possible given the medication's route. Despite the availability of the medication, as confirmed by the pharmacy delivery manifest, there was no evidence that the doses were administered as ordered. Additionally, the facility staff failed to provide appropriate care for a skin tear on Resident #151's right arm. The resident was observed with dried blood on her Geri sleeve, indicating a lack of timely wound care. The resident reported that the blood had been there for more than a day, and the skin tear was possibly due to the wheelchair. The facility's Skin Observation Tool confirmed the presence of a skin tear, but there was no evidence of assessment, cleaning, or treatment of the wound as per the facility's protocol. Interviews with facility staff, including LPNs and administrative staff, revealed a lack of adherence to medication administration protocols and wound care procedures. The staff acknowledged that missed doses could impact treatment effectiveness and that proper wound care involves assessment, cleaning, and notifying the nurse practitioner. Despite being made aware of these deficiencies, no further information or corrective actions were provided by the facility before the survey's conclusion.
Significant Medication Error Due to Missed Doses
Penalty
Summary
The facility staff failed to prevent a significant medication error for one resident, who was cognitively intact and able to make daily life decisions. The resident was prescribed Teflaro, an intravenous antibiotic, to be administered three times a day. However, the medication was not administered as ordered on six occasions over a three-day period. The medication was available for administration, but there was no evidence that it was given at the scheduled times, resulting in a significant medication error. The MAR revealed discrepancies in the administration of Teflaro, with some doses marked as unwitnessed self-administration, which was not possible given the medication's route. Interviews with LPNs indicated that the medication should have been administered as soon as it was available, and any missed doses should have been communicated to the Nurse Practitioner. The facility's policy on medication administration, which includes the 5 Rights, was not followed, leading to the deficiency. The facility's administrative staff was made aware of the findings, but no further information was provided by the end of the survey.
Kitchen Sanitation and Temperature Log Deficiencies
Penalty
Summary
The facility staff failed to maintain the kitchen in a safe and sanitary manner, as observed during a survey. On the specified date, food debris such as crumbs, onion skins, lettuce, and paper were found on the kitchen floor. Additionally, there was a lack of documentation for freezer temperature checks, with no evidence of a second temperature check on one day and no morning check on the following day. During an interview, the food services manager acknowledged that the temperature logs were not completed as required at the beginning and end of each shift, citing staff shortages as a reason. The manager also admitted that the kitchen floor needed sweeping and was unsure if it had been cleaned the previous evening. The facility's policy requires that frozen foods be stored at a target temperature of 10 degrees or below, with daily temperature records maintained, but these procedures were not followed as per the observations.
Infection Control and Communication Failures
Penalty
Summary
The facility staff failed to implement proper infection control practices during medication administration for multiple residents. For Resident #45, the blood glucose glucometer was not cleaned before or after use, contrary to the facility's policy and the manufacturer's recommendations. The registered nurse (RN) involved acknowledged the oversight and admitted to using an alcohol swab instead of the recommended bleach wipes due to unavailability. This failure to adhere to infection control protocols was also observed with Resident #25, where the same RN did not clean the glucometer before or after use. In another instance, the RN used her fingers to handle medications for Resident #132, which is against the facility's medication administration policy. The RN was observed picking up a dropped medication with her fingers and placing it into a medication cup, which she later admitted was not the correct procedure. Similarly, for Resident #118, an LPN dropped medications on the top of the medication cart and then administered them to the resident without ensuring the surface was clean, acknowledging that the medications could have been contaminated. Additionally, the facility failed to communicate with the local health department during outbreaks of communicable diseases. The facility's infection preventionist, who had been in the position for only two weeks, was unaware of the contact process and had not been able to obtain accurate information on whom to contact. This lack of communication was contrary to the facility's policy, which mandates reporting outbreaks to the local health department.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility staff failed to maintain the call bell in a position accessible to two residents, Resident #89 and Resident #13, leading to a deficiency. For Resident #89, who was moderately impaired in making daily decisions and dependent on staff for toileting and personal hygiene, the call bell was observed on the floor, out of reach. Despite the resident's care plan encouraging the use of the call bell for assistance, the resident was unaware of its location. Interviews with staff confirmed that the call bell should be within reach at all times, yet it was not, indicating a lapse in adherence to the care plan. Similarly, for Resident #13, who was severely impaired in decision-making and required assistance with ADLs due to advanced age and chronic health conditions, the call bell was found hanging out of reach behind the resident's head. Observations confirmed that the call bell remained inaccessible even after staff entered and exited the room. Staff interviews reiterated the importance of keeping the call bell within reach, but the call bell's placement did not reflect this practice. The facility's administrative staff, including the administrator and regional vice president of operations, were informed of the issue. However, it was noted that the facility lacked a specific policy regarding call bell placement, which may have contributed to the oversight. No further information or corrective actions were presented before the survey exit.
Failure to Implement Baseline Care Plan for Resident with Aspira Drain
Penalty
Summary
The facility staff failed to implement a baseline care plan for Resident #470, who was admitted with diagnoses including cancer, congestive heart failure, and adult failure to thrive. The resident, who was not cognitively impaired, required maximum assistance for bed mobility, transfer, hygiene/bathing, and supervision for eating. The comprehensive care plan dated 7/10/24 indicated that the resident had an Aspira drain, with interventions to drain and change the dressing as ordered. However, the baseline care plan to monitor the Aspira drain was not implemented within the required 48 hours of admission. Interviews with facility staff revealed a lack of adherence to the facility's Baseline Care Plan policy, which mandates the development and implementation of an individualized care plan within 48 hours of admission. LPN #2 acknowledged that a resident with a drain should have it included in the baseline care plan. The deficiency was brought to the attention of the facility's administrative and clinical leadership, but no further information was provided prior to the survey exit.
Failure to Update Care Plans for Resident Safety and Preferences
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for Resident #148 to reflect the need for supervision during smoking. Despite being assessed as requiring supervision on the Smoking Safety Screen, the care plan inaccurately documented that the resident may smoke independently. Observations revealed that the resident smoked unsupervised in a garden area without proper safety measures, such as devices for safe disposal of cigarette butts or fire safety equipment. Interviews with the resident and staff confirmed the discrepancy between the care plan and the resident's assessed needs. For Resident #120, the facility staff did not update the comprehensive care plan to address the resident's preference and safety concerns related to ambulating offsite independently to a local drug store. The resident, who was moderately impaired in decision-making ability, frequently left the facility without notifying staff or signing out. Physical therapy notes from the previous year indicated the resident's ability to ambulate safely over various surfaces, but the care plan lacked interventions for independent leave of absence to the drug store. Interviews with LPNs revealed that the care plans should have been updated to reflect the residents' current conditions and preferences. The facility's policy requires care plans to be updated as changes occur and reviewed quarterly. Despite being informed of these findings, the administrative staff, including the administrator and the Director of Nursing, did not provide further information by the end of the survey.
Deficiencies in ADL Care and Personal Hygiene
Penalty
Summary
The facility staff failed to provide adequate ADL care for three residents, resulting in deficiencies related to personal hygiene and grooming. Resident #90, who was moderately impaired in making daily decisions and required assistance for personal hygiene, was observed with untrimmed long fingernails on the right hand. Despite the resident's inability to trim their nails due to paralysis, the facility's care plan indicated the need for staff assistance, which was not provided as evidenced by multiple observations of the untrimmed nails. Resident #89, also moderately impaired and dependent on staff for personal hygiene, was observed with a brown substance underneath their fingernails on multiple occasions. The resident expressed that the staff did their best, but the observations indicated a lack of proper cleaning and grooming. The care plan required staff assistance for personal hygiene, yet there was no documentation of care refusal, suggesting a failure in providing necessary assistance. Resident #151, with an upper extremity impairment, was observed with excessively long and yellow fingernails. The facility's staff, including CNAs and LPNs, acknowledged that nails should be groomed weekly, but the observations showed that this standard was not met. The clinical record did not indicate any refusal of grooming assistance, highlighting a deficiency in the facility's adherence to its care protocols for grooming and personal hygiene.
Failure to Monitor and Document Pressure Injury
Penalty
Summary
The facility staff failed to properly assess and monitor a pressure injury for a resident, identified as Resident #86, who was part of a survey sample. The deficiency was noted when the staff did not document the size and stage of the pressure injury on the sacrum when treatment was initiated on 5/31/24. Furthermore, the staff failed to monitor the wound with weekly measurements to track healing progress. The resident was cognitively intact, as indicated by a perfect score on the BIMS, and had a documented stage two pressure injury on the most recent MDS assessment. The wound care physician had documented the pressure injury as a stage two, measuring approximately 1x1x0.1 cm, and treatment orders were put in place. However, the Skin Observation forms from May to July 2024 lacked consistent documentation of measurements and staging of the pressure injury. Interviews with the wound nurse and other nursing staff revealed a lack of proper documentation and tracking of the wound, despite the facility's policy requiring weekly skin assessments and documentation of any skin impairments. The director of nursing confirmed that the resident was being followed by a wound clinic, but this did not absolve the facility from its responsibility to track the wound. The facility's policy required licensed nurses to assess and document any skin impairments weekly, but this was not adhered to in the case of Resident #86. The deficiency was communicated to the facility's administrative and clinical leadership, but no further information was provided before the survey exit.
Failure to Provide Appropriate Toenail Care
Penalty
Summary
Facility staff failed to provide appropriate toenail care for Resident #56, who was observed with toenails between one and one and a half inches long on multiple occasions. The resident, who is dependent on staff for personal hygiene, was admitted with diagnoses including traumatic brain dysfunction, seizure disorder, and diabetes mellitus. According to the resident's care plan, she requires total assistance for personal hygiene. Interviews with facility staff revealed that while daily nail care is provided, toenail care for diabetic residents is typically performed by a podiatrist. Despite this protocol, the resident's toenails were not adequately maintained, leading to the deficiency being identified during the survey.
Failure to Apply Splints for Resident with Upper Extremity Impairment
Penalty
Summary
The facility staff failed to apply right- and left-hand splints for Resident #56, who was observed without the splints on multiple occasions. The resident was noted to have functional limitations in range of motion and an upper extremity impairment on both sides, as documented in the most recent Minimum Data Set (MDS) assessment. The resident's care plan specified the need for bilateral upper extremity splints to be worn for four hours each shift, totaling eight hours daily, as tolerated. Despite these instructions, the resident was observed without the splints on three separate occasions. Interviews with facility staff revealed a lack of adherence to the care plan. An LPN stated that the need for splints would typically be communicated through the care plan rather than physician's orders or medical administration records. The LPN acknowledged that the resident should have been wearing the splints and suggested that the night shift staff might have forgotten to apply them. The administrative staff, including the administrator and director of nursing, were informed of the issue, but no further information was provided before the surveyors exited the facility.
Failure to Maintain Sanitary Conditions for Urinary Catheter Bag
Penalty
Summary
The facility staff failed to maintain a urinary catheter collection bag in a sanitary manner for a resident identified as having an indwelling catheter. During observations, the resident was found with the catheter bag touching the floor, which is against the facility's policy. The resident, who was moderately impaired in making daily decisions, stated that the staff were responsible for the catheter care. The comprehensive care plan for the resident noted the presence of a Foley catheter. Interviews with a CNA and an LPN confirmed that the catheter bag should be kept below the bladder for proper drainage and to prevent infection, and it should not touch the floor due to sanitary concerns. The facility's policy on urinary catheterizations also specified that drainage bags should be maintained below the bladder and not touch the floor. The administrative staff, including the administrator and the director of nursing, were informed of the issue, but no further information was provided before the survey exit.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. For one resident, the staff did not administer oxygen at the physician-prescribed rate of five liters per minute. Despite the care plan and physician's order specifying this rate, observations on multiple occasions revealed that the resident was receiving only two and a half liters per minute. An LPN confirmed that the oxygen concentrator should have been set to the five-liter line as per the order. The facility's policy on respiratory care emphasized following the provider's order, but this was not adhered to in this case. For another resident, the staff failed to provide oxygen as ordered, as the resident was observed with a nasal cannula attached to an empty portable oxygen tank set at zero. The physician's order required oxygen at two liters per minute via nasal cannula, but the resident was not receiving any oxygen due to the empty tank. An LPN stated that portable tanks should be checked every two hours to ensure they are not empty, and it was unclear why the resident was on a portable tank in their room. The facility's policy required oxygen therapy to be administered per the provider's order, but this was not followed, resulting in the resident not receiving the necessary oxygen therapy.
Failure to Act on Pharmacy Recommendation for PRN Antipsychotic Use
Penalty
Summary
The facility staff failed to act on a pharmacy recommendation for a resident, identified as Resident #79, regarding the discontinuation of PRN use of the antipsychotic medication Zyprexa. The pharmacy recommendation, dated April 24, 2024, suggested discontinuing the PRN use of Zyprexa due to its limited effectiveness for short-term use and recommended considering an alternative medication. Despite this recommendation, no response was documented by the physician or prescriber, and the resident continued to receive PRN Zyprexa. Interviews with administrative staff revealed that the pharmacist's recommendations are placed into a computer portal, which is checked regularly by the Director of Nursing. These recommendations are then printed and given to the assigned nurse practitioner for documentation and implementation. However, in this case, the nurse practitioner did not document a response to the pharmacy's recommendation, and the recommendation was not entered into the resident's chart. The facility's policy requires the physician to review and sign the Medication Regimen Review within 30 days, but this was not adhered to in the case of Resident #79.
Failure to Document Evaluation for Continued Use of Antipsychotic Medication
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary psychotropic medication. Specifically, for Resident #79, the staff did not ensure that the physician or prescribing practitioner evaluated the resident for the continued use of the as-needed antipsychotic medication Olanzapine and documented the rationale for its continued use. The clinical record review revealed a physician's order for Olanzapine as needed for terminal delirium related to dementia, and the resident received the medication on a specific date in June 2024. During an interview, the Director of Nursing acknowledged that as-needed antipsychotic medications should only be ordered for up to 14 days. However, due to the resident's hallucinations and behaviors, the hospice physician wanted to continue the use of Olanzapine. Despite this, the facility could not provide documentation that the physician evaluated the resident for the continued use of the medication or documented the rationale for its continued use. Additionally, the facility lacked a policy regarding as-needed antipsychotic medications.
Medication Security Lapses in Resident Rooms
Penalty
Summary
The facility staff failed to secure medications in a safe and secure manner for two residents. In the first instance, a bottle of Nystatin powder labeled for a different resident was found on the bedside table of Resident #32, who was not in the room at the time. When questioned, Resident #32, who was not cognitively impaired, stated they did not notice the bottle. The LPN acknowledged that the medication was not Resident #32's and should have been locked in the medication cart. The facility's policy requires that medications be locked when not attended by authorized personnel. In the second instance, an inhaler prescribed to Resident #519 was found unattended on the bedside table. The LPN confirmed that the inhaler should have been stored in the medication cart and not used without supervision. The facility's policy mandates that medications be stored securely and only accessible to authorized personnel. Both incidents were reported to the facility's administrative and clinical leadership.
Failure to Inspect Bariatric Beds for Safety
Penalty
Summary
The facility staff failed to perform necessary safety inspections on bariatric beds for two residents, leading to a deficiency. For Resident #86, the staff did not inspect the bariatric bed for safety and entrapment risks, despite the resident being observed in bed with two half side rails. The bed inspection book indicated that the bed in use was not the same as the one documented, and no inspection had been conducted for the current bariatric bed. The director of maintenance, when interviewed, was unable to provide a reason for the lack of inspection, despite the facility's policy requiring annual and intermittent audits of bed systems. Similarly, for Resident #124, the staff also failed to inspect the bariatric bed for safety and entrapment. The resident was observed in bed with two half side rails, and the bed inspection book again showed a discrepancy between the documented bed and the one in use, with no inspection performed. The director of maintenance confirmed the process for inspecting bariatric beds but could not explain why the inspection was not completed. The facility's administrative and clinical leadership were informed of these concerns, but no further information was provided before the survey exit.
Failure to Complete QAPI Training for New Staff Member
Penalty
Summary
The facility staff failed to ensure that a floor technician, identified as OSM #5, completed the mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program. OSM #5 was hired on June 1, 2023, but there was no evidence provided that they had completed the QAPI training. During an interview, ASM #4, the regional vice president of operations, mentioned that the QAPI training was scheduled to be added to OSM #5's computer-based training program in August. However, it was unclear if the training was included in the system upon hire. Further investigation revealed that the QAPI training was supposed to be part of the general orientation and onboarding education for all staff, as confirmed by ASM #2, the director of nursing. The facility's assessment and the Relias 2024 Onboarding All Employees calendar documented that the course "Quality & You: QAPI" was included in the onboarding education for all staff. Despite this, no additional information or evidence of completion was provided for OSM #5 before the exit interview with the facility's administrative staff.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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