Glenburnie Rehab & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 1901 Libbie Ave, Richmond, Virginia 23226
- CMS Provider Number
- 495391
- Inspections on file
- 28
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Glenburnie Rehab & Nursing Center during CMS and state inspections, most recent first.
Facility staff did not update care plans for three residents after new wounds or pressure injuries were identified, despite clinical documentation and treatment recommendations. Care plans failed to reflect new or worsening skin conditions, and staff interviews confirmed that care plans should include all current wounds and interventions, in accordance with facility policy.
Staff failed to implement timely and appropriate interventions for pressure injury prevention and treatment for three residents, including delays in following wound care recommendations, improper infection control practices during wound care, and lack of updates to care plans and treatment records. There was confusion among staff regarding responsibility for entering and implementing wound care orders, resulting in missed or delayed treatments.
A resident with a history of acute respiratory failure, CHF, and OSA was not provided with CPAP therapy as ordered in the hospital discharge summary. Although staff communicated with a NP and a respiratory therapist about setting up a device, there was no documentation that CPAP was initiated during the resident's stay. Staff interviews confirmed that the facility is responsible for providing a CPAP if the resident cannot bring their own, but this was not done.
Staff did not follow infection control procedures by failing to use enhanced barrier precautions for a resident with chronic wounds and a Foley catheter. An LPN provided wound care without donning PPE or ensuring appropriate signage, and there was no documentation of enhanced barrier precautions being implemented since the resident's admission, despite facility policy and staff interviews confirming these requirements.
A resident with severe cognitive impairment and total incontinence was not offered incontinence care for over seven hours while being moved between rooms. Staff interviews confirmed that incontinent residents should be checked at least every two hours, and management acknowledged that extended lack of care can cause emotional distress and loss of dignity.
A resident with significant mobility limitations and pressure injuries was unable to access their call bell, which was found on the floor and out of reach. Despite care plan interventions to keep items within reach and remind the resident to use the call light, staff did not ensure the call bell was accessible, and an LPN acknowledged it had fallen earlier. Facility policy requires call bell cords to be off the floor and properly clipped, but this was not followed.
A resident's room was observed over several days to have a roughly plastered wall section and white plaster dust on the headboard and floor. Both maintenance and housekeeping staff confirmed the room was not in good repair or clean, contrary to facility policy requiring regular inspection and maintenance of resident rooms.
A resident admitted with sleep apnea and using a C-PAP machine did not have this device or related care needs documented in the baseline care plan within 48 hours of admission. Staff confirmed the omission, and administrative staff were notified during the survey.
Facility staff did not timely implement the care plan for a resident with pressure injuries, resulting in delayed wound care treatments and interventions such as wound dressings and use of an air mattress. Documentation and staff interviews confirmed that care plan orders were not followed as recommended, and the facility's policy lacked guidance on the importance of adhering to care plans.
A resident who was fully dependent on staff for bathing did not receive a bath or shower on two occasions, with no documentation of refusal. Interviews with CNAs confirmed that care is expected to be provided and documented daily, and facility policy supports regular bathing routines.
Staff failed to provide incontinence care for a cognitively impaired, fully incontinent resident over a period exceeding seven hours, despite facility practice and staff interviews indicating that such care should be provided at least every two hours. The resident was moved between common areas but was not taken for incontinence checks or care during this time.
A resident with a history of fractures and recent knee surgery reported severe, unrelieved pain, but staff failed to provide immediate pain management or contact the on-call physician. Documentation showed a delay in reinstating as-needed Oxycodone, and no evidence that the attending provider was notified or that a pain assessment was completed as required by facility policy.
A resident with a critically low potassium level had a lab result communicated to nursing staff overnight, but repeated attempts to reach the on-call physician were unsuccessful. Nursing staff did not escalate the issue to the medical director or backup provider, and the attending physician was not made aware of the critical result. Facility policy and expectations for 24-hour physician coverage were not met.
Staff failed to accurately document medication administration for two residents, including missing entries for a prescribed medication on the eMAR for a resident with severe cognitive impairment and incomplete controlled drug records for another resident receiving pain management. These deficiencies were confirmed through staff interviews and record reviews.
A resident with severe cognitive impairment and a history of wandering was involved in multiple fire incidents, including setting fire to a mattress and bathroom tissue, due to inadequate supervision and failure to monitor for fire-starting materials. Staff did not consistently inspect the resident's room or belongings, and some residents who smoked did not use required lock boxes for their smoking materials. Staff interviews revealed a lack of awareness and education regarding the need for monitoring, and the facility did not conduct a thorough investigation into how the resident obtained lighters, resulting in repeated safety hazards.
Facility staff did not effectively implement a QAPI program after a fire incident caused by a resident who used a lighter in their room. Although a plan was in place requiring lock boxes for smoking materials and staff education, a resident reported not using a lock box, and staff interviews revealed they were not informed or educated about the incident or necessary interventions. The administrator was unaware of the plan's ineffectiveness, and the facility's policy assigning responsibility for QAPI oversight was not followed.
Facility staff did not maintain or provide valid, signed agreements for contracted podiatry and eye care services. When requested, only unsigned agreements dated the day before the survey were available, and the administrator could not locate the original contracts, contrary to facility policy requiring signed approval for third-party service agreements.
A resident did not receive physician visits within the required sixty-day interval, as facility records showed a gap between documented visits. Although the resident saw two outside providers during this period, they were not seen by a facility physician, contrary to facility policy requiring provider visits at least every 60 days after the initial 90 days post-admission.
Facility staff did not post complete daily nurse staffing records for 30 days, omitting required resident census information for all shifts. Staff interviews revealed a lack of training on documenting census data, and facility policy did not address this requirement.
Multiple residents did not receive their medications within the required timeframes, with repeated late or missed doses of critical medications such as Acyclovir, Cresemba, Metoprolol, Eliquis, Carvedilol, Gabapentin, and others. Nursing staff confirmed that medications were not always administered as ordered, and medication administration records showed significant delays. Facility policy and professional standards requiring timely administration were not followed.
Staff failed to monitor and document required blood pressure readings before administering antihypertensive medications to two residents, resulting in medications being given outside of physician-ordered parameters. Nursing staff and the DON confirmed that vital sign checks and documentation were required but not performed, and facility policy on medication administration was not followed.
Facility staff did not maintain a resident's room and bathroom in a clean and dignified state, as evidenced by persistent holes, stains, and debris in the flooring and on fall mats, despite scheduled cleaning. The resident, who was moderately cognitively impaired, reported feeling bad about the room's condition and uncomfortable using the bathroom. The director of environmental services agreed the environment was not clean or dignified, in violation of the facility's policy on resident rights.
A resident's room and bathroom were found to be in an unclean and unhomelike condition, with damaged flooring, stains, and debris persisting despite regular housekeeping. Facility staff, including environmental services and maintenance, confirmed the poor state of the environment and acknowledged the need for repairs, while the resident expressed dissatisfaction with the bathroom conditions.
A resident with AML and other complex medical needs did not receive medications as ordered, with multiple late or missed doses documented. Nursing staff confirmed that the care plan, which required timely medication administration, was not implemented as prescribed.
Staff did not update or revise care plans for three residents after significant changes or incidents, including the start of hospice care and multiple falls. In each case, care plans failed to reflect new interventions or changes in condition, such as hospice services or the use of fall mats, despite staff acknowledging that such updates were required. Documentation and observations confirmed that care plans were not reviewed or revised as expected following these events.
Staff failed to administer ordered blood glucose checks and insulin at bedtime for a resident with diabetes and did not complete wound care treatments for another resident's skin tear on multiple occasions. Documentation in the MAR and eTAR confirmed these omissions, and staff interviews verified that these treatments were not performed as required.
Staff failed to implement and document required fall prevention measures for two residents with a history of falls. One resident, dependent for mobility and with multiple diagnoses, was not provided with all care plan interventions such as bilateral bed rails and non-skid socks, resulting in multiple falls. Another resident, moderately impaired and with recent falls, was observed without fall mats in place despite documentation that they were needed. Staff interviews and care plan reviews confirmed that fall prevention interventions were not consistently in place or documented.
A resident did not receive meals in the physician-ordered mechanically altered texture due to a delay in communicating the diet change from nursing to dietary staff. The process required nurses to update records and hand-deliver a diet communication slip, but the form was not completed until several days after the order, resulting in the resident not receiving food in the correct form.
A resident did not receive their prescribed Flonase medication for two days due to unavailability, and the facility staff failed to notify the physician and responsible party. The facility's policy required such notifications and documentation, which were not completed. An LPN indicated that over-the-counter medications should not be marked as waiting for pharmacy delivery, and the administrative staff were informed of the findings.
Two residents were subjected to verbal abuse by an intoxicated LPN who was not scheduled to work. The LPN yelled and cursed at residents, making threats of physical harm. Despite the residents' cognitive impairments preventing them from recalling the incident, staff corroborated the abusive behavior. The facility failed to immediately review or revise the residents' care plans or conduct trauma assessments, violating their policy on abuse and neglect.
A facility failed to protect two residents from verbal abuse by an intoxicated LPN who was not scheduled to work. The LPN was observed yelling and making threats, and claimed to have over-medicated another resident. The residents involved could not recall the incident due to cognitive impairment, and the facility did not document the incident in their care plans or conduct necessary trauma assessments.
A resident with a history of wandering and severe cognitive impairment eloped from the facility without supervision. The investigation into the incident was incomplete, lacking documentation on the functionality of the resident's wander guard and door alarms. The resident was found and returned without injury, but the investigation did not meet the facility's policy standards.
The facility failed to update the care plans for two residents following a verbal abuse incident involving an intoxicated LPN. Despite the incident being substantiated, the care plans for the affected residents, who were cognitively impaired, were not reviewed or revised to include new interventions. Staff interviews revealed confusion about responsibility for updating care plans after such incidents.
A resident in an LTC facility was found lethargic and only responsive to sternal rubs after an LPN, who was reportedly intoxicated, claimed to have overmedicated them. Despite the resident's condition, the nurse practitioner only advised continued monitoring, and the family took the resident to the hospital, where they were admitted with elevated troponin and lactic acid levels. The investigation found no evidence of medication administration by the LPN on the day of the incident.
A resident with severe cognitive impairment was involved in a fire incident in their room, where a mattress and privacy curtain were burned. Despite a previous incident where a lighter was confiscated from the resident, the facility failed to prevent the resident from accessing another lighter. Another resident discovered the fire and extinguished it. The facility's lack of effective supervision and interventions led to this deficiency.
A facility failed to provide necessary social services to a resident after a verbal abuse incident involving an intoxicated LPN. The resident, who was moderately impaired, did not receive a trauma screen or social service assessment following the incident. The facility's policy required addressing psychosocial needs, but these procedures were not followed, leading to a deficiency.
A resident did not receive Flonase as prescribed due to unavailability in the facility. Despite the physician's order and documentation in the MAR, the medication was not administered on multiple days. Staff interviews revealed that the facility's process for obtaining medications was not fully effective, as Flonase was not found in the medication room or stock room. The central supply staff member indicated that their supplier did not carry Flonase, and the facility's policy for notifying the provider and responsible party was not fully followed.
A resident with Type II Diabetes Mellitus was repeatedly administered Humalog insulin despite physician orders to withhold it when blood sugar was below 150. This occurred multiple times over three months, as documented in the eMAR. An LPN confirmed the oversight, which was against the facility's medication administration policy.
The facility failed to maintain an operational resident call system in seven rooms, as observed during a survey. The call systems in these rooms were not functioning, with issues such as missing pull stations and non-activating call bells/lights. The director of maintenance acknowledged the problem, citing a wait for parts to fix the systems. The facility's policy requires monthly inspections and documentation of repairs, but this was not adhered to, leading to the deficiency.
The facility failed to maintain a safe and sanitary environment in the rehab restroom, where a ceiling tile was covered with a black substance due to a leak. Staff interviews revealed the issue had been ongoing for years, worsening recently, leading to the restroom's closure. The director of maintenance was aware of the leak and was awaiting a repair quote.
Failure to Update Care Plans Following New Wounds and Pressure Injuries
Penalty
Summary
Facility staff failed to revise and update care plans for three residents after the development of new wounds or pressure injuries. For one resident, the care plan was not updated to reflect a newly identified pressure injury on the left heel, despite clinical documentation and treatment recommendations by the wound nurse practitioner. The care plan only referenced prior skin impairments and did not include the new wound, as confirmed by both the regional director of clinical operations and the unit manager during interviews. Another resident developed a stage 3 pressure ulcer on the left buttock, as documented in the skin and wound progress notes. The care plan for this resident did not include the presence of the stage 3 pressure ulcer or any interventions to address it, even though the wound nurse practitioner had provided specific treatment recommendations. Staff interviews confirmed that the care plan should have been updated to include all current wounds and interventions. A third resident developed an abrasion on the left gluteal fold that required treatment. The care plan was not updated to reflect the presence of this wound, despite clinical documentation and treatment recommendations. Staff interviews consistently indicated that care plans are intended to map out all aspects of resident care, including wounds, and that all nurses have the ability to update care plans as needed. The facility's policy requires care plans to be updated on an ongoing basis as changes occur, but this was not followed in these cases.
Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
Facility staff failed to implement timely and appropriate interventions to prevent and treat pressure injuries for three residents. For one resident, staff did not follow the wound nurse practitioner's recommendations for wound care, including delayed implementation of prescribed treatments and failure to provide an air mattress as recommended. Observations revealed improper infection control practices during wound care, such as not using personal protective equipment (PPE), cross-contaminating clean and dirty supplies, and placing clean gloves and wound cleanser on soiled bed linens. The resident reported not receiving heel boots as recommended, and documentation showed delays in updating care plans and treatment administration records to reflect new or worsening wounds. Another resident was admitted with moisture-related skin irritation and later developed a Stage 3 pressure ulcer. The wound nurse practitioner's recommendations for wound care and preventive measures, such as floating the heels, were not implemented. The treatment administration record did not show evidence of the recommended interventions being carried out, and the care plan was not updated to reflect the presence of the Stage 3 pressure ulcer or the necessary interventions. Interviews with staff revealed a lack of clarity regarding roles and responsibilities for implementing wound care recommendations, with some staff unaware of the process for ensuring that recommendations were entered into orders and care plans. A third resident developed a new wound during their stay, and the wound nurse practitioner's treatment recommendations were not implemented prior to discharge. The care plan was not updated to include the new wound, and the treatment administration record did not reflect the prescribed care. Staff interviews indicated that recommendations from the wound nurse practitioner were not always translated into actionable orders or care plan updates, and there was confusion about who was responsible for ensuring implementation. Facility policy required notification of providers and implementation of treatments as ordered, but this was not consistently followed.
Failure to Provide Required CPAP Therapy for Resident with Sleep Apnea and CHF
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident who required CPAP therapy following a hospital stay for acute respiratory failure secondary to congestive heart failure and obstructive sleep apnea. The hospital discharge summary specified the need for CPAP at night, but a review of the resident's clinical record showed no evidence that CPAP therapy was initiated during the resident's stay. Progress notes indicated that staff communicated with a nurse practitioner regarding the placement of a BiPAP device, and a respiratory therapist was notified to set up the machine, but there was no documentation that the CPAP was ever provided. Interviews with staff revealed that the admitting nurse is responsible for verifying CPAP orders with the physician and informing them if the facility does not have a CPAP machine available. Staff also stated that it is the facility's responsibility to provide a CPAP device if the resident is unable to bring their own from home. Despite these procedures, the facility did not provide the required CPAP therapy, and no policy or additional information regarding CPAP provision was supplied when requested by surveyors.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control procedures for one of eight residents reviewed, specifically by not applying enhanced barrier precautions for a resident with chronic wounds and a Foley catheter. During wound care, the LPN responsible did not don any personal protective equipment (PPE) such as gown or gloves prior to entering the resident's room or providing care. Additionally, there was no signage or PPE related to isolation precautions visible outside the resident's room. Review of the clinical record showed no orders for or evidence of enhanced barrier precautions being implemented since the resident's admission, despite the presence of risk factors. Interviews with the director of nursing and the regional director of clinical operations confirmed that enhanced barrier precautions are required for residents with chronic wounds or indwelling medical devices. Facility policy also mandates the use of gown and gloves during high-contact care activities for such residents. However, these precautions were not followed for the resident in question, as evidenced by both observation and documentation review.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
Facility staff failed to provide care in a dignified manner for one resident who was observed from 10:07 a.m. to 5:30 p.m. without being offered incontinence care. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken back to her room for incontinence care. Continuous observation confirmed that no staff member provided or offered incontinence care throughout the entire period. Interviews with CNAs and an LPN confirmed that incontinent residents should be checked at least every two hours, with some requiring more frequent checks, especially those unable to communicate their needs. Staff acknowledged that failing to provide timely incontinence care can lead to skin breakdown and is not consistent with treating residents with dignity. Facility management agreed that lack of incontinence care for an extended period could result in emotional distress and a diminished quality of life for the resident.
Failure to Ensure Resident Call Bell Accessibility
Penalty
Summary
Facility staff failed to accommodate the needs of a resident by not ensuring the resident's call bell was accessible. The resident, who was admitted with diagnoses including diabetes mellitus, pressure injury, and embolism, was assessed as cognitively intact but required moderate to total assistance for mobility and activities of daily living. The resident's care plan included interventions to place common items within reach and to remind the resident to use the call light for assistance. However, during observation, the call bell was found dangling from the side rail to the floor, out of the resident's reach, and the resident was unaware of its location. An interview with an LPN revealed that the call bell had likely fallen off the bed earlier and had not been returned to an accessible position. Facility policy requires that call bell cords not be in contact with the floor and be properly clipped. The administrative staff, including the interim administrator, DON, and vice president of operations, were made aware of the finding. No additional information was provided prior to the survey exit.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Facility staff failed to maintain a homelike and clean environment in one of the resident rooms, specifically room [ROOM NUMBER]-B. Multiple observations over several days revealed a section of wall behind the head of the bed that was roughly plastered, measuring approximately 15 inches wide and 36 inches long. White plaster dust was noted coating the top of the headboard and the floor under the head of the bed during each observation. The call bell was within reach, but the room's condition remained unchanged across the observed dates. During interviews, the maintenance director acknowledged that the wall required further work, including sanding, re-mudding, and painting, and confirmed that the room was not in good repair or homelike. The housekeeping director also stated that the room should not have been left in its observed condition, describing it as neither clean nor homelike. The facility's policy requires regular inspection and maintenance of patient rooms to ensure safety and proper upkeep, including the replacement of damaged wall or floor tiles. Despite these policies, the room remained in disrepair and unclean throughout the survey period.
Failure to Include C-PAP Use in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop a baseline care plan addressing the use of a C-PAP machine for one resident within 48 hours of admission. The resident was admitted with a diagnosis that included sleep apnea and was documented as cognitively intact and oriented. The admission assessment and nurse's notes confirmed the resident's use of a C-PAP machine, and the device was observed in the resident's room. However, review of the baseline care plan did not show any documentation regarding the C-PAP use. Staff interviews confirmed that the purpose of the care plan is to ensure all staff are informed about the resident's care needs, and that the C-PAP should have been included. Administrative staff were made aware of the omission during the survey, but no additional information was provided prior to the survey team's exit.
Failure to Implement Care Plan for Pressure Injuries
Penalty
Summary
Facility staff failed to implement the care plan for a resident with pressure injuries, as evidenced by delays in carrying out wound care treatments and interventions as ordered by the wound nurse practitioner. The resident was admitted with existing skin impairments, including a Stage 2 sacral pressure injury and deep tissue injuries (DTIs) on both heels. The care plan and treatment recommendations included specific wound care regimens, use of an air mattress, and heel-floating interventions. However, documentation review showed that these treatments were not initiated in a timely manner. For example, wound care orders for the sacrum and right heel were not implemented until several days after being recommended, and the air mattress was not provided until even later. Similarly, a new wound on the left heel was not treated according to recommendations until over a week after the order was given. Interviews with facility staff, including a unit manager and administrative staff, confirmed that all staff are responsible for implementing care plan elements, which are designed to address the resident's diagnoses and needs. Despite this, the care plan interventions for the resident's pressure injuries were not followed as ordered. Additionally, a review of the facility's care planning policy revealed no information emphasizing the importance of adhering to the care plan, further highlighting the lack of implementation for this resident's wound care needs.
Failure to Provide and Document Bathing for Dependent Resident
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically bathing, to a dependent resident on two separate days in October 2025. The resident, who was completely dependent on staff for bathing according to the most recent Minimum Data Set (MDS) admission assessment, did not receive a shower or bath on these days as documented in the point of care records. There was no evidence in the records that the resident refused bathing on either day. Interviews with two CNAs revealed that both staff members stated they routinely bathe and document care for all assigned residents daily. The lead CNA confirmed that if a bath is not documented in the electronic medical record, there is no way to verify that the care was provided. Facility policy indicates that bathing typically occurs after breakfast or the evening meal, and the resident's choice of bath type and timing is respected when possible. No additional information was provided prior to the survey exit.
Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide timely incontinence care for one resident who was observed continuously from 10:07 a.m. to 5:30 p.m. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken to her room for incontinence checks or care. Staff interviews confirmed that the standard practice is to check incontinent residents at least every two hours, with some staff indicating even more frequent checks for residents unable to communicate their needs. However, the assigned CNA admitted that, despite walking by and checking in on the resident, she did not take the resident to her room for incontinence care at any time during her shift. The resident's most recent assessment indicated severe cognitive impairment, inability to communicate needs effectively, and total dependence on staff for toileting. Facility management and staff acknowledged that extended periods without incontinence care could lead to skin breakdown and emotional distress. A review of the facility's urinary elimination policy did not specify the required frequency for incontinence care, and no additional relevant documentation was provided prior to the survey exit.
Failure to Provide Timely Pain Management for Resident with Severe Pain
Penalty
Summary
Facility staff failed to provide appropriate pain management for a resident with a history of fractures and recent surgical wounds on both knees. The resident was observed multiple times reporting knee pain and stated that while pain was usually managed, there were instances of severe pain that were not relieved by medication. On one occasion, the resident reported experiencing 10/10 pain in both knees and requested as-needed Oxycodone, but was informed by nursing staff that it was no longer on her medication list. The nurse documented the request and updated the MD Communication Book but did not provide immediate intervention or contact the on-call physician for alternative pain relief. A review of the resident's clinical records showed that an order for as-needed Oxycodone was not reinstated until several hours later, and there was no evidence that the attending nurse practitioner or physician was made aware of or addressed the severe pain episode at the time it occurred. Interviews with facility staff confirmed that the appropriate protocol would have been to contact the on-call physician for immediate pain management, especially for a report of 10/10 pain. The facility's pain management policy required a pain assessment whenever a patient experienced unusual pain, but there was no documentation of such an assessment or timely intervention in this case.
Failure to Provide 24-Hour On-Call Physician Services for Critical Lab Result
Penalty
Summary
Facility staff failed to provide 24-hour on-call physician services for one resident when a critical laboratory result was received. The resident had a potassium level of 2.9 mEq/L, which is below the normal range. Nursing staff documented that they attempted to contact the on-call physician multiple times during the early morning hours, but did not receive a return call. The progress notes indicate that the on-call physician was not reached despite repeated attempts, and the issue was not escalated to the medical director or backup provider as per facility expectations. Interviews with administrative and clinical staff confirmed that nurses are expected to reach an on-call physician at all times and should escalate to the medical director if unable to do so. The attending physician stated that there is always a backup provider available and that the on-call service has their contact information. He also confirmed he was not made aware of the resident's critical potassium level and would have ordered immediate treatment if notified. No additional documentation or policy regarding 24-hour physician coverage was provided prior to the survey exit.
Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for two residents. For one resident with severe cognitive impairment and a diagnosis including gastro-esophageal reflux disease, staff did not document the administration of Protonix on the electronic medication administration record (eMAR) as required. Although nursing notes indicated the medication was given while the resident was waiting for dialysis, the eMAR entry for the scheduled time was left blank. The nurse responsible later acknowledged in a written statement that the medication was administered but the eMAR was not signed immediately due to oversight. For another resident, who was cognitively intact and admitted with diagnoses including nerve damage and chronic pain, staff failed to accurately document the administration of Oxycodone on the Controlled Drug Administration Record. The eMAR showed that the resident received the medication at two scheduled times, but the corresponding entries were missing from the controlled substance log. The DON confirmed that the nurse forgot to document the administration on the controlled drug record as required. Both deficiencies were identified through staff interviews and clinical record reviews. The failures involved not immediately documenting medication administration in the appropriate records, as confirmed by staff and administrative interviews. No additional information or documentation was provided by facility leadership prior to the survey exit.
Failure to Prevent and Investigate Repeated Fire Incidents Involving Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to thoroughly investigate and implement effective interventions following multiple fire incidents involving a resident with severe cognitive impairment. The resident, who had a history of wandering, collecting items, and previous smoking, was found with a lighter and was involved in several fire-related incidents, including a fire on a mattress, burn spots on privacy curtains, and a toilet tissue roll set on fire in his bathroom. Despite these events, staff did not consistently monitor the resident or his room for fire-starting materials, nor did they ensure that interventions such as the use of lock boxes for smoking materials were properly implemented for all residents. Clinical records and staff interviews revealed that the resident was severely cognitively impaired, with a low BIMS score, and was unable to recall the fire incidents or how he obtained lighters. Documentation showed that after each incident, staff searched the resident and his room but failed to identify how the resident continued to access fire-starting materials. There was also a lack of consistent and ongoing supervision, as the resident was observed unsupervised in his room and wandering the halls. Staff interviews indicated a lack of awareness and education regarding the need to monitor the resident and inspect his belongings for lighters or other fire-starting materials. Additionally, the facility did not ensure that all residents who smoked used lock boxes for their smoking materials, and some residents left their lock boxes unlocked or did not use them at all. Staff did not routinely inquire whether other residents had been approached for lighters or smoking materials, and there was no documentation of a thorough investigation into how the resident obtained these items. The facility's failure to implement and maintain effective supervision and safety interventions resulted in repeated fire incidents and placed all residents at risk.
Failure to Implement Effective QAPI Program Following Fire Incident
Penalty
Summary
Facility staff failed to implement an effective QAPI (Quality Assurance and Performance Improvement) program related to a fire incident involving residents. On the date of the incident, a resident lit a roll of toilet paper on fire in his bathroom, which was extinguished by staff. Both residents in the affected room were evacuated, and the fire department responded. The resident responsible for the fire had a known history of attempting to use a lighter in the room and was placed on one-on-one supervision until cleared by psych evaluation. Assessments for pain, skin, and respiratory status were conducted for both residents involved. Despite the QAPI plan outlining steps to prevent recurrence, including the use of lock boxes for smoking materials and staff education, the facility failed to ensure these measures were effectively implemented. During interviews, a resident who smoked stated she did not use a lock box and hid her belongings in her room, with a lock box found open and unsecured. Multiple staff members, including CNAs, LPNs, and a housekeeper, reported not receiving education or instructions regarding the fire incident, interventions for the resident involved, or the need to inspect rooms for lighters and smoking paraphernalia. The administrator acknowledged not noticing the ineffectiveness of the QAPI plan. The facility's policy assigns responsibility to the administrator for directing the QAPI plan to identify and address risks or deficiencies, but the documented actions and staff interviews indicate a lack of follow-through and communication regarding the interventions required to prevent similar incidents.
Lack of Signed Contracts for Podiatry and Eye Care Services
Penalty
Summary
Facility staff failed to maintain and provide evidence of signed agreements for contracted podiatry and eye care services. During a review of facility contracts, no agreements were found for these services. When requested, the director of nursing presented agreements dated the day prior to the survey, but these were unsigned by a facility representative. The administrator stated that the facility began using the podiatry and eye care companies before her employment and was unable to locate the original contracts. Facility policy requires that all contracts with third-party providers be approved and signed by designated officers prior to the initiation of services, and unsigned agreements are not considered valid.
Failure to Provide Timely Physician Visits
Penalty
Summary
Facility staff failed to provide timely physician visits for one of nine residents reviewed, specifically for Resident #5. Clinical record review showed that the resident had physician visits on 4/22/24 and 7/16/24, with no physician visits documented between these dates, resulting in a gap longer than the required sixty days. The director of nursing confirmed that most residents are to be seen quarterly unless receiving skilled nursing services and acknowledged that, although the resident saw two outside providers during this period, they were not seen by a facility physician as required by facility policy. The facility's policy mandates that after the first 90 days post-admission, residents must be seen by a provider at least every 60 days.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to post a complete and accurate daily nursing staffing record for 30 consecutive days, as required. Review of staffing posting sheets for a 30-day period revealed that none included resident census information for any shift. Interviews with a CNA indicated that while she was trained to calculate RN, LPN, and CNA hours, she had not been trained to record the resident census for each shift. The facility's policy on the Daily Nurse Staffing Summary also lacked guidance regarding the inclusion of resident census information. No additional information was provided prior to the survey exit. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Administer Medications Timely According to Professional Standards
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards of practice for multiple residents. For one resident with acute myeloblastic leukemia, congestive heart failure, and renal insufficiency, there were repeated instances of late or missed administration of critical medications, including Acyclovir, Cresemba, Revumenib Citrate, and Cefdinir. The medication administration audit revealed numerous occasions where medications were given outside the prescribed timeframes, sometimes hours late or not until the following day. Interviews with nursing staff confirmed that medications were not always administered as ordered, and that this constituted a failure to implement the care plan interventions. Additional deficiencies were observed for three other residents. One resident was observed receiving Metoprolol and Eliquis later than the scheduled administration times, as documented in the electronic medication administration record. Another resident was given Carvedilol and Gabapentin outside of the scheduled times. A third resident reported receiving evening and bedtime medications late, sometimes after midnight or in the early morning, which was corroborated by the medication administration records showing significant delays for multiple medications, including Xarelto, Nabumetone, Bupropion, Hydromorphone, Gabapentin, Finasteride, and Seroquel. Staff interviews indicated an understanding of the one-hour window before and after scheduled medication times, but also revealed that late administration was not consistently communicated to physicians, as required when significant delays occurred. Facility policy required medications to be administered in a safe and effective manner, and reference materials cited the standard of administering medications within 60 minutes of the scheduled time. The failure to adhere to these standards was confirmed through observation, record review, and staff interviews.
Failure to Monitor and Follow Medication Hold Parameters for Antihypertensives
Penalty
Summary
Facility staff failed to properly monitor and follow medication administration orders for two residents, resulting in the administration of antihypertensive medications without adhering to required blood pressure parameters. For one resident, an LPN administered Carvedilol without obtaining a blood pressure reading beforehand, despite physician orders specifying the medication should be held if the systolic blood pressure was less than 110. Review of the electronic medication administration record (eMAR) and clinical records showed no evidence of blood pressure monitoring prior to administration, and staff interviews confirmed that vital signs should have been checked and documented as per facility policy. For another resident, staff administered Metoprolol Succinate on multiple occasions even when the resident's systolic blood pressure was below the ordered threshold of 110. The eMAR documented administration of the medication with blood pressures as low as 88/55, 97/73, and 108/58, contrary to the physician's hold parameters. Interviews with nursing staff and the DON confirmed that medications with vital sign parameters require supplementary documentation and should be held if the resident's vital signs fall outside the specified range. Facility policy also required checking for vital signs prior to medication administration, but this was not followed in these cases.
Failure to Maintain Resident Room and Bathroom in a Dignified Condition
Penalty
Summary
Facility staff failed to maintain a resident's room and bathroom in a dignified and clean condition. Multiple observations over two days revealed the resident's bathroom had approximately 14 holes in the linoleum flooring, with sizes ranging from one-and-a-half inches to six inches in length and up to three inches in width. The flooring was curling away from the wall under the sink and behind the toilet, with multiple cuts, black substances, and several stained areas throughout. The area around the resident's bed had two fall mats with food stains and debris, and the room floor had visible food debris, dirt, and stained areas from food and spilled liquids. These conditions persisted despite the housekeeper cleaning the room during one of the observations. The resident, who was moderately cognitively impaired but able to make daily decisions, expressed feeling bad about the condition of the room and uncomfortable using the bathroom in its state. The director of environmental services confirmed the room and bathroom were not clean or dignified after reviewing the conditions. The facility's policy states that residents have the right to live in safe, decent, and clean conditions, but this standard was not met for this resident.
Failure to Maintain Clean and Homelike Resident Room and Bathroom
Penalty
Summary
Facility staff failed to maintain a resident's room and bathroom in a clean, safe, and homelike condition. Multiple observations over two days revealed the resident's bathroom had approximately 14 holes in the linoleum flooring, with sizes ranging from one-and-a-half inches to six inches in length and up to three inches in width. The flooring was curling away from the wall under the sink and behind the toilet, with multiple cuts, black substances, and several stained areas. The floor area around the resident's bed had two fall mats with food stains and debris, and the room floor itself had food debris, dirt, and stained areas from food and spilled liquids. These conditions persisted even after the housekeeper had cleaned the room. Interviews with facility staff, including the director of environmental services and the assistant director of maintenance, confirmed the unclean and unhomelike state of the room and bathroom. The assistant director of maintenance acknowledged that the bathroom floor needed repair or replacement and that no work order had been submitted for the issue. The resident, who was moderately cognitively impaired, stated that while the room felt homelike, the bathroom did not. The facility's policy affirms residents' rights to live in safe, decent, and clean conditions, which was not upheld in this instance.
Failure to Implement Care Plan for Timely Medication Administration
Penalty
Summary
Facility staff failed to implement the comprehensive care plan for a resident diagnosed with acute myeloblastic leukemia (AML) and other significant medical conditions, including congestive heart failure and renal insufficiency. The care plan required administration of specific medications as ordered for AML management. Review of the medication administration audit reports revealed multiple instances where medications such as Acyclovir, Cresemba, Revumenib Citrate, and Cefdinir were administered late or not at the scheduled times as prescribed by the physician. These delays and missed doses occurred repeatedly over several days, as documented in the medication administration records. Interviews with nursing staff confirmed that the care plan interventions, specifically timely medication administration, were not being followed. Staff acknowledged that medications not given as ordered meant the care plan was not being implemented. The facility's own care planning policy requires licensed nurses and the interdisciplinary team to develop and implement individualized care plans to provide necessary health-related care. The deficiency was brought to the attention of facility administration, but no further information was provided prior to the survey exit.
Failure to Revise and Update Care Plans After Significant Changes and Incidents
Penalty
Summary
Facility staff failed to review and/or revise the comprehensive care plans for three residents following significant changes in their conditions or care needs. For one resident, the care plan was not updated to reflect the initiation of hospice care, despite physician orders specifying hospice involvement, do-not-hospitalize status, and no further diagnostic testing. The care plan only documented a DNR directive and had not been revised to include hospice services, even though staff interviews confirmed that such updates were expected as part of the care planning process. Another resident experienced multiple falls, including one with injury, and was discussed in high-risk meetings where fall mats were identified as an intervention. However, the care plan did not document the use of fall mats, and there was no physician order for them. Observations confirmed that fall mats were not present in the resident's room during multiple checks, and staff acknowledged that the care plan should have included this intervention following the falls and risk meetings. A third resident had a fall without injury, but the care plan was not reviewed or updated after the incident. Progress notes indicated the fall and described the circumstances, but no new interventions were implemented, and the care plan's revision dates did not correspond to the fall event. Staff interviews confirmed that care plans are expected to be reviewed after any fall, but this was not evidenced in the documentation for this resident.
Failure to Administer Ordered Treatments and Wound Care
Penalty
Summary
Facility staff failed to provide care and services as ordered for two residents. For one resident with diagnoses including muscular dystrophy, diabetes mellitus, and congestive heart failure, staff did not administer blood glucose checks and insulin at bedtime as ordered by the physician. The medication administration record (MAR) for this resident showed that on a specific date, the required blood sugar check and insulin administration at bedtime were not completed, although other scheduled doses and checks before meals were documented. Staff interviews confirmed that a blank MAR indicated the task was not performed. For another resident, staff did not complete wound care treatments for a skin tear on the left upper arm as ordered by the physician. The electronic treatment administration record (eTAR) showed that on several dates in November and December, the required wound care was not documented as completed. Staff interviews confirmed that treatments are evidenced as completed by signing off on the eTAR, and the facility's policy requires treatments to be provided as ordered. The administrator and director of nursing were made aware of these findings.
Failure to Implement and Document Fall Prevention Measures for Two Residents
Penalty
Summary
Facility staff failed to provide a safe environment and implement fall prevention measures for two residents, resulting in deficiencies related to accident hazards and supervision. For one resident with diagnoses including muscular dystrophy, diabetes mellitus, and congestive heart failure, the admission documentation and care plan identified a history of falls and specified interventions such as non-skid socks, bed in lowest position, and use of bed rails. However, there was no evidence that these fall prevention measures were implemented. Progress notes indicated that only one side rail was in place despite orders for bilateral rails, and the resident experienced multiple falls from bed. Staff interviews confirmed that fall prevention interventions were not in place, and the care plan did not reflect the necessary measures outlined in the admission assessment. Another resident, who was moderately impaired in decision-making and had a recent history of falls with and without injury, was observed multiple times in bed without fall mats in place, despite documentation from a high-risk meeting indicating that fall mats were an intervention. The care plan and physician orders did not include fall mats, and staff interviews revealed that fall mats should have been in place but were not. The resident reported recent falls, including one resulting in injury, and was observed without socks and with the call bell in reach, but without the required fall prevention equipment. The facility's Fall Management Program policy states that all patients are considered at risk for falls and that evidence-based interventions should be implemented. Despite this, the facility failed to ensure that fall prevention measures were consistently implemented and documented for both residents, as required by their own policies and the residents' care plans. Administrative staff, including the administrator and director of nursing, were made aware of these concerns during the survey.
Failure to Timely Communicate and Implement Diet Texture Change
Penalty
Summary
Facility staff failed to provide food in a form designed to meet the individual needs of a resident. Specifically, a physician ordered a change in diet texture for a resident from regular texture to dysphagia mechanically altered texture. The order for the diet change was dated 11/25/24, but the dietary communication form reflecting this change was not completed until 11/30/24. During this period, the resident did not receive meals in the prescribed mechanically altered texture. Interviews with dietary and nursing staff revealed that the process for communicating diet changes involved nurses updating the electronic medical record and manually delivering a diet communication slip to the dietary department. The dietary manager confirmed that meal tickets and food preparation were based on these communication forms. Facility policy required licensed nurses to promptly complete and send the communication form to dietary services for any diet changes. The delay in communication resulted in the resident not receiving food in the appropriate form as ordered by the physician.
Failure to Notify Physician and Responsible Party of Medication Unavailability
Penalty
Summary
The facility staff failed to notify the physician and the responsible party when a medication, Flonase, was not available for administration to Resident #2. The physician had ordered Flonase Allergy Relief Nasal Suspension to be administered daily, but the medication was not given on two consecutive days, as indicated by the medication administration record (MAR). The MAR showed a notation of 'Other/ See progress notes' for these days, and on the third day, the administration block was left blank. Nurse's notes documented that the medication had been ordered and the pharmacy contacted, but there was no documentation of notifying the physician or the responsible party about the unavailability of the medication. An interview with an LPN revealed that the facility had a process for obtaining medications, including checking other medication carts, the medication room, and a backup pharmacy system. The LPN stated that over-the-counter medications like Flonase should not have been documented as waiting for pharmacy delivery, and that the nurse should have contacted the doctor and responsible party if the medication was not administered. The facility's policy on medication unavailability required notifying the provider and responsible party and documenting this in the medical record, which was not done in this case. The administrative staff, including the administrator and regional director of clinical services, were informed of these findings.
Failure to Protect Residents from Verbal Abuse by Intoxicated LPN
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a staff member, specifically an LPN who was reported to have arrived at work intoxicated and belligerent. The LPN was observed yelling and cursing at residents, including making threats of physical harm. This incident occurred in front of the nurse's station, where other staff members witnessed the behavior. The LPN was not scheduled to work at the time and was removed from the facility by the police after being reported by a supervisor. The residents involved, identified as having low BIMS scores, were unable to recall the incident due to cognitive impairments. Despite this, staff interviews corroborated the supervisor's report of the LPN's abusive behavior. The facility's documentation did not show any immediate review or revision of the residents' care plans following the incident, nor was there evidence of trauma assessments being conducted for the affected residents. The facility's policy on abuse and neglect was not adhered to, as evidenced by the lack of immediate follow-up and documentation regarding the incident. The LPN's behavior was substantiated through employee interviews, although the allegation of over-medication was not supported by evidence. The facility's response included terminating the LPN and filing a police report, but the deficiency lies in the initial failure to protect the residents from abuse and the lack of immediate care plan adjustments or trauma assessments.
Failure to Implement Abuse Policy Leads to Verbal Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy to protect two residents from verbal abuse by a staff member. On the day of the incident, an LPN arrived at the facility intoxicated and was observed yelling and cursing at residents. The LPN was not scheduled to work and claimed to be there to complete documentation. Witnesses reported that the LPN made threatening remarks to the residents and claimed to have over-medicated another resident the previous night. The residents involved in the verbal abuse incident were unable to recall the event due to low BIMS scores, indicating cognitive impairment. The facility's comprehensive care plans for these residents did not document the verbal abuse incident, and there was no evidence of trauma screening or social service assessments being completed following the incident. Staff interviews corroborated the supervisor's report of the LPN's behavior, and the police were called to remove the LPN from the premises. The facility's policy on abuse and neglect requires immediate removal of the accused individual and thorough documentation of the incident. However, the facility's response to the incident was inadequate, as there was a lack of documentation in the residents' care plans and progress notes regarding the verbal abuse. Additionally, the facility did not conduct necessary assessments to address the potential trauma experienced by the residents involved.
Incomplete Investigation of Resident Elopement
Penalty
Summary
The facility staff failed to conduct a complete and thorough investigation into an elopement incident involving a resident identified as R5. On the date of the incident, R5, who had a history of wandering and was assessed as high risk for elopement, exited the facility without supervision. The resident was later found sitting on a curb by emergency medical services and returned to the facility without injury. The investigation summary documented the incident but lacked critical details regarding the functionality of the resident's wander guard and the door alarms at the time of the elopement. The resident had been admitted to the facility with a severely impaired mental status, as indicated by a low score on the BIMS assessment, and had documented wandering behaviors. A wander guard was ordered for the resident, with instructions for its placement and function to be checked regularly. However, the investigation folder did not include documentation on whether the wander guard was functioning properly or if the door alarms were operational during the incident. Interviews with administrative staff revealed that the wander guard had stopped working, which was not initially included in the investigation report. The facility's policy required a thorough internal investigation of such incidents, including collecting evidence and interviewing relevant parties. However, the investigation into R5's elopement did not meet these standards, as it failed to address the root cause of the incident, specifically the malfunctioning wander guard and door alarms. The lack of comprehensive documentation and analysis of the incident led to the deficiency noted in the report.
Failure to Update Care Plans After Abuse Incident
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents, Resident #9 and Resident #10, following a verbal abuse incident involving a staff member. On December 14, 2024, a Licensed Practical Nurse (LPN) arrived at the facility intoxicated and belligerent, verbally abusing residents, including Resident #9 and Resident #10. The incident was substantiated through staff interviews, and the LPN was removed from the property and terminated. Despite the severity of the incident, the care plans for the affected residents were not reviewed or updated to reflect the abuse or to include any new interventions. Resident #9, who was severely impaired in making daily decisions as indicated by a low score on the Brief Interview for Mental Status (BIMS), was involved in the incident. The facility's policy required care plans to be updated as changes occurred, yet no revisions were made to Resident #9's care plan following the abuse. Interviews with facility staff revealed a lack of clarity and responsibility regarding who should update the care plans after such incidents, with the MDS coordinator and other staff members indicating that they did not typically review care plans after abuse incidents. Similarly, Resident #10, who was moderately impaired in decision-making, also did not have their care plan reviewed or revised following the incident. The assistant director of social services and other staff members confirmed that while trauma screenings and follow-ups were conducted, the care plans were not updated. The facility's failure to update the care plans for both residents after the abuse incident highlights a significant deficiency in adhering to their own care planning policies.
Failure to Provide Adequate Care Following Alleged Overmedication
Penalty
Summary
The facility staff failed to provide adequate care and services to maintain a resident's highest level of well-being, specifically for Resident #4. On 12/14/24, the staff became aware of a potential medication overdose involving Resident #4, who was found lethargic and only responsive to sternal rubs. Despite this, the nurse practitioner only gave telephone orders to continue monitoring the resident, and the family eventually decided to take the resident to the emergency room. The facility's documentation and interviews revealed that an LPN, who was reportedly intoxicated and belligerent, claimed to have overmedicated the resident during a previous shift. The investigation into the incident revealed that the LPN in question was not scheduled to work at the time of the incident but had arrived at the facility, allegedly intoxicated, and was verbally abusive to residents. The LPN was removed from the property, and the police were called. Witness statements corroborated the supervisor's report of the LPN's inappropriate behavior, including threats and claims of overmedicating a resident. However, the investigation found no evidence of medication administration by the LPN on the day of the incident, and the allegation of overmedication was unsubstantiated due to a lack of supporting evidence. Interviews with other staff members indicated that Resident #4 was being monitored for changes in condition, but there was a lack of documentation and communication regarding the resident's status and the nurse practitioner's recommendations. The facility's policy required critical nursing assessment and decision-making in potentially life-threatening situations, but the response to Resident #4's condition was inadequate. The resident was eventually taken to the hospital by family members, where they were admitted with elevated troponin and lactic acid levels, indicating a serious medical condition.
Failure to Prevent Fire Incident Due to Inadequate Supervision
Penalty
Summary
The facility staff failed to provide adequate supervision and interventions to prevent a fire incident involving a resident with severe cognitive impairment. The resident, who scored a four out of 15 on the BIMS, indicating severe cognitive impairment, was found with a lighter on 12/30/24, but no further lighters were found after a room search. Despite this, the resident was later involved in a fire incident on 1/1/25, where a mattress and privacy curtain were burned. The resident was unable to recall the fire incident due to cognitive impairment. Another resident, who was not cognitively impaired, discovered the fire upon returning to his room and managed to extinguish it using sheets. This resident reported the incident to staff, who responded but found no active fire or smoke upon arrival. The facility's maintenance team confirmed that the fire was not electrical in nature, and a lighter was later found on the bed of the resident who discovered the fire. Interviews with staff revealed that the resident with cognitive impairment had a history of wandering and socializing with other residents, including those who smoked. The facility had previously confiscated a lighter from this resident, but it was unclear how the resident obtained another lighter. The facility's failure to implement effective interventions and supervision to prevent the resident from accessing lighters and starting a fire led to the deficiency.
Failure to Provide Social Services After Verbal Abuse Incident
Penalty
Summary
The facility failed to provide medically related social services to a resident following a verbal abuse incident involving a staff member. The incident occurred when an LPN, who was reportedly intoxicated and belligerent, verbally abused several residents, including Resident #10. The LPN was not scheduled to work and was removed from the facility by the police after making threats and claiming to have over-medicated another resident. The investigation substantiated the verbal abuse but found no evidence to support the medication misuse claim. Resident #10, who was moderately impaired in decision-making as indicated by a BIMS score of nine out of 15, did not receive a trauma screen or social service assessment following the incident. The facility's documentation lacked evidence of any follow-up or care plan revision addressing the verbal abuse. Interviews with staff revealed that social services typically conducted trauma screens and care plan reviews after such incidents, but this was not done for Resident #10. The facility's policy required social work staff to identify and address patients' psychosocial needs, including providing emotional support and documenting interventions. However, the report indicates that these procedures were not followed for Resident #10 after the verbal abuse incident. The failure to conduct a trauma screen and update the care plan represents a deficiency in the facility's provision of medically related social services.
Medication Unavailability for Resident
Penalty
Summary
The facility staff failed to ensure that medications were available at the scheduled time of administration for a resident, specifically Flonase, which is used to treat allergies. The physician's order dated 12/17/24 documented that Flonase Allergy Relief Nasal Suspension was to be administered as two sprays in each nostril once a day. However, the medication administration record (MAR) for January 2025 showed that on 1/12/25 and 1/13/25, a code indicating 'Other/See progress notes' was documented, and on 1/14/25, the administration block was left blank. Nurse's notes indicated that the medication had been ordered and the pharmacy had been contacted, but the medication was still unavailable. Interviews with staff revealed that the facility had a process for obtaining medications, including checking other medication carts, the medication room, and a backup pharmacy system. However, Flonase was not found in the medication room or stock room, and the central supply staff member stated that their supplier only carried a generic saline nasal spray, which was not equivalent to Flonase. The facility's policy required notifying the provider and responsible party of medication unavailability and documenting this in the medical record, but it appears this process was not fully followed. The director of nursing and other administrative staff were informed of these findings, but no further information was provided before the survey exit.
Failure to Withhold Insulin as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the staff did not adhere to the physician's order to hold Humalog insulin when the resident's blood sugar was below 150. This oversight occurred multiple times over three months, with documented instances in January, February, and March 2024. The resident, who has a diagnosis of Type II Diabetes Mellitus, was administered Humalog insulin despite having blood sugar levels below the threshold specified in the physician's order. The facility's electronic medication administration record (eMAR) showed that the insulin was administered on several occasions when the resident's blood sugar was below 150, contrary to the physician's instructions. An LPN confirmed during an interview that the insulin should have been withheld on those occasions. The facility's policy on medication administration requires adherence to prescriber's orders, which was not followed in this case. The deficiency was brought to the attention of the facility's administrative and clinical staff, but no further information was provided before the survey exit.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility staff failed to maintain an operational resident call system for seven of 72 resident rooms, as observed during a survey. Specifically, the call systems in rooms 111A, 133A, 205B, 209B, 211B, 222B, and 230A were not functioning properly. In room 111A, the call system pull station in the bathroom was missing, preventing the call bell/light from being activated. In the other rooms, the call bell/lights by the beds did not activate when the button was pushed. This deficiency was confirmed through observations conducted with the director of maintenance and the maintenance assistant. During an interview, the director of maintenance acknowledged that some call bells/lights in resident rooms were not working and stated that he was waiting on parts to fix them. The facility's policy requires that each nursing unit call system be thoroughly inspected and tested monthly to verify operating efficiency, with documentation of malfunctions and repairs. However, the failure to maintain a functioning call system in these rooms indicates a lapse in adherence to this policy. The administrative staff, including the administrator and the interim director of nursing, were made aware of the issue.
Rehab Restroom Maintenance Deficiency
Penalty
Summary
The facility staff failed to maintain a safe, functional, and sanitary environment in the rehab restroom, as evidenced by a leak and a ceiling tile covered with a black substance. During an observation, it was noted that approximately one fourth of a 12-inch by 24-inch ceiling tile was covered with this substance. Interviews with staff members revealed that the substance had been present for a significant period, initially thought to be a water stain, but it became more pronounced and mold-like over time. The rehab staff eventually decided to shut down the bathroom due to the worsening condition. Further interviews indicated that the issue had been ongoing for several years, with the tile being replaced previously, but the problem resurfaced and worsened in the past 12 weeks. The director of maintenance acknowledged the issue, attributing it to a leak in a water pipe and was in the process of obtaining a quote for repairs. The administrator and interim director of nursing were informed of the concern, highlighting a failure to adhere to the facility's policy of maintaining a high-quality environment.
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Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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