Harrisonburg Hlth & Rehab Cntr
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisonburg, Virginia.
- Location
- 1225 Reservoir Street, Harrisonburg, Virginia 22801
- CMS Provider Number
- 495093
- Inspections on file
- 25
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Harrisonburg Hlth & Rehab Cntr during CMS and state inspections, most recent first.
Staff failed to maintain clean, properly supplied rooms, protect personal property, and process laundry in a timely manner. A resident with complex medical needs did not consistently receive correctly sized fitted sheets for a bariatric mattress, despite an adequate central supply and 24‑hour access to laundry, and staff sometimes used whatever sheets were available instead of obtaining the proper ones. Another resident with severe cognitive impairment remained in a room with damaged walls, visible drips and spatters, trash on the floor, and a persistently dirty floor, while housekeeping and maintenance were unaware or unable to keep up with daily cleaning expectations. Two residents experienced missing personal items, including a shaving mirror and multiple laminated family photos, with incomplete or absent property inventories and grievances that were entered but never investigated or resolved. Multiple residents reported that personal clothing took more than two weeks to be returned from laundry and was often mixed up, and surveyors observed a significant backlog of soiled and clean laundry in the department, with the EVS director acknowledging delays and infrequent handling of lost‑and‑found items.
Facility staff did not follow physician orders for two residents, resulting in one resident not receiving a newly recommended glaucoma medication for over a month due to a missed consultation report, and another resident missing three doses of a prescribed antibiotic after admission because of delays in order entry and verification. These deficiencies were linked to lapses in communication, documentation, and adherence to medication administration policies.
A resident with multiple chronic conditions and bowel incontinence, who was cognitively intact but unable to sense bowel movements due to numbness, did not have a care plan addressing bowel incontinence. Staff interviews confirmed regular checks for incontinence, but review of the clinical record showed that a care plan for this issue was not developed.
Two residents with significant medical conditions and frequent incontinence did not receive timely incontinence care during an overnight shift. Both were found at the start of the day shift with soiled briefs and, in one case, wet bed linens. Staff interviews and facility documentation confirmed that required checks and changes were not performed as outlined in their care plans.
Staff failed to serve palatable and properly heated meals to two residents, as observed during a meal service where food was served lukewarm and described as bland. A test tray confirmed that food temperatures were significantly lower than when prepared in the kitchen, and a resident reported that meals were never served hot. The dietary manager acknowledged that food temperatures dropped while waiting to be served, contrary to facility policy requiring appetizing temperatures.
Three residents did not receive their documented meal preferences, including requests for baked potatoes, dessert, and milk, during a lunch service. Interviews confirmed that these preferences were routinely unmet, and a CNA was unable to explain the omissions despite facility policy requiring accommodation of resident preferences.
A resident did not receive prescribed doses of niacin and oxycodone-acetaminophen because the medications were not available in the facility. Staff documented the unavailability, notified the provider and responsible party, and explained that delays in ordering and pharmacy authorization contributed to the missed doses. The emergency medication supply did not contain the required medications, and facility policies for medication unavailability were not fully effective in preventing the deficiency.
A resident experienced prolonged discomfort and safety concerns due to unresolved maintenance issues, including a non-functioning air conditioning unit, broken closet doors, and a loose ceiling tile. Despite repeated reports to staff and open maintenance work orders, these deficiencies were not addressed in a timely manner, and the facility lacked an effective system for tracking and resolving maintenance requests.
Staff failed to supervise and secure hazardous items, resulting in a resident with dementia ingesting body wash left on her bedside table, leading to severe medical complications. The facility also lacked protocols to monitor hot liquid temperatures, causing the same resident to sustain a coffee burn. Additional observations found unsecured hazardous items accessible to cognitively impaired residents, with staff confirming inconsistent storage practices.
Multiple residents experienced neglect when staff failed to provide timely incontinence care and respond to call bells, resulting in prolonged exposure to urine and feces, skin injury, and psychosocial harm. One resident with quadriplegia was left in feces for over fifty minutes, another was left in feces for two hours leading to significant skin redness and burning, and a third was found by a family member in a saturated brief that had not been changed for eight hours, resulting in moisture-associated skin damage.
Facility staff failed to provide timely incontinence care to three residents who were dependent on staff, resulting in psychosocial harm and the development of incontinence-associated dermatitis. Delays in responding to call lights and incontinence needs led to residents remaining in soiled briefs for extended periods, causing skin breakdown, discomfort, and emotional distress. Staff interviews and documentation confirmed inconsistent practices and lack of timely care.
A resident with a history of severe weight loss and on a full liquid diet continued to lose substantial weight after admission due to the facility's failure to implement timely nutritional interventions, accurately assess malnutrition risk, and promptly arrange a gastroenterology consult. Meal trays were repetitive and sometimes missing prescribed items, and there was a lack of interdisciplinary follow-up despite ongoing weight loss and the development of wounds.
The facility did not maintain an effective pest control program for all units, with a lapse in professional pest control services for two months due to a change in providers. During this period, staff documented sightings of cockroaches in resident areas, and the facility's policy requiring monthly inspections and treatments was not followed.
Staff did not maintain comfortable temperatures in two units when boilers malfunctioned, resulting in residents experiencing cold conditions for several days. A resident and her family reported discomfort and concern, and documentation showed that room temperatures dropped as low as 60°F before temporary heating solutions were implemented.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on several occasions because the medication was not available, despite active physician orders. Interviews with LPNs revealed that medication unavailability was sometimes due to staff not ordering the medication or agency staff being unaware of overstock supplies. Facility policy required staff to notify providers and use backup pharmacy procedures, but these steps were not effectively followed, resulting in missed doses.
Staff failed to follow infection control protocols for handling soiled linen and disposing of incontinent briefs, with observations of dirty linen being transported without bags or gloves, and soiled items left on floors or in unlined trash cans. Interviews confirmed these actions were not in line with facility policy, which requires contaminated laundry to be bagged and handled with protective equipment.
Staff failed to maintain sanitary and comfortable conditions in multiple resident rooms and bathrooms, with persistent soiling, mold, and damaged walls left unaddressed despite daily cleaning policies. Residents reported ongoing concerns about cleanliness, lack of supplies, and communication barriers with housekeeping. Maintenance issues were exacerbated by staffing shortages and unfulfilled renovation promises, resulting in unsanitary and uncomfortable living conditions.
A review of staff records and facility documentation found that five employees had not received required behavioral health training, despite the facility's assessment indicating the need for such competencies to support residents with mental health and behavioral needs. Facility leadership confirmed the absence of training records for these staff members.
Facility staff did not notify the Department of Health Professions (DHP) of abuse or neglect allegations involving two certified nursing assistants, despite reporting these incidents to APS, the ombudsman, and VDH. The administrator acknowledged not following the facility's policy, which requires DHP notification within 24 hours for incidents involving licensed or certified staff.
Staff failed to promptly report allegations of abuse and neglect for two residents. In one instance, a resident was left in a soiled brief for an extended period, with evidence provided by a family member, but the incident was not escalated to management or authorities in a timely manner. In another case, a resident reported being left in feces for hours, resulting in skin irritation and emotional distress, yet the allegation was not promptly reported by the ADON. Both cases demonstrate lapses in timely reporting of suspected abuse and neglect.
Facility staff did not conduct comprehensive investigations into two separate allegations of neglect and possible abuse. In one case, a resident with severe dementia was hospitalized after presumed ingestion of body wash, with multiple staff observing symptoms consistent with ingestion, but only two staff were interviewed and the incident was deemed unsubstantiated. In another case, a resident was found in a wet brief for an extended period, with staff and photographic evidence confirming the neglect, yet the investigation was limited and concerns were dismissed. Both cases show the facility did not follow its own investigation protocols.
Staff did not update a resident's care plan to include nonskid strips as a fall intervention after a fall incident, despite documentation in progress notes and device assessments. Interviews with LPNs and CNAs revealed inconsistent awareness of the intervention, and facility policy required such interventions to be added to the care plan and reviewed by licensed nurses.
A resident with severe cognitive impairment and multiple health issues did not receive required grooming and shower care, despite being dependent on staff for ADLs. Staff accounts and documentation conflicted, with some indicating care was provided and others, including family, observing the resident was not groomed or showered. The facility lacked a policy for ADL care, contributing to the deficiency.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on two occasions, as confirmed by MAR review and resident interview. Facility staff, including LPNs and the DON, indicated issues with medication availability and lack of awareness among agency staff regarding medication storage. Required documentation explaining the missed doses was not present, and the facility's policy for medication administration and documentation was not followed.
Facility staff failed to accurately complete a hot liquid safety evaluation for a resident with behavioral issues and did not properly document or provide clear evidence of a shower for another dependent resident. In both cases, clinical records were incomplete or inconsistent, and staff interviews and documentation did not align, resulting in deficiencies in maintaining accurate resident records.
A review of employee records revealed that two CNAs did not have documented abuse training, as required. When asked, facility leadership confirmed they could not provide evidence of completed training for these staff members.
Two certified nursing assistants did not have documented evidence of receiving mandatory infection control training, as required by the facility's infection prevention and control program. This was identified during a review of employee records, and facility leadership confirmed the absence of training documentation.
The facility failed to maintain a clean and sanitary environment, with observations of feces, mold, and dirt in resident areas and the dining room. Residents reported infrequent cleaning, and staff confirmed a shortage of housekeeping personnel. Equipment and supplies were improperly stored in hallways, creating potential hazards. The maintenance director acknowledged some responsibility but had not addressed the issues.
The facility failed to provide appetizing and palatable meals to residents on the West unit. Observations and interviews revealed that meals were often cold and unappealing by the time they reached residents. Despite appropriate temperatures at the steam table, delays in delivery led to lukewarm meals. Residents consistently complained about the food's quality and temperature, as documented in Resident Council Meeting Minutes and confirmed by the activities director and dietary manager.
Failure to Maintain Clean, Homelike Environment and Safeguard Residents’ Personal Property and Laundry
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and to protect residents’ personal property. One cognitively intact resident with multiple chronic conditions, including polyarthritis, chronic respiratory failure, diabetes, Crohn’s disease, and bipolar disorder, did not consistently receive properly sized fitted sheets for a bariatric mattress. Surveyors observed an ill‑fitting sheet that did not cover the entire mattress, and the resident reported that the correctly sized orange‑trimmed bariatric sheets were often unavailable on the unit. Staff interviews confirmed that the resident had voiced concerns about sheet availability, that the unit linen room sometimes lacked the needed sheets, and that CNAs sometimes used whatever sheet was available at shower time instead of obtaining the correct size from the laundry, despite 24‑hour access to clean linen and an adequate central inventory of the correct sheets. Another resident with COPD, mood disorder, chronic pain syndrome, major depressive disorder, and severely impaired cognition was found in a room where housekeeping was not maintained. Over multiple days, surveyors observed scraped and damaged drywall, missing sections of wall, brown/tan drips and spatters on the wall, paper trash and candy wrappers on the floor beside and under the bed, and a dirty floor with black/gray film, drips, footprints, and black/brown specks near the toilet. A family member reported having to pick up trash from the floor and stated that housekeeping "could be better." The maintenance director was unaware of the wall damage and reported no work order had been entered, while the housekeeping supervisor and housekeeper acknowledged that rooms and bathrooms were supposed to be cleaned daily but that room changes and deep cleans sometimes prevented the housekeeper from getting to all rooms each day, resulting in some rooms only being cleaned every other day. The facility also failed to protect residents’ personal property and to process laundry in a timely manner. One resident with moderately impaired cognition reported that pictures and other personal items were lost during room changes, particularly laminated pictures of family and pets, and that grievances had been filed without any response or apparent search for the items. Records showed two room changes and two grievances documenting missing glasses, fingernail clippers, hats, a fan, and multiple laminated pictures, with no investigation, findings, or actions recorded. Interviews with the administrator, housekeeping supervisor, social services director, and unit manager revealed that no personal belongings inventory had been completed on admission, no department had been assigned to investigate the grievances, and personal items left in a room for pest treatment were not accounted for. Another cognitively intact resident reported a shaving mirror missing for about six months; the property list did not specifically list the mirror, lacked the resident or responsible party signature, and had no dates or signatures for items added or removed, contrary to facility policy. In addition, multiple residents reported problems with timely return of personal clothing from laundry, stating that laundry sometimes took more than two weeks to be returned, was not returned in the order sent, and that they received items that were not theirs while not receiving items sent earlier. A tour of the laundry department revealed large amounts of mixed soiled facility and resident laundry in bags at the bottom of the chute, multiple bins of soiled laundry awaiting washing, tables piled high with clean facility linen to be folded, and a long rack of clean resident clothing awaiting return to units. The EVS director acknowledged that laundry sometimes became backed up, that delays occurred, and that unlabeled items were placed in lost and found, which was only brought to units about once every two months, despite a stated goal of returning resident laundry within three days.
Failure to Administer Medications as Ordered and Implement Physician Recommendations
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and care coordination. For one resident with a history of glaucoma and multiple other diagnoses, an eye physician recommended the addition of Dorzolamide-Timolol eye drops to the resident's existing glaucoma treatment. The recommendation was made during an on-site consultation, but the report was sent to an outdated email address and was not received by current facility staff. As a result, the new medication order was not reviewed or implemented, and the resident did not receive the recommended eye drops for over 30 days. Interviews with staff revealed a lack of awareness regarding the new recommendation, and the facility's process for updating consultant contact information was not followed, leading to the oversight. In a separate incident, another resident was admitted with physician orders for an antibiotic to be administered four times daily. Upon review, it was found that the antibiotic was not initiated until the following day at noon, resulting in three missed doses. The delay was attributed to the late entry and verification of the medication orders in the electronic system, despite the medication being available in the facility's backup supply. The DON and Regional Director of Clinical Services were unable to clarify why certain doses were missed after the orders were entered into the system. Facility policies require that medications be administered according to prescriber orders and that consultation reports be reviewed and implemented as indicated. In both cases, failures in communication, documentation, and timely order entry led to residents not receiving prescribed treatments as ordered by their physicians.
Failure to Develop Care Plan for Bowel Incontinence
Penalty
Summary
Facility staff failed to develop a care plan addressing bowel incontinence for one resident, despite the resident being assessed as bowel incontinent on the most recent MDS and having diagnoses including diabetes, congestive heart failure, respiratory failure, and peripheral vascular disease. The resident, who was cognitively intact, reported numbness from the waist down and an inability to sense bowel movements, requiring frequent checks by staff. Interviews with a CNA and the MDS coordinator confirmed that the resident was regularly checked for incontinence and that a care plan for bowel incontinence should have been in place but was missed. Review of the clinical record and care plan revealed no documentation of a bowel incontinence care plan for this resident.
Failure to Provide Timely Incontinence Care for Two Residents
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents who were unable to perform activities of daily living independently. One resident, with diagnoses including quadriplegia and spinal cord compression, was assessed as cognitively intact and frequently incontinent of bowel and bladder. On the early morning in question, the resident was found soaked at the start of the day shift, indicating that incontinence care had not been provided during the previous shift. The resident did not recall receiving care during the night and reported sleeping through most of it. Staff interviews and facility documentation confirmed that the resident was not checked or changed prior to the day shift, despite care plan interventions requiring frequent checks and changes. Another resident, with a history of COPD, diabetes, BPH, congestive heart failure, and dementia, was also assessed as cognitively intact and frequently incontinent. This resident was found with a heavily soiled brief and wet bed linens at the start of the day shift. The resident's roommate reported that the assigned CNA did not provide a brief change during the last round of the shift. Staff interviews and facility investigation corroborated that incontinence care was not provided as required by the resident's care plan, which called for frequent checks and changes. In both cases, the lack of timely incontinence care was identified through staff and resident interviews, review of facility documentation, and clinical record review. The findings were discussed with facility leadership, and the facility's own investigation supported the evidence of failure to provide care as outlined in the residents' care plans. No skin issues were identified for either resident following the incidents.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
Facility staff failed to serve palatable and appropriately heated meals to two residents out of a sample of eleven. During a lunchtime meal service observation, several residents were noted not eating, and one resident specifically complained that her food was not served hot, which she preferred. A test tray conducted during the same meal service revealed that the baked ham, scalloped potatoes, and mixed vegetables were served at lukewarm temperatures (121.6°F, 138.4°F, and 129.7°F, respectively), despite being much hotter in the kitchen prior to service. The vegetables and potatoes were also described as bland and lacking seasoning. The dietary manager acknowledged that food temperatures dropped significantly due to hot plates sitting and waiting to be served on the cart. Resident interviews confirmed dissatisfaction with meal temperatures, with one resident stating that her meals were never served hot. Facility documentation reviewed indicated a policy requiring food to be palatable, attractive, and served at a safe and appetizing temperature. The dietary manager stated that food should be served below 150°F to prevent scalding, but acknowledged the temperature drop before service. The deficiency was brought to the attention of facility leadership during an end-of-day meeting.
Failure to Honor Resident Meal Preferences During Service
Penalty
Summary
During a lunchtime meal service, three residents did not receive their stated meal preferences as documented on their meal tickets. Specifically, two residents had requested baked potatoes and milk with their meals, while another resident preferred dessert and milk. These preferences were not honored during the observed meal service. Resident interviews confirmed that one resident consistently did not receive dessert or milk without specifically asking, another did not receive milk or condiments, and a third seldom received milk or the requested baked potato. A Certified Nursing Assistant (CNA) reviewed a meal ticket and was unable to explain why the baked potato was not served, indicating a lack of awareness or communication regarding resident preferences. Facility documentation stated that menus are to be served as written unless changes are made in response to resident preference, unavailability, or for special meals. Despite this policy, the observed meal service did not accommodate the residents' documented preferences, resulting in a failure to provide meals according to individual needs and requests.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
Facility staff failed to provide ordered medications for a resident, specifically niacin and oxycodone-acetaminophen, as prescribed by the medical provider. The clinical record review showed that the resident had active orders for oxycodone-acetaminophen for pain management and niacin as a supplement. The medication administration records indicated missed doses of both medications over several days, with documentation codes referencing unavailability and progress notes explaining that the medications were not on hand, were in transit, or awaiting delivery from the pharmacy. The emergency medication supply (Omnicell) did not contain the required strength of oxycodone-acetaminophen or niacin. Interviews with nursing staff revealed that when medications were not available, they notified the provider and responsible party, and documented the situation in the medical record. Staff explained that over-the-counter medications like niacin were typically ordered through a supply company with less frequent deliveries, and that the pharmacy required an authorization form to dispense such medications. Delays in returning the authorization form contributed to the delay in obtaining niacin for the resident. The pharmacy confirmed that they did not receive the necessary authorization to dispense niacin until several days after the initial order, resulting in a gap in administration. Facility policy required staff to search for missing medications, contact the pharmacy, and use the emergency kit if necessary. The policies also required provider notification and documentation when medications were unavailable. Despite these policies, the resident did not receive the ordered medications as scheduled, and there was a lack of documentation explaining the hold on niacin for certain days. The deficiency was identified through interviews, record reviews, and review of facility documentation, which confirmed that the facility did not have the medications available for administration as ordered.
Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
Facility staff failed to provide a safe, functional, and comfortable environment for a resident who reported multiple unresolved maintenance issues in his room. The resident expressed concerns about a non-functioning air conditioning unit, which had not been operational for several weeks despite rising temperatures and his pre-existing breathing issues. He also reported that the closet doors were broken, making the drawers inaccessible, and that a ceiling tile was out of place and appeared as if it could fall. The resident stated he had reported these issues to staff multiple times, but no corrective action had been taken. Direct observation by the surveyor confirmed the air conditioning unit was not working, the closet doors posed a safety hazard, and the ceiling tile was not properly secured. A review of facility maintenance work orders revealed that requests for repairs to the air conditioning unit and closet doors had been entered but remained open and unresolved for an extended period. Interviews with the maintenance director and staff indicated a lack of an effective system for tracking and addressing maintenance requests, with reliance on verbal reports and handwritten notes rather than the facility's electronic system. The maintenance director acknowledged that the electronic system was not being monitored and that many issues were prioritized informally, leading to delays in addressing non-urgent repairs. These actions and inactions resulted in the resident continuing to live in an environment that was not safe, functional, or comfortable.
Failure to Prevent Resident Access to Hazards and Inadequate Hot Liquid Safety
Penalty
Summary
Facility staff failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in multiple incidents of resident harm. One resident with severe dementia ingested an unknown amount of body wash that had been left accessible on her bedside table. This resident was known to be impulsive, grab at objects, and was not oriented, requiring total care. Staff interviews and clinical documentation confirmed that the body wash was left within reach after a bed bath, and the resident subsequently ingested it, leading to respiratory distress, hospitalization, intubation, and the need for a tracheostomy and feeding tube. The incident was not directly witnessed, but multiple staff and the resident's roommate confirmed the presence of the body wash and the resident's symptoms following ingestion. Additionally, the facility did not have a system or protocol in place to monitor the temperature of hot liquids served to residents. This failure resulted in another incident where the same resident spilled hot coffee on herself, causing redness and requiring medical attention. Review of the resident's hot liquid safety evaluation revealed inaccuracies and omissions, as the assessment did not reflect the resident's documented agitation, impulsivity, and behavioral symptoms. Staff interviews confirmed that coffee temperatures were not routinely checked, and observations during the survey found that coffee was being served at temperatures exceeding safe limits. Further observations during the survey revealed that hazardous items, such as toiletry products and cleaning supplies, were left unsecured in resident rooms and common areas, including shower rooms with open doors and accessible gallon jugs of shampoo and body wash. Residents with cognitive impairment and poor safety awareness were found to have access to these items, and staff interviews confirmed a lack of consistent practice regarding the storage of potentially hazardous materials. These deficiencies were found to have the potential to affect multiple residents across all nursing units.
Failure to Provide Timely Incontinence Care and Call Bell Response Resulting in Neglect and Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care and respond to call bells for multiple residents, resulting in neglect, skin injury, and psychosocial harm. One resident, who was cognitively intact and completely dependent on staff for all activities of daily living due to quadriplegia, was left sitting in feces for over fifty minutes after activating the call light. The resident reported feeling humiliated and unimportant, and was observed to be emotionally distressed. The resident's care plan indicated a high risk for pressure ulcers and required prompt incontinence care, but staff did not respond in a timely manner, and the call bell system showed the call had been active for over fifty minutes before staff entered the room. Another resident, who was dependent on staff for toileting and had no cognitive impairment, reported being left in feces for approximately two hours. The resident described that after activating the call bell and informing a CNA of the need for incontinence care, the CNA turned off the call light and did not return. The resident was eventually assisted by another CNA, who found fecal material on the resident's thighs, bed pad, and sheets, and observed significant skin redness and burning. The resident reported the incident to staff and Adult Protective Services, and photos documented the extent of the soiling and skin injury. A third resident, with severe cognitive impairment and dependent on staff for care, was found by a family member in a saturated brief and wet bedding. The family member marked the brief and found it unchanged eight hours later. Staff interviews confirmed that incontinence rounds were expected every two hours, but the resident's brief was not changed as required, resulting in moisture-associated skin damage. Staff acknowledged that the resident was wet enough to require a change, and documentation showed redness and treatment for skin damage following the incident.
Failure to Provide Timely Incontinence Care Resulting in Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care to multiple residents who were dependent on staff for activities of daily living, resulting in psychosocial and physical harm. One resident with quadriplegia, who required total assistance, was observed to have his call light engaged for over 50 minutes before staff responded to his request for incontinence care. The resident reported routinely waiting extended periods for care, which led to feelings of anger, humiliation, and being unimportant. Clinical records indicated that this resident developed incontinence-associated dermatitis (IAD) on both buttocks, with wound care documentation confirming new skin breakdown attributed to delayed incontinence management. Another resident, who was dependent for toileting and had no cognitive impairment, reported being left in feces for approximately two hours after notifying staff of the need for a brief change. The resident described significant discomfort, burning, and emotional distress as a result of the delay. Observations and interviews confirmed that the resident's skin was red and irritated, and photographic evidence showed feces on the resident's thighs, bed pad, and sheets. Staff interviews corroborated the delay, and the resident reported the incident to multiple facility leaders, who were unaware of the situation until informed by surveyors. A third resident, with severe cognitive impairment and a history of urinary tract infection, was found to have remained in the same brief for eight hours, as confirmed by staff interviews and photographic evidence provided by the resident's daughter. The resident's brief was saturated, and skin assessments documented redness and moisture-associated skin damage to the coccyx and groin areas. Staff interviews revealed inconsistent practices regarding the frequency of incontinence care and reliance on visual indicators rather than direct assessment, contributing to prolonged exposure to moisture and subsequent skin breakdown.
Failure to Timely Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
Facility staff failed to ensure that a resident with a history of significant weight loss maintained acceptable nutritional status. Upon admission, the resident had already experienced a 40-pound weight loss due to self-imposed starvation and was placed on a full liquid diet per hospital discharge instructions. Despite this, the resident lost an additional 18 pounds in the first nine days at the facility and a total of 24 pounds over five weeks. Observations revealed that the resident's meal trays were repetitive and sometimes missing prescribed items, such as ice cream, which the resident expressed a preference for and was ordered to receive. The facility did not implement timely interventions to address the resident's ongoing weight loss. There was a delay in initiating nutritional supplements, with the first supplement order not placed until nearly a month after admission. The registered dietician's initial malnutrition screening inaccurately assessed the resident as low risk and did not account for the significant weight loss. There was also a lack of documented follow-up or reassessment by the dietician until several weeks later, during which time the resident continued to lose weight and developed wounds. Additionally, the facility failed to promptly arrange a necessary gastroenterology appointment to address the resident's underlying condition of achalasia, which restricted dietary advancement. Staff interviews revealed confusion and lack of communication regarding the scheduling of this appointment, with no evidence of attempts to secure an earlier consultation until several weeks after admission. The facility's own policies required timely weight monitoring, interdisciplinary review, and provider notification for significant weight changes, but these procedures were not followed, resulting in the resident's continued decline.
Failure to Maintain Consistent Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program across all three units. Although a tour of the nursing units did not reveal immediate concerns, interviews and document reviews showed that the facility did not have pest control services in place for the months of January and February 2025. The administrator confirmed that pest control was not present during these months due to a change in service providers, acknowledging that this lapse was an oversight. During the period without pest control coverage, work orders documented the presence of cockroaches in a resident's nightstand and sightings of roaches in a resident's bathroom. The facility's policy required monthly inspections and treatments by a corporate-approved contractor, which was not followed during the lapse. Staff interviews indicated that pest sightings were reported and addressed internally, but the absence of professional pest control services during the specified months led to the deficiency.
Failure to Maintain Safe and Comfortable Temperatures Due to Boiler Malfunction
Penalty
Summary
Facility staff failed to maintain a comfortable and safe environment for residents by not ensuring adequate internal temperatures in two of three units due to malfunctioning boilers. The east and west wings experienced significant heating issues when the primary boilers were not operating properly. Residents and their family members reported that it was cold in the facility, with one resident stating she had to use multiple sheets and still felt cold, and her family member expressing concern to the point of requesting a welfare check from the police department. Documentation and interviews revealed that the facility's boilers had ongoing mechanical problems, including frequent shutdowns, water leaks, and malfunctioning recirculating pumps. Service logs indicated repeated failures and the need for manual resets to restore heat. The administrator and maintenance staff confirmed that the boilers would often trip and require intervention, and that parts were difficult to obtain due to the manufacturer no longer being in business. During this period, the facility resorted to using portable heaters and spot coolers to provide some heat, but temperature monitoring showed that several resident rooms remained below comfortable levels, with some rooms measuring between 60-67°F. The deficiency was further substantiated by service technician reports, which described a cracked heat exchanger and the inability of staff to consistently reset the boiler to maintain adequate temperatures. The lack of a reliable heat source persisted until a temporary boiler was installed, but prior to this, residents in affected wings were exposed to uncomfortably low temperatures for an extended period. The facility's failure to maintain a safe and comfortable environment directly impacted residents' well-being during the time the boilers were inoperable.
Failure to Provide Ordered Glaucoma Medication Due to Unavailability
Penalty
Summary
Facility staff failed to ensure that a resident received Latanoprost eye drops for glaucoma as ordered by the physician. The medication order, active since 2/14/24, required the drops to be administered at bedtime in both eyes. Clinical record review and interviews revealed that the resident did not receive the eye drops on multiple occasions, specifically on 1/16/25, 3/2/25, and 3/4/25, due to the medication not being available. Documentation indicated that the drops were reordered or that the pharmacy was contacted, but the medication was still not administered as prescribed. Interviews with two LPNs indicated that medication unavailability could be due to staff not ordering the medication or agency staff being unaware of overstock supplies stored in the medication room refrigerator. Facility policy required nurses to notify the provider and discuss alternatives or activate backup pharmacy procedures when medications were unavailable. Despite these policies, the resident's medication was not consistently available or administered as ordered, and the issue was brought to the attention of the facility administrator and DON.
Failure to Follow Infection Control Standards for Soiled Linen and Brief Disposal
Penalty
Summary
Facility staff failed to adhere to infection control standards regarding the handling of soiled linen and disposal of incontinent briefs across all three units. Multiple observations revealed staff transporting dirty linen without using bags, carrying it against their bodies, and not wearing gloves. Dirty linen was found on the floor in shower rooms and resident rooms, and soiled incontinent briefs were disposed of in trash cans without liners. Staff interviews confirmed that these practices were not in accordance with facility policy, which requires contaminated laundry to be bagged at the site of generation and handled with appropriate personal protective equipment. Further observations showed that during resident care, staff placed soiled linen directly on the floor rather than in designated bags or carts. Some staff acknowledged the improper handling when questioned and indicated awareness of the correct procedures. Facility documentation reviewed stated that contaminated laundry must be bagged and handled with protective gear, but these protocols were not consistently followed as evidenced by the surveyor's findings.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to maintain a sanitary, clean, and comfortable environment in multiple resident rooms and bathrooms across several units. Observations revealed brownish/black substances on bathroom walls and trashcans, persistent soiling and sticky floors, and missing or damaged wall plaster with visible mold and musty odors. In several instances, these unsanitary conditions remained unaddressed over multiple days, despite daily cleaning schedules outlined by facility policy. Staff interviews confirmed that cleaning was not consistently performed as required, with some staff unaware of ongoing issues and others acknowledging that bathrooms had been in poor condition for extended periods. Residents reported ongoing concerns about the cleanliness of their rooms and bathrooms, with some expressing fear of using the facilities due to the level of filth and lack of cleaning. One resident noted a lack of paper towels for several days, requiring family to bring supplies from outside. Staff interviews further revealed communication barriers between residents and housekeeping staff, and a lack of follow-through on promised renovations and repairs, particularly in bathrooms where mold and water damage were present. Maintenance staff were not always aware of the problems, and the maintenance department had open positions, including a vacant director role, which contributed to delays in addressing these issues. Facility documentation confirmed that daily cleaning tasks were not being completed as required, with specific failures to clean toilets, sinks, floors, and to remove visible stains and debris. The administrator and corporate staff were made aware of these deficiencies during the survey, and acknowledged the poor state of repair and cleanliness in resident areas. The lack of consistent cleaning and maintenance resulted in unsanitary and uncomfortable living conditions for residents on multiple units.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
Facility staff failed to provide behavioral health training to five out of eight employees reviewed during an extended survey. The survey included a review of staff interviews, staff records, and facility documentation, which revealed that there was no credible evidence that these employees had received the required behavioral health training. The facility assessment, last reviewed on 8/6/25, indicated that the facility serves residents with mental health and behavioral needs and outlined the necessity for staff competencies in managing psychiatric symptoms, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. Despite being asked to provide evidence of behavioral health training for the selected employees, the facility was unable to produce documentation showing that the identified staff had completed such training. The administrator, DON, and corporate staff confirmed that they could not locate the required training records for these employees. The facility's own assessment highlighted the need for behavioral health competencies, particularly for memory care units, but the training records for the reviewed staff did not reflect completion of this requirement.
Failure to Report Abuse Allegations to DHP as Required by Policy
Penalty
Summary
Facility staff failed to implement their abuse policy regarding timely reporting of allegations involving licensed staff to the Department of Health Professions (DHP) for two residents out of a sample of 26. In both cases, allegations of abuse or neglect involving certified nursing assistants were reported to Adult Protective Services (APS), the ombudsman, and the Virginia Department of Health (VDH), but there was no evidence that DHP was notified as required by facility policy. Documentation for one incident showed confirmation of notifications to APS, ombudsman, and VDH, but not to DHP. In the other case, similar notifications were made, but again, DHP was not notified. During interviews, the administrator initially claimed to have sent the report to DHP, but upon review, the documentation provided was addressed to VDH, not DHP. The administrator later admitted to not faxing allegations to DHP unless they were substantiated, contrary to the facility's written policy, which requires notification within 24 hours for incidents involving licensed or certified staff. No additional information was provided prior to the survey exit.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
Facility staff failed to timely report allegations of abuse and neglect for two residents. In the first case, a resident's daughter discovered her father had not been changed for approximately eight hours, as evidenced by a marked brief and photographs. The resident was found with a saturated brief, red and irritated skin, and poor grooming. Although the incident was reported to a charge nurse and later discussed with a unit manager, neither staff member escalated the allegation to upper management or regulatory authorities in a timely manner. Documentation and witness statements were delayed, and the issue was not brought to the administrator's attention until days after the incident. In the second case, a resident reported to a CNA and later to the ADON that she had been left in a soiled brief with feces for nearly two hours, resulting in skin irritation and visible soiling of her bed and body. The resident expressed emotional distress over the incident and provided photographic evidence. The ADON acknowledged being informed but did not immediately report the allegation to appropriate authorities. The administrator was not made aware of the situation until after the resident had already been visited by Adult Protective Services. In both cases, the facility failed to follow timely reporting protocols for suspected abuse and neglect.
Failure to Conduct Thorough Investigations into Allegations of Neglect and Abuse
Penalty
Summary
Facility staff failed to conduct a thorough investigation into two separate allegations of neglect and possible abuse involving two residents. In the first case, a resident with severe dementia was presumed to have ingested a body wash, resulting in hospitalization for acute hypoxic and hypercapnic respiratory failure. Multiple staff members observed symptoms consistent with soap ingestion, such as foaming at the mouth, pink-tinged bubbles, and respiratory distress. Despite these observations and statements from several staff and the resident's roommate, the facility's internal investigation was limited to interviews with only two staff members and a review of hospital records. The facility concluded the incident was unsubstantiated due to lack of direct witness, despite substantial circumstantial evidence and staff testimony indicating otherwise. In the second case, the facility failed to thoroughly investigate an allegation of neglect regarding timely incontinent care for another resident. The resident's daughter reported that her father had not been changed for an extended period, and staff witness statements, as well as photographic evidence, confirmed the resident was found in a wet brief that had been marked earlier in the day. Staff interviews revealed inconsistencies in care documentation and a lack of timely intervention. The administrator, who also served as the abuse coordinator, acknowledged the situation but did not conduct a comprehensive investigation, relying instead on limited staff interviews and dismissing the daughter's concerns. Both incidents demonstrate a failure by facility staff to follow their own abuse and neglect investigation policies, which require immediate and thorough internal investigations, including collecting evidence and interviewing all relevant witnesses. The lack of comprehensive investigations in both cases was directly observed and documented by surveyors, who noted that the facility did not meet its own standards for responding to allegations of abuse and neglect.
Failure to Revise Care Plan with Fall Interventions
Penalty
Summary
Facility staff failed to review and revise the care plan to include fall interventions for one resident. Specifically, after a fall incident, a progress note indicated that nonskid strips should be placed by the resident's bedside as a new intervention. However, this intervention was not added to the resident's care plan, despite documentation in a device assessment that it had been. Multiple staff interviews revealed inconsistent knowledge about whether nonskid strips were in place for the resident, and staff relied on care plans and other documentation to implement interventions. Housekeeping staff were responsible for removing nonskid strips after resident discharge, but there was no clear record of the intervention being implemented for the resident in question. A review of facility policies showed that interventions identified after falls or through device assessments were to be incorporated into the care plan and reviewed by licensed nurses. The care plan for the resident did not reflect the intervention for nonskid strips, even though it was documented elsewhere as necessary. The deficiency was identified through observation, staff interviews, and review of clinical records and facility documentation, and was communicated to facility leadership.
Failure to Provide ADL Care and Grooming
Penalty
Summary
Facility staff failed to provide adequate activities of daily living (ADL) care, specifically grooming and showering, for one resident who was dependent on staff for these needs. The resident, who had severe cognitive impairment and multiple diagnoses including urinary tract infection, muscle weakness, and underweight status, did not receive a shower or proper grooming on the day in question. Staff statements conflicted regarding whether a shower was provided, with one CNA documenting that a shower was given, while both an LPN and a physical therapist assistant indicated the resident was not showered and remained in bed for much of the morning. The resident's daughter also reported that her father was not groomed and appeared unshowered, with greasy hair. Review of facility documentation showed inconsistencies between staff statements and recorded care, as the CNA had documented both a bed bath and a shower, but other staff and family observations contradicted this. The facility did not have a policy for ADL care, and the incident was confirmed through interviews and record reviews. The lack of consistent and accurate care documentation, as well as the absence of a clear ADL policy, contributed to the failure to provide necessary hygiene and grooming for the resident.
Failure to Administer Physician-Ordered Eye Drops and Inadequate Documentation
Penalty
Summary
Facility staff failed to administer Latanoprost eye drops as ordered by the physician for a resident with glaucoma. The resident reported during an interview that he frequently did not receive his prescribed eye drops. Review of the clinical record and medication administration record (MAR) confirmed that the eye drops were not administered on two specific dates, with one date left blank on the MAR and the other marked as held, without any documentation explaining the omission. The physician's order for the eye drops had been active since February and remained so at the time of the survey. Interviews with the DON and two LPNs revealed that medication administration was inconsistent, particularly when medications were not available or when agency staff were unaware of where extra supplies were stored. The facility's policy required medications to be administered as ordered and documented immediately after administration, but this was not followed in the resident's case. No documentation was provided in the nursing progress notes to explain why the medication was not given, and the DON acknowledged that blanks on the MAR indicated the medication was not administered and should have been explained.
Failure to Accurately Complete Safety Evaluation and Maintain Clinical Records
Penalty
Summary
Facility staff failed to accurately complete and document a hot liquid safety evaluation for a resident with a history of agitation, restlessness, and impulsive behavior. Despite multiple progress notes indicating the resident was agitated and required lorazepam in the week prior to the evaluation, the hot liquid safety form did not reflect these behaviors. Required sections indicating risk factors were not properly checked, and the form was left incomplete, omitting the necessary indication that the resident was at risk for injury from hot liquids. Additionally, staff failed to maintain accurate clinical records for another resident who was dependent for activities of daily living and had severe cognitive impairment. There were conflicting accounts regarding whether the resident received a shower, with CNA documentation indicating a shower was given, while statements from other staff, including an LPN and a physical therapist assistant, indicated the resident was not showered. The resident's daughter also reported that her father did not appear to have been showered, providing photographic evidence of poor hygiene and soiled bedding. The facility did not have a policy for activities of daily living documentation, and the inconsistencies in staff statements and documentation led to uncertainty about the care provided. The lack of accurate and complete clinical records for both residents was confirmed through staff interviews, clinical record reviews, and supporting documentation.
Lack of Documented Abuse Training for Two CNAs
Penalty
Summary
Facility staff failed to provide credible evidence of abuse training for two certified nursing assistants out of eight employee records reviewed. During an extended survey, a sample of eight employees was selected, and the facility administrator was asked to provide documentation of staff training in abuse prevention and reporting. Upon review of the employee records, it was found that two CNAs did not have documentation indicating they had received the required abuse training. The facility administrator and corporate staff confirmed the absence of this documentation and were unable to locate records of the training for these staff members. No further information was provided before the exit conference.
Lack of Documented Infection Control Training for Two CNAs
Penalty
Summary
Facility staff failed to provide mandatory infection control training as part of their infection prevention and control program for two certified nursing assistants out of eight employee records reviewed. During an extended survey, a sample of eight employees was selected, and the facility administrator was asked to provide evidence of infection control training for these staff members. Upon review of the employee records, it was found that there was no credible evidence that the two certified nursing assistants had received the required infection control training. This finding was confirmed with the facility administrator, director of nursing, and corporate staff, who were unable to locate documentation of the training for these employees. No additional information or documentation was provided by the facility prior to the exit conference.
Facility Fails to Maintain Sanitary Environment and Proper Equipment Storage
Penalty
Summary
The facility staff failed to maintain a clean, sanitary, and comfortable environment for residents across all three nursing units and the dining room. Observations revealed feces on the floor in the shower room, black mold-like coloring around tiles, and heavily soiled shower mats. Several rooms had missing tiles, black and brown stains on floors and walls, and significant dirt build-up. The dining room was found with trash, cobwebs, and a severely soiled IV pole with a missing wheel. Residents reported that their rooms were not cleaned daily, and housekeeping staff were observed to be short-staffed and often on their cell phones. Interviews with residents and staff highlighted the lack of adequate cleaning due to insufficient housekeeping staff. Residents reported that their rooms were cleaned infrequently, with some areas never receiving a deep clean. The housekeeping manager confirmed the shortage of staff and the inability to complete deep cleaning as scheduled. The facility's cleaning policy was not being followed, as evidenced by the state of the rooms and common areas. Additionally, equipment and supplies were improperly stored in hallways and alcoves, creating potential hazards. A broken floor tile was observed in a hallway, and various items such as mattresses, wheelchairs, and a mechanical lift were stored inappropriately. The maintenance director acknowledged responsibility for some of these issues but had not addressed them. The therapy department manager noted that equipment should be stored out of resident use areas, but this was not being done.
Failure to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility staff failed to provide appetizing food with palatable temperatures and appearance to residents on the West unit. Observations and interviews revealed that residents consistently received meals that were cold and unappealing. On July 1, 2024, Resident #4 expressed dissatisfaction with the meals, describing them as cold and unpleasant. The food temperatures were checked at the steam table, showing appropriate temperatures, but delays in delivery resulted in lukewarm meals by the time they reached the residents. Resident #5, a vegetarian, also complained about the limited choices and the unappealing appearance of the food. Resident Council Meeting Minutes from April to June 2024 documented ongoing complaints about the food being cold, bland, and dry. The activities director confirmed that residents consistently voiced these concerns, which were communicated to the administrator. The dietary manager acknowledged awareness of the issue, attributing it to delays in serving the food. Despite efforts to maintain appropriate temperatures at the steam table, the problem persisted, as noted by the administrator and director of nursing during the exit conference on July 2, 2024.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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