Fair Oaks Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfax, Virginia.
- Location
- 12475 Lee Jackson Memorial Highway, Fairfax, Virginia 22033
- CMS Provider Number
- 495217
- Inspections on file
- 16
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Fair Oaks Health & Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not notify a physician when a resident's blood glucose readings repeatedly exceeded the threshold specified in the physician's order. Despite multiple high blood sugar results documented in the clinical record, there was no evidence of physician notification, as confirmed by staff interviews and record review.
Staff failed to administer medications as ordered for three residents, including incorrect dosing of insulin, giving Midodrine when blood pressure was above the ordered threshold, and not providing insulin per sliding scale for a resident with diabetes and ESRD. Nursing staff and a unit manager confirmed these discrepancies during interviews, and facility policy requiring verification of orders and safe medication administration was not followed.
A resident with severe cognitive impairment was unable to identify a nurse who was not wearing a required name badge during care. The nurse, unfamiliar with the unit and residents, admitted to not having the badge visible, and staff confirmed that identification badges are a required part of the uniform. This failure to ensure staff identification did not promote dignity or respect for the resident, as required by facility policy.
Staff did not ensure a call bell was within reach for a severely cognitively impaired resident with limited arm mobility, despite facility policy and staff knowledge that call bells must be accessible at all times for resident safety.
Staff did not ensure that both facility elevators were clean and well-maintained, as observations showed large wall scrapes, indentations, and visible dirt and grime on the floors. Both the regional director of maintenance and the administrator agreed that the elevators, which are used by multiple residents daily, did not meet the facility's standards for a clean, homelike environment.
A resident's MDS assessment was inaccurately coded by an LPN, indicating a persistent vegetative state when clinical records showed otherwise. This error resulted in the omission of required responses in cognition, mood, and behavior sections. The mistake was acknowledged by the staff member responsible, and facility leadership was notified.
A nurse, unfamiliar with the medication cart, repeatedly left the locked cart's keys hidden under a towel on top of the cart while leaving the area to retrieve medications from another floor. During these absences, the unattended cart was accessible in the hallway, and two residents walked by it. Facility policy requires keys to be kept in the nurse's pocket, and the incident was reported to administrative and clinical leadership.
Staff did not follow enhanced barrier precautions or sanitize vital sign equipment before and after use for a resident with wounds. A nurse took vital signs without PPE and failed to disinfect equipment, which was then used on another resident. Staff interviews and policy review confirmed these actions were not in line with required infection control procedures.
Staff did not consistently implement enhanced barrier precautions or contact isolation for residents with wounds or CRE colonization, as required by facility policy and physician orders. PPE and signage were missing, and staff were unaware of which residents required precautions. Additionally, the facility lacked documentation and implementation of a water management program to control Legionella risk.
Facility staff did not provide required written notification to the ombudsman when several residents were discharged to the hospital. In each case, there was no documentation to show that the ombudsman had been notified, despite facility policy requiring this step. One affected resident had multiple medical conditions and required significant assistance with daily activities. Staff interviews confirmed that notifications may have been attempted but were not documented.
Staff failed to develop or implement comprehensive care plans for several residents, resulting in missed medication administration, lack of care planning for specific diagnoses such as genital warts and PTSD, inadequate monitoring for anticoagulation, improper oxygen therapy administration, incomplete communication with a dialysis facility, and neglect of ADL care such as nail trimming. Staff interviews and documentation confirmed that care plans were either missing or not followed, leading to unmet resident needs.
Staff failed to provide necessary ADL care for five residents, including not dressing two residents in clothes, not assisting two residents with transfers from bed, and not maintaining proper grooming and nail care for three residents. Interviews and observations revealed that residents were left in gowns, not offered assistance to get out of bed, and had long, untrimmed fingernails and hair, with staff uncertain about responsibilities and processes for obtaining clothing and providing grooming.
A resident with multiple medical conditions did not receive several prescribed medications as ordered, despite the medications being available in the facility's automated dispensing cabinets and stock. The electronic medication administration record showed missed doses with no documentation or explanation, and staff interviews confirmed that the medications should have been accessible and administered.
Staff failed to follow physician orders and care plan interventions for two residents at risk for or with pressure injuries. One resident did not receive the prescribed Heelzup cushion to offload heels, and instead had heels in contact with the bed surface during multiple observations. Another resident with a new unstageable pressure ulcer did not receive the recommended wound treatment for 27 days after identification, despite orders being in place. Staff interviews and documentation confirmed these lapses in pressure injury prevention and management.
Multiple deficiencies were identified in the provision of respiratory care, including failure to store CPAP masks in sanitary conditions, not maintaining physician-ordered oxygen flow rates, and not labeling or regularly changing oxygen tubing. Staff interviews confirmed knowledge of proper procedures, but these were not consistently followed, and documentation for cleaning and equipment handling was lacking.
Facility staff did not maintain complete communication records with the dialysis center for a resident with ESRD, as required by physician orders and facility policy. Several dialysis communication sheets were missing, and staff confirmed they could not provide the missing documentation.
Facility staff did not provide evidence of required face-to-face visits by a physician or nurse practitioner at least every 60 days for two residents, one with ESRD, CHF, and diabetes, and another with PTSD, viral hepatitis, and pulmonary fibrosis. Both residents had care plans necessitating physician involvement, but no visit documentation was found for extended periods, as confirmed by facility leadership.
A resident with a history of atrial fibrillation and other conditions was prescribed Rivaroxaban, but staff failed to monitor for anticoagulation side effects as required. The care plan and MAR lacked documentation of monitoring, and interviews with the resident and an LPN confirmed that no assessments for bleeding or bruising were conducted, contrary to facility policy.
A resident with moderate cognitive impairment and communication-related diagnoses did not receive a physician-ordered speech therapy evaluation and treatment. The speech therapist was unaware of the order, and the director of rehabilitation did not schedule the resident for speech therapy, resulting in no documented intervention.
Staff failed to dress two residents in regular clothing before they were seated in common areas, leaving them in gowns and slipper socks. Another resident, who required assistance with grooming, was left with long, unkempt hair and beard despite his preference for a short, trimmed appearance. Additionally, a resident's call bell was left unanswered for an extended period while multiple staff members, including a CNA who was sleeping, were present nearby. These actions did not uphold residents' rights to dignity and prompt care.
Staff failed to ensure call bells were within reach for a resident with muscle weakness and cognitive impairment, and did not provide communication aids for two residents with severe cognitive impairment and limited English proficiency, resulting in ineffective communication. Additionally, a resident's preference for daytime laboratory services was not accommodated, with blood draws occurring during early morning hours and disrupting sleep.
Staff did not store or label food items properly in the kitchen and nourishment rooms, resulting in expired, unlabeled, and improperly stored food being found in both areas. Open food packages were left exposed, expired products were not discarded, and food items in nourishment rooms lacked required resident names and dates. Staff interviews revealed inconsistent cleaning and monitoring practices, and facility policies for safe food storage and labeling were not followed.
Three residents were discharged from Medicare Skilled Nursing services without being issued the required Advance Beneficiary Notice (ABN), even though they still had days remaining in their benefit period. Clinical records lacked documentation of the ABN, and staff interviews revealed that the therapy department, responsible for issuing the notices, was unaware of this duty at the time.
Facility staff did not provide the required physician documentation when a resident with multiple chronic conditions was transferred to the hospital. Despite facility policy and staff acknowledgment that a progress note should be completed at the time of transfer, no such documentation was found in the resident's record.
Facility staff did not ensure a Level I PASARR screening was completed for a resident admitted from another facility. The required screening was missing from the clinical record, and staff interviews confirmed that the admissions process failed to identify or complete the PASARR as required by facility policy.
A resident with left hemiplegia and muscular weakness following a CVA had a care plan that previously included use of a left-hand resting splint. After a corporate-led care plan revision, the new care plan failed to include documentation of the splint, and staff confirmed this omission was an oversight during the transition.
Two residents did not receive proper foot and toenail care, with one resident observed to have thick, overgrown toenails and dry, scaly feet, and another resident found with excessively long and thick fingernails and toenails. Both residents required significant assistance with personal care, and staff interviews confirmed that nail care was not provided as needed, with no evidence of podiatrist visits documented.
A resident with limited left-hand range of motion did not receive the recommended splinting care as outlined in their occupational therapy discharge summary. Despite documented instructions and staff training, the splint was not applied during multiple observations, and both the CNA and LPN responsible for care were unaware of the splinting requirement. The facility's policy to provide appropriate equipment and services for residents with limited mobility was not followed.
Facility staff did not assess whether a bed met manufacturer weight restrictions for a cognitively intact resident weighing 484 pounds, despite the bed's 500-pound safe working load including all accessories. The resident expressed concerns about the bed's size and function, and staff interviews revealed that nurses did not address weight restrictions as required by facility policy.
A resident was observed receiving tube feeding through tubing that was visibly soiled with a brown sticky substance over a significant portion of the tubing. Nursing staff confirmed that the substance was likely leaked tube feeding material and acknowledged that the tubing should have been replaced to maintain sanitary conditions and ensure proper nutrition delivery.
A resident with PTSD, viral hepatitis, and pulmonary fibrosis did not receive trauma-informed care, as staff failed to assess for PTSD triggers or provide related social services. Although the care plan addressed medication monitoring and included psychiatric consults, it did not include interventions specific to trauma history or triggers, and staff were unaware of the resident's needs in this area.
A resident with ESRD, CHF, and diabetes mellitus was readmitted after a hospital transfer without evidence of a physician's admission note or recommendation, as required by facility policy. Staff interviews and record reviews confirmed the absence of documentation detailing the reason for hospitalization or readmission, despite the resident's moderate cognitive impairment and need for assistance with daily activities.
A resident with PTSD did not receive appropriate medically related social services, as staff failed to conduct a PTSD-specific assessment or follow up on psychosocial needs. Although the resident was seen by psychiatry, staff were unaware of her triggers and social services had not engaged with her, contrary to facility policy and job descriptions.
A resident with hypertension and hyperlipidemia did not receive prescribed doses of Diltiazem, Ezetimibe, and Methylcobalamin due to the medications not being available in the facility's Omnicell or stock. The eMAR showed missed doses without documentation or evidence that the pharmacy was notified, and staff confirmed the medications were not on hand and would have needed to be ordered.
A nurse failed to follow physician orders for glaucoma treatment by administering two drops of Timoptic Ophthalmic Solution in each eye instead of one, and omitting Trusopt Ophthalmic Solution in the left eye for a resident. This resulted in two medication errors out of 32 opportunities, leading to a medication error rate of 6.25%, exceeding the acceptable threshold.
Facility staff did not ensure timely offering, education, or administration of pneumonia vaccines for two residents, despite policy and CDC recommendations requiring assessment and vaccination within a set timeframe. Documentation was missing or delayed, and staff interviews revealed uncertainty about the cause of these lapses.
Facility staff did not notify a resident's responsible party about a new outbreak of genital warts and related bleeding, despite the resident's complex medical history and care needs. Although staff and the medical team were aware of the condition and provided treatment, the responsible party was not informed as required by facility policy.
Facility staff did not include the facility name or resident census on daily posted nurse staffing information, as confirmed by multiple observations and a review of prior postings. The staffing coordinator stated she had never completed the census section and had not noticed the missing facility name, despite facility policy requiring both details.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
Facility staff failed to notify a physician when a resident's blood glucose levels exceeded the parameters set by the physician's order. The order specified that the physician should be notified if the resident's blood glucose was greater than 200. Despite this, clinical record review showed multiple instances in June 2025 where the resident's blood sugar readings were above 200, but there was no documentation of physician notification. Specific dates and times were identified where blood glucose levels ranged from 250 to 462, and no corresponding physician notification was found in the medical record. During staff interviews, a unit manager (LPN) confirmed that the physician should have been notified according to the order and acknowledged that the nurse did not follow the required notification protocol. The facility's policy on changes in a resident's condition also requires prompt physician notification of significant changes. The deficiency was confirmed through review of clinical records, medication administration records, and staff interviews, with no additional information provided prior to the survey exit.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
Facility staff failed to implement physician orders for three residents, resulting in deficiencies related to medication administration. For one resident with diabetes, a registered nurse administered 10 units of Lantus insulin instead of the ordered 9 units during a medication pass observation. The nurse confirmed the administration and stated she checks orders multiple times due to the high-risk nature of insulin, but the dose given did not match the physician's order. Facility policy requires checking the order and the five rights of medication administration at multiple points, but this was not followed in this instance. Another resident with hypotension received Midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 120. The medication administration record showed the resident received Midodrine on several occasions when blood pressure readings were above the specified threshold, and in one instance, no blood pressure was recorded prior to administration. The unit manager reviewed the orders and records, confirming that the medication should not have been given under these circumstances. A third resident with end-stage renal disease and diabetes did not receive insulin as ordered according to a sliding scale protocol. The medication administration records indicated that insulin was not administered at multiple times when blood glucose levels required it per the sliding scale order. The unit manager acknowledged that the order should have been clarified, and failure to do so led to improper administration. Facility policy requires medications to be administered safely and as ordered, but this was not adhered to in these cases.
Failure to Ensure Staff Identification Compromises Resident Dignity
Penalty
Summary
The facility failed to promote and enhance a resident's right to a dignified existence and respect. A resident with severe cognitive impairment, as indicated by a BIMS score of 6 out of 15 and diagnoses including dementia, osteoarthritis, and metabolic encephalopathy, was observed during care interactions where staff did not follow established protocols for resident dignity. Specifically, a registered nurse providing care was not wearing a name badge, which is required as part of the staff uniform and is necessary for residents and families to identify staff members. The nurse admitted to not usually working on the unit, being unfamiliar with the residents, and not having the name badge visible because it had fallen off in the break room. When questioned, the resident was unable to identify the nurse by name and confirmed the absence of a name badge. Further interviews with other staff, including the unit manager and administrative staff, confirmed that wearing identification badges is a facility requirement and part of the uniform. The facility's Resident Rights policy states that each resident should be cared for in a manner that promotes well-being, satisfaction, self-worth, and self-esteem. The failure of the nurse to wear a name badge and ensure proper identification was recognized by staff as not demonstrating dignity and respect for the resident, directly contravening facility policy and resident rights.
Failure to Ensure Call Bell Accessibility for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to place a call bell within reach for one resident on multiple occasions, as observed on two consecutive days. The call bell was found clipped to the bottom sheet more than halfway down the bed, making it inaccessible to the resident while he was sitting up or lying in bed. During one observation, a registered nurse entered the room, interacted with the resident, and left without ensuring the call bell was within reach. The resident involved was assessed as being severely cognitively impaired, had range of motion impairment in both arms, and required staff assistance for bed mobility. Interviews with facility staff, including a CNA and a unit manager LPN, confirmed that call bells should always be within a resident's reach for safety. Facility policy also requires that call lights be easily accessible to residents when in bed or confined to a chair.
Failure to Maintain Clean and Homelike Elevator Environment
Penalty
Summary
Facility staff failed to maintain a clean, comfortable, and homelike environment in both of the facility's elevators. Observations revealed that both elevators had large scrapes and indentations on the walls, as well as visible dirt and grime on the floors. Staff interviews confirmed that the elevators were used frequently by multiple residents throughout the day and evening, and both the regional director of maintenance and the administrator acknowledged that the elevators did not provide a clean, homelike environment. Review of facility policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including clean and orderly equipment. No additional information was provided prior to exit.
Inaccurate MDS Assessment Due to Miscoding of Resident's Level of Consciousness
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Specifically, the resident's quarterly MDS was incorrectly coded to indicate a persistent vegetative state with no discernable consciousness, despite clinical records and progress notes showing that the resident was never in such a state during their stay. This miscoding in Section B of the MDS led to the omission of responses in subsequent sections related to cognition, mood, and behaviors. The error was made by the LPN serving as the MDS coordinator, who acknowledged the mistake during an interview and confirmed that the resident was never in a persistent vegetative state. The coding instructions from the RAI manual were not followed, as there was no documented diagnosis of coma or persistent vegetative state during the required look-back period. The deficiency was identified through staff interviews and clinical record review, and facility leadership was informed of the findings.
Medication Cart Keys Left Unsecured During Nurse Absence
Penalty
Summary
Facility staff failed to store medications securely on one of three medication carts on the second floor. A registered nurse, who was unfamiliar with the medication cart and only worked a few shifts per month, was observed searching for medications and, upon needing to retrieve medications from another floor, locked the cart but left the keys hidden under a towel on top of the cart. The nurse left the cart unattended in the hallway while retrieving medications from the emergency supply on another floor, returning several minutes later to retrieve the keys and continue medication administration. This sequence occurred multiple times, with the keys repeatedly left on top of the cart under a towel while the nurse was away. During one of these absences, two residents walked by the unattended medication cart. The nurse later acknowledged that the cart was not fully secure because the keys had been left on top of it. Interviews with a unit manager confirmed that facility policy requires nurses to keep medication cart keys in their pocket when leaving the cart, and the facility's written policy mandates that medication storage areas be locked and not left unattended if accessible to others. The administrator, director of nursing, and regional director of clinical operations were informed of these concerns.
Failure to Follow Enhanced Barrier Precautions and Equipment Sanitization
Penalty
Summary
Facility staff failed to follow infection control procedures for a resident who had a physician's order for enhanced barrier precautions due to wounds. On observation, a registered nurse was seen taking the resident's vital signs without wearing any personal protective equipment (PPE), such as a gown or gloves, as required by the enhanced barrier precautions. The nurse also did not sanitize the blood pressure cuff or pulse oximeter before or after use, and the equipment was subsequently handed to another staff member for use on a different resident without disinfection. Interviews with facility staff confirmed that enhanced barrier precautions require the use of gown and gloves when providing care to residents with certain infection risks, such as wounds, and that vital sign equipment should be sanitized before and after each use. Review of facility policy and CDC recommendations further supported these procedures. The failure to adhere to these protocols was acknowledged by staff and administration during the survey.
Failure to Implement Infection Control and Isolation Precautions
Penalty
Summary
Facility staff failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. For several residents with wounds, including those with sacral and thigh/perineum wounds, staff did not implement enhanced barrier precautions (EBP) as required by facility policy and CDC guidance. Specifically, during wound care, staff wore gloves but did not don gowns, and there was no signage indicating EBP in resident rooms. Staff interviews revealed a misunderstanding of when EBP should be applied, with reliance on external advice that contradicted facility policy, which mandates EBP for all residents with wounds, regardless of drainage status. Additionally, the facility failed to follow contact isolation precautions for residents with documented colonization of carbapenem-resistant Enterobacterales (CRE). Despite physician orders and care plans specifying contact isolation, there was no signage or personal protective equipment (PPE) available at the rooms of affected residents. Multiple staff members entered these rooms without donning PPE, and interviews indicated a lack of awareness among staff regarding which residents required contact precautions. Facility policy requires clear signage and PPE availability for residents on transmission-based precautions, but these measures were not observed in practice. The facility also lacked evidence of an active water management program to minimize the risk of Legionella and other opportunistic pathogens in the building water system. Although a policy existed, staff could not provide documentation of a current water management plan or routine water testing. The director of maintenance was unaware of any ongoing water management interventions and had not conducted water testing since starting at the facility. This absence of a documented and implemented water management program was confirmed by administrative staff during the survey.
Failure to Provide Written Ombudsman Notification for Resident Discharges
Penalty
Summary
Facility staff failed to provide required written notification to the ombudsman following the discharge of four residents to the hospital. For each of these residents, a review of clinical records did not reveal evidence that the ombudsman was notified in writing at the time of discharge, as required by facility policy. The director of social services stated during interviews that she believed she had faxed notifications but had not retained any documentation or records to support this. There was no evidence of written notification for any of the four residents in question. One of the residents involved had a history of CVA with hemiparesis/hemiplegia, diabetes mellitus, and osteomyelitis, and was assessed as moderately cognitively impaired and requiring maximal assistance for daily activities. The facility's policy requires that a copy of the discharge notice be sent to the ombudsman, but staff interviews and document reviews confirmed that this process was not followed or documented for the affected residents. No additional information or documentation was provided by the facility prior to the survey exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for multiple residents, resulting in deficiencies related to medication administration, disease management, and daily care. For one resident with depression, anxiety, and muscle weakness, staff did not follow the care plan for administering several prescribed medications, including Gabapentin, Oxycodone, Lidocaine Patch, Tylenol, Lorazepam, Mirtazapine, and Sertraline. The electronic medication administration record showed missed doses with no documentation or explanation, and the care plan specifically required medications to be administered as ordered. Interviews with staff confirmed that the care plan was not being followed. Another resident with a history of genital warts did not have a care plan developed for this condition, despite having a physician's order for topical Imiquimod. The care plan only addressed urinary and bowel incontinence, with no mention of genital warts or related interventions. Staff interviews confirmed that a care plan should have been developed for this diagnosis. Similarly, a resident with PTSD did not have a care plan addressing PTSD, even though it was an active diagnosis and the resident reported that staff were unaware of her triggers. The care plan only addressed risks related to medication use, not the underlying psychiatric condition. Additional deficiencies included the lack of a care plan for anticoagulation monitoring for a resident on Rivaroxaban, failure to implement the care plan for oxygen therapy by administering oxygen at a higher rate than ordered, incomplete communication with a dialysis facility as required by the care plan, and failure to provide fingernail and toenail care as outlined in the care plan for a resident with self-care deficits. In each case, staff interviews and documentation review confirmed that care plans were either not developed for specific needs or not implemented as written, resulting in unmet resident needs.
Failure to Provide ADL Care and Assistance for Multiple Residents
Penalty
Summary
Facility staff failed to provide adequate activities of daily living (ADL) care for five residents who were unable to perform these tasks independently. Two residents with severe cognitive impairment were repeatedly observed dressed only in gowns and slipper socks, both in public and private areas of the facility. Staff interviews revealed that these residents did not have personal clothing available, and there was uncertainty among staff regarding efforts to obtain clothing for them. The facility's policy required assistance with ADLs, including grooming and dressing, for residents unable to perform these tasks independently. Another resident, who was cognitively intact but required extensive assistance for grooming, personal care, and transfers, was observed with long, untrimmed fingernails containing dark material, and with long hair and beard. This resident reported that staff did not offer to get him out of bed regularly, and that he was unable to trim his own nails or hair. Staff interviews confirmed inconsistent assistance with transfers and a lack of clarity regarding responsibility for haircuts and shaving. There was no documentation indicating the resident refused care. Additional deficiencies included a resident who was never offered or assisted out of bed during the survey period, despite requiring extensive assistance for transfers, and another resident with significant physical impairments who had excessively long fingernails and toenails. Staff interviews revealed confusion about the process for nail care, with aides deferring to nurses or podiatry, and no evidence of recent nail care provided. The care plan for this resident indicated a need for physical assistance with ADLs, but records did not show that fingernail care was performed.
Failure to Administer Medications as Ordered
Penalty
Summary
Facility staff failed to administer multiple prescribed medications according to physician's orders for one resident. The medications involved included treatments for conditions such as swelling, pain, anxiety, high blood pressure, depression, benign prostatic hypertrophy, and coronary artery disease. The resident's clinical record indicated that these medications were to be given daily or as needed, with specific instructions for administration and monitoring. A review of the electronic medication administration record (eMAR) for the resident revealed that on a specific date, there were blanks for all the listed medications, indicating they were not administered as ordered. There was no documentation in the nursing progress notes or eMAR notes to explain the missed doses or provide a reason for the omission. Further investigation showed that the medications were available in the facility's Omnicell automated dispensing cabinets or as facility stock, and staff confirmed that these medications should have been accessible to the nurses on duty. Interviews with facility staff, including the unit manager and director of nursing, confirmed the process for medication administration and access to medications. Staff stated that if medications were not in the medication cart, they should be obtained from the Omnicell or facility stock, and if unavailable, the pharmacy should be notified. Despite this, there was no evidence that the medications were administered or that any follow-up occurred regarding the missed doses.
Failure to Implement Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
Facility staff failed to implement physician-ordered interventions for the prevention and treatment of pressure injuries for two residents. One resident, who was at risk for pressure ulcers and had a history of protein-calorie malnutrition, was observed multiple times lying in bed with his heels in contact with the bed surface, despite a physician's order and care plan intervention for a Heelzup cushion to be in place while in bed. Instead, staff used a flat pillow that did not adequately elevate the heels, and the prescribed Heelzup cushion was found unused on the floor. Interviews with staff confirmed that the intended intervention was not properly implemented, and staff were aware that the resident's heels were not being offloaded as required. For another resident, staff failed to initiate timely treatment for a newly identified unstageable pressure ulcer on the right ischium. Although a wound assessment recommended the use of calcium alginate and foam dressing, this treatment was not started until 27 days after the wound was first observed. Nursing staff interviews confirmed that the order for wound care was in place but not implemented promptly, and documentation in the treatment administration record did not show evidence of the treatment being provided until nearly a month later. The facility's own policy requires preventive interventions and timely treatment for pressure injuries based on risk assessments and physician orders. However, observations, record reviews, and staff interviews demonstrated that these standards were not met for the two residents, resulting in a failure to provide care and services consistent with professional standards of practice for pressure injury prevention and management.
Deficiencies in Respiratory Care Services and Equipment Handling
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for multiple residents, resulting in several deficiencies. For one resident with sleep apnea, staff did not store the CPAP mask in a plastic bag when not in use, leaving it uncovered on the bedside table during multiple observations. The resident was cognitively intact and had physician orders for nightly and PRN CPAP use. Staff interviews confirmed the mask should have been stored in a plastic bag to prevent contamination, but this was not done. Another resident with COPD was observed receiving oxygen therapy at a flow rate between two and three liters per minute, despite a physician's order for three liters per minute via nasal cannula. Multiple observations confirmed the flow rate was not consistently set at the ordered amount. Staff interviews revealed knowledge of how to read the flow meter, but the oxygen was still not administered as ordered. Additional deficiencies included failure to label oxygen tubing with the date it was last changed for a resident on continuous oxygen, as well as failure to store and clean a CPAP mask and tubing regularly for another resident. Staff interviews indicated that tubing should be changed weekly and labeled, and that CPAP masks should be cleaned after each use and stored in a sanitary manner. However, these practices were not followed, and there was no documentation or care plan interventions for cleaning the CPAP equipment. These findings were communicated to facility administration, and no further information was provided prior to exit.
Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to provide adequate dialysis care and services for one resident with end stage renal disease, congestive heart failure, and diabetes mellitus. The resident required regular hemodialysis and had physician orders for transportation to a dialysis center and daily checks of the AV fistula site. The resident's care plan included instructions to confer with the physician or dialysis center regarding medication adjustments as needed before dialysis. However, a review of facility-to-dialysis center communication sheets revealed that several required communication records were missing for a significant period. Interviews with the resident and facility staff confirmed that the communication documentation was incomplete, and the facility was unable to provide the missing dialysis communication sheets when requested. The facility's own policy required ongoing communication and coordination with the contracted dialysis center, but there was no evidence that this process was consistently followed for the resident in question.
Failure to Document Required Physician Visits for Two Residents
Penalty
Summary
Facility staff failed to provide evidence that required face-to-face visits between residents and their physicians or nurse practitioners occurred at least every 60 days, as mandated by federal and facility policy. For one resident with end stage renal disease, congestive heart failure, and diabetes mellitus, there were no documented physician or nurse practitioner notes for an eight-month period, despite the resident's moderate cognitive impairment and need for moderate assistance with daily activities. The resident's care plan required coordination with the physician regarding medication and dialysis, but no visit documentation was available for the specified timeframe. Similarly, another resident with diagnoses including PTSD, viral hepatitis, and pulmonary fibrosis, and who required maximal assistance for mobility and daily activities, had no evidence of physician or nurse practitioner visits for nearly six months. The care plan for this resident included monitoring for adverse effects of psychiatric medications and physician notification of any changes, but no visit documentation was found for the period in question. Facility administrative and clinical leadership confirmed the absence of required visit documentation for both residents during staff interviews.
Failure to Monitor Anticoagulant Therapy as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications by not monitoring anticoagulant therapy as ordered. The resident, who had a history of pulmonary embolism, spondylosis, cord compression, and atrial fibrillation, was prescribed Rivaroxaban 20 mg daily for atrial fibrillation. The resident's care plan initially did not include any information regarding anticoagulation until after a specific date, and the medication administration record (MAR) did not show evidence of any anticoagulation monitoring. Interviews with the resident and staff revealed that there was no documentation or active monitoring for anticoagulation side effects, such as checking for bruising or bleeding. The LPN unit manager confirmed that no documentation was kept for anticoagulation monitoring. The facility's own policy required appropriate clinical and laboratory monitoring for anticoagulant use, with periodic documentation by the attending physician, but this was not followed for the resident in question.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
Facility staff failed to provide required speech therapy services for one resident who was admitted with communication-related diagnoses and demonstrated moderate cognitive impairment, as indicated by a BIMS score of 8 out of 15 on the most recent MDS assessment. The physician's order sheet documented an order for speech therapy evaluation and treatment, but a review of the resident's electronic health record showed no evidence that speech therapy intervention was provided. Interviews with the speech-language pathologist and the director of rehabilitation revealed that the speech therapist was not made aware of the physician's order, and the director of rehabilitation did not schedule the resident for speech therapy evaluation or treatment. The director of rehabilitation stated that physical therapy did not see a clinical need or change in condition, so the resident was not added to the speech therapist's schedule. The facility's job description for speech-language pathologists requires review and evaluation of physician referrals and medical records to determine therapy needs. Facility administrative staff were made aware of these findings during the survey.
Failure to Provide Dignified Care and Prompt Response to Resident Needs
Penalty
Summary
Facility staff failed to honor residents' rights to dignity and self-determination in several instances. Two residents with severe cognitive impairment were repeatedly observed sitting in common areas dressed only in gowns and slipper socks, rather than regular clothing. A CNA reported that one resident did not have clothes available, so a gown was used instead, and acknowledged that being dressed in a gown in public areas would not feel dignified. Facility leadership was made aware of these concerns, but no further information was provided prior to the survey exit. Another resident, who was cognitively intact but required extensive assistance with grooming, was observed multiple times with long, unkempt hair and a beard, despite his preference for short hair and a trimmed beard. The resident stated that staff told him there was no one available to assist with haircuts or shaving. A CNA familiar with his care was unaware of who was responsible for grooming, and agreed that failing to maintain the resident's preferred appearance was not dignified care. Facility policy reviewed by surveyors stated that residents should be groomed as they wish to be. Additionally, a resident's call bell was left unanswered for at least 20 minutes while several staff members, including a CNA who was observed sleeping, were present in the immediate area. The unit manager confirmed that it was unacceptable for staff to sleep on duty and that any staff member should have responded to the call bell promptly, as delays in response can impact resident dignity. These findings were communicated to facility leadership, and no additional information was provided before the survey exit.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
Facility staff failed to reasonably accommodate the needs and preferences of several residents in multiple ways. For one resident with muscle weakness and moderate cognitive impairment, the call bell was repeatedly observed to be placed inside a bedside table drawer, out of the resident's reach, despite the resident being unable to locate or activate it when asked. Staff interviews confirmed that the call bell should always be within reach and checked each time someone enters the room, as per facility policy, but this was not followed. Two other residents, both with severe cognitive impairment and limited English proficiency, were not provided with effective communication aids. One resident, who spoke a Moroccan dialect, was unable to communicate with staff who did not speak her language, relying instead on her son to translate via video chat, which was acknowledged as neither effective nor efficient. The other resident, who spoke Spanish, also had no communication aid available and depended on her roommate to translate or used gestures, with staff confirming the absence of any communication device or system for her. Additionally, another resident reported that laboratory services were provided at times that did not accommodate his preferences, specifically having blood drawn between 2:00 a.m. and 4:00 a.m., which disrupted his sleep. The contract phlebotomist confirmed that this was her regular schedule and acknowledged that it might not be desirable for residents, but stated she had no control over the timing. Facility administrative staff were made aware of these findings, and no further information was provided prior to the survey exit.
Failure to Store and Label Food Items Properly in Kitchen and Nourishment Rooms
Penalty
Summary
Facility staff failed to store food in a sanitary manner in both the main kitchen and two of three nourishment rooms. In the kitchen's dry storage area, several food items were found improperly stored or past their use-by dates, including an open bag of elbow noodles exposed to air, a container of chocolate fudge icing, and a bag of white cake mix, both of which were past their labeled use-by dates. In the walk-in refrigerator, there were sandwiches with questionable labeling, thickened dairy drinks past their best-by date, and tortillas that were expired, with one package previously opened. Staff interviews confirmed that these items should have been discarded and that proper storage procedures, such as sealing open bags, were not followed. In the nourishment rooms, unsanitary conditions and improper labeling were observed. The second-floor nourishment room's freezer contained a dried brown substance on the bottom surface, and the refrigerator held a lunchbox and a food container with rice, both lacking names or dates, as well as an expired carton of milk. The first-floor nourishment room contained a plastic bag with two food containers, also without names or dates. Staff interviews revealed confusion over responsibilities for cleaning and monitoring the refrigerators, with some staff believing housekeeping was responsible for daily checks and others stating that checks occurred weekly. There was a lack of clarity regarding the ownership and dating of food items stored in these areas. Facility policies required that all resident food items be labeled with the resident's name and date and that foods be stored in a manner compliant with safe food handling practices. Despite these policies, observations and staff interviews demonstrated that expired, unlabeled, and improperly stored food items were present in both the kitchen and nourishment rooms, and cleaning protocols were not consistently followed.
Failure to Provide Required Medicare ABN Prior to Discharge
Penalty
Summary
Facility staff failed to provide the required Medicare Advance Beneficiary Notice (ABN) to three residents prior to their discharge from Medicare Skilled Nursing services, despite each resident still having days remaining in their skilled nursing benefit at the time of discharge. Clinical record reviews for each resident did not contain documentation of the ABN, which is mandated by facility policy to inform Medicare beneficiaries of their potential liability for payment when services may not be covered. The absence of these notices was confirmed through staff interviews and review of facility policy. Interviews with administrative staff revealed that the therapy department was responsible for issuing ABNs, but at the time of the discharges, the department was unaware of this responsibility. This lack of awareness led to the failure to issue the required ABNs to the affected residents. The deficiency was communicated to facility leadership, including the administrator, DON, and regional directors, during the survey process.
Lack of Required Physician Documentation After Resident Hospital Transfer
Penalty
Summary
Facility staff failed to provide the required physician documentation following the transfer of a resident to the hospital. Specifically, for one resident with diagnoses including end stage renal disease, congestive heart failure, and diabetes mellitus, there was no evidence of a physician or nurse practitioner progress note documenting the reason for transfer, medications, or other pertinent information at the time of the hospital transfer. This was confirmed through staff interviews, clinical record review, and facility document review. The resident in question was moderately cognitively impaired and required moderate assistance with daily activities. Despite the facility's policy stating that the attending physician or nurse practitioner must provide a summary of pertinent medical discharge information within 30 days of discharge or transfer, no such documentation was found in the resident's record. Staff interviews confirmed that this documentation was expected but not completed for the transfer event.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
Facility staff failed to implement PASARR (Preadmission Screening and Resident Review) requirements for one resident. Specifically, the clinical record review for this resident did not contain evidence of a completed Level I PASARR screening upon admission. The resident was admitted from a sister facility, and the omission was not identified or rectified prior to or at the time of admission. During interviews, the director of social services confirmed that all residents should have a Level I PASARR completed, and that the admissions department is responsible for ensuring this is done before admission. If not completed, the director of social services would typically complete it. However, in this case, the process was not followed, and the required screening was not present in the resident's record. Facility policy also specifies the steps for ensuring PASARR completion, but these were not adhered to for this resident.
Failure to Update Care Plan for Splint Use After Care Plan Revision
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for one resident following a corporate decision to revamp care plans. The resident had a history of left hemiplegia and muscular weakness related to a cerebrovascular accident (CVA), and previously had a care plan that included the use of a left-hand resting splint. When the new care plan was initiated, documentation regarding the left-hand splint was omitted and not carried over from the previous plan. Staff interviews confirmed that the omission was an oversight during the transition to new care plans, and the current care plan did not reflect the resident's need for the splint as previously documented. The facility's policy requires that each resident's comprehensive care plan describe all services necessary to attain or maintain their highest practicable well-being, but this was not followed in this instance.
Failure to Provide Appropriate Foot and Toenail Care
Penalty
Summary
Facility staff failed to provide appropriate foot and toenail care for two residents. One resident, who was cognitively intact and required extensive assistance with grooming and personal care, was repeatedly observed with thick, overgrown toenails containing dark material and dry, scaly skin on his left foot. The resident reported that no staff had attempted to cut his toenails or apply lotion, and although he was told he needed to see a podiatrist, this had not occurred. Review of his records showed no evidence of refusal of care, and staff interviews confirmed that his toenails were long and that he was supposed to be on a podiatrist list, but no documentation or list was provided. The facility's policy on activities of daily living did not address toenail or foot care. Another resident, with a history of CVA, diabetes, and osteomyelitis, and who was moderately cognitively impaired and required maximal assistance for self-care, was observed with excessively long and thick fingernails and toenails. The resident stated he had to bite his fingernails to shorten them and that his toenails were also long. Staff interviews revealed that CNAs were instructed to notify nurses for nail care, and that nurses would add residents to a podiatrist list for toenail care, but there was no evidence in the medical record that the resident had been seen by a podiatrist. The resident's care plan indicated a need for physical assistance, but no documentation of podiatry care was found.
Failure to Implement Splinting Protocol for Resident with Limited ROM
Penalty
Summary
Facility staff failed to provide necessary care and services for a resident with limited range of motion in the left hand. The resident had an occupational therapy discharge summary recommending the use of a left-hand resting splint for eight hours daily to manage muscle tone and prevent decline. The summary documented that the resident tolerated the splint well, and the interdisciplinary team had completed training and instructions for splint or brace care. Despite these recommendations, multiple observations over two days found the resident in bed with a left-hand contracture and no splint in place; the splint was instead seen on the windowsill. Interviews with facility staff revealed a lack of awareness and implementation of the splinting protocol. The occupational therapist confirmed the splint should be worn for seven hours at a time and that training had been provided to CNAs, nurses, and unit managers. However, the CNA responsible for the resident and an LPN both stated they were unaware of the need for the splint. The facility's policy requires that residents with limited mobility receive appropriate services and equipment to maintain or improve mobility, but this was not followed in this case.
Failure to Assess Bed Weight Restrictions for Resident
Penalty
Summary
Facility staff failed to assess whether a resident's bed met the manufacturer's weight restrictions, as required to ensure safety. The resident in question had a recent weight of 484 pounds, and the bed's safe working load was documented as 500 pounds, which includes the resident, mattress, bedding, accessories, and any other equipment or persons likely to be on the bed. There was no evidence in the clinical record that an assessment was conducted to confirm the bed's suitability for the resident's weight and associated equipment. The resident was observed using the bed, which included a trapeze bar and an air mattress, and expressed concerns about the bed's size and functionality. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assessment of bed weight restrictions. The director of maintenance stated that nurses are responsible for determining if weight restrictions are met, but was not familiar with the specific resident. An LPN reported that nurses do not address weight restrictions in relation to the manufacturer's instructions. The facility's policy requires the interdisciplinary team to evaluate the resident's sleeping environment for safety, but there was no documentation that this evaluation occurred for the resident in question.
Unsanitary Tube Feeding Administration
Penalty
Summary
Facility staff failed to administer tube feeding in a sanitary manner for one resident. On multiple occasions, the resident was observed lying in bed receiving tube feeding through tubing that was visibly soiled, with a brown sticky substance covering approximately half of the tubing. According to a registered nurse, the substance was likely tube feeding material that had leaked from the bottle onto the tubing, and the appropriate response would have been to stop the feeding and replace the tubing. The nurse also noted that such a leak could result in the resident not receiving the full amount of tube feeding and could present an infection concern. Facility administrative and clinical leadership were informed of these observations, and no additional information was provided prior to the survey exit.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Facility staff failed to provide trauma-informed care for one resident diagnosed with PTSD, viral hepatitis, and pulmonary fibrosis. The resident was cognitively intact, as indicated by a BIMS score of 13 out of 15, and required maximal assistance for mobility and activities of daily living. The care plan focused on monitoring for adverse effects of antianxiety and antidepressant medications and included a psychiatric consult, but did not address trauma-informed interventions or identify the resident's PTSD triggers. There was no evidence of a PTSD screening or provision of medically related social services specific to trauma care. During interviews, the resident reported that while psychiatry was involved in her care, staff were unaware of her PTSD triggers and social services were not working with her. The resident identified her triggers as seeing violence, even on television, and loud noises, which caused her migraines. Staff interviews confirmed a lack of assessment for PTSD triggers and appropriate trauma-informed interventions. Facility policy required identification of trauma history and use of screening tools, but this was not implemented for the resident.
Lack of Physician Admission Documentation on Resident Readmission
Penalty
Summary
Facility staff failed to provide evidence of a physician's admission note or recommendation for a resident who was readmitted to the facility following a hospital transfer. Specifically, there was no documentation in the clinical record of a physician's note detailing the reason for the resident's hospitalization or the medical justification for readmission on the specified date. This was confirmed through staff interviews and review of the resident's clinical record and facility documents. The resident involved had diagnoses including end stage renal disease (ESRD), congestive heart failure (CHF), and diabetes mellitus, and was assessed as moderately cognitively impaired, requiring moderate assistance with daily activities. Despite the facility's policy requiring attending physicians to assess new admissions in a timely manner, no physician documentation was found for the resident's readmission, as acknowledged by multiple administrative and clinical staff members.
Failure to Provide Medically Related Social Services for PTSD
Penalty
Summary
Facility staff failed to provide medically related social services for one resident who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), among other conditions. The resident was not cognitively impaired and required significant assistance with daily activities. The care plan included monitoring for adverse effects of psychiatric medications and a referral for a psychiatric consult, but there was no evidence of a PTSD-specific assessment or follow-up by social services. The resident reported that while psychiatry was involved in her care, staff were unaware of her PTSD triggers and social services had not engaged with her regarding her diagnosis. Interviews with facility staff revealed that the Director of Social Services was unaware of the resident and had not completed a social services assessment, citing a lack of referral notification. The LPN interviewed identified that a PTSD assessment should include identifying triggers and behaviors, but this was not documented or implemented. Review of the facility's social worker job description confirmed the responsibility to provide medically related social services and follow up on psychosocial needs, which was not fulfilled in this case.
Failure to Provide and Document Availability of Prescribed Medications
Penalty
Summary
Facility staff failed to maintain the availability of prescribed medications for one resident, who had diagnoses including hypertension and hyperlipidemia and was moderately cognitively impaired. The resident had active physician orders for Diltiazem, Ezetimibe, and Methylcobalamin, but on a specified date, these medications were not administered as indicated by blanks in the electronic medication administration record (eMAR). There was no documentation in the nursing progress notes or eMAR notes explaining the missed doses, nor was there evidence that the pharmacy was notified about the need for these medications. Further review showed that the medications were not available in the facility's Omnicell inventory or as part of the facility's stock, and staff interviews confirmed that the medications would have needed to be obtained from the pharmacy. The deficiency was identified through clinical record review and staff interviews, with facility leadership being made aware of the findings during the survey. No additional information or documentation was provided prior to the survey exit.
Medication Error Rate Exceeds Five Percent During Medication Pass
Penalty
Summary
Facility staff failed to maintain a medication error rate below five percent during medication administration observation. Specifically, a registered nurse administered two drops of Timoptic Ophthalmic Solution in each eye to a resident, contrary to the physician's order, which specified one drop in both eyes. Additionally, the nurse failed to administer Trusopt Ophthalmic Solution in the resident's left eye as ordered. These actions resulted in two medication errors out of 32 opportunities, yielding a medication error rate of 6.25%. The resident involved was being treated for glaucoma, with physician orders documented for both Timoptic and Trusopt ophthalmic solutions. The errors were observed during a medication pass, and the nurse later stated she was unaware of having administered the Timoptic drops twice and omitting the Trusopt drops. The facility's medication administration policy requires confirmation of the five rights (right resident, right medication, right dose, right route, right time) at each stage of administration, but this protocol was not followed in this instance.
Failure to Implement Complete Pneumococcal Immunization Program
Penalty
Summary
Facility staff failed to implement a complete immunization program for two of five residents reviewed for immunizations. For one resident, there was no evidence that the resident or their representative was offered the pneumonia vaccine or educated about it upon admission. The resident had previously received a pneumococcal vaccine prior to admission, but documentation regarding the offer, education, or administration of the recommended follow-up vaccine was missing until a later date. Staff interviews revealed uncertainty about the delay, with the LPN stating that vaccines were typically offered upon admission and the infection preventionist, who usually handled vaccinations, was no longer employed at the facility. For another resident, the facility failed to document administration of the pneumonia vaccine despite evidence that the resident's representative had consented to the vaccine after receiving education. The clinical record did not show that the vaccine was administered until a later date. Staff interviews again indicated that vaccines were usually offered upon admission, but the reason for the delay was unclear to both the LPN and the DON. Facility policy required assessment for vaccine eligibility and offering of the pneumococcal vaccine series within thirty days of admission unless contraindicated or already vaccinated. CDC recommendations for pneumococcal vaccination were referenced, but the facility did not provide documentation showing timely compliance with these guidelines for the two residents in question. The findings were communicated to facility leadership, and no further information was provided prior to the survey exit.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
Facility staff failed to notify the responsible party (RP) of a change in condition for one resident who experienced an outbreak of genital warts beginning in July 2024. The resident, who was moderately cognitively impaired and required maximal assistance for daily activities, had a history of recurrent genital warts, incontinence, and multiple comorbidities including CVA, diabetes, and epilepsy. Despite the presence of a care plan intervention to report changes in skin integrity and a physician's order for topical treatment, there was no documented or confirmed notification to the resident's wife regarding the outbreak and subsequent bleeding from the warts. Interviews with facility staff, including an LPN and a nurse practitioner, revealed that while the staff and medical team were aware of the resident's condition and provided regular care, they did not inform the RP about the genital warts during this episode. The nurse practitioner acknowledged that the resident's wife was upset upon discovering the bleeding and was unaware of the outbreak, and staff could not confirm prior notification. The facility's policy required prompt notification of changes in a resident's condition to the resident, physician, and representative, but this was not followed in this instance.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to post daily nurse staffing information that included all required elements, specifically omitting the facility name and resident census from the posted documents. Observations conducted in the entrance lobby area on two separate days confirmed that the posted nurse staffing information did not display the facility census or the facility name. A review of the previous 30 days of staff postings also showed that these required details were consistently missing from the nurse staffing data sheets. During an interview, the staffing coordinator responsible for posting the daily nurse staffing data sheets stated that she had never included the census on the form, as it was available on the nursing schedules and subject to change. She also acknowledged that she had not noticed the absence of the facility name on the form. The facility's own policy, dated 10/6/22, requires that both the facility name and resident census be included in the daily posting at the beginning of each shift. No additional information was provided prior to the survey exit.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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