Holly Manor Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmville, Virginia.
- Location
- 2003 Cobb Street, Farmville, Virginia 23901
- CMS Provider Number
- 495339
- Inspections on file
- 19
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holly Manor Rehab And Nursing during CMS and state inspections, most recent first.
Facility staff did not resolve ongoing resident grievances about shortages of washcloths and towels, as documented in resident council meetings over several months. Multiple residents and staff reported delays in care, such as bathing and getting out of bed, due to insufficient linens. Observations confirmed low linen supplies, and repeated complaints were not effectively addressed, despite periodic linen orders and staff education.
A resident with schizophrenia received prn lorazepam without the physician documenting the intended duration of use, and staff failed to attempt or document non-pharmacological interventions before administering the medication, contrary to facility policy.
Nursing staff did not administer multiple medications within the required timeframes for four residents, resulting in significant delays for treatments addressing conditions such as pain, high blood pressure, allergies, and seizures. Facility policy and staff interviews confirmed that medications should be given within one hour of the scheduled time, but audit records showed repeated late administrations.
Staff did not provide or document required personal hygiene care, including mouth care and washing, for a resident unable to perform these activities independently on multiple shifts, as shown by missing entries in ADL records. Interviews confirmed that such care should be provided and documented each shift, in accordance with facility policy.
A resident experienced multiple significant medication errors, including the incorrect application of fluorouracil cream to the neck instead of the chest, repeated administration of Debrox ear drops into the eye rather than the ear, and late administration of Baclofen. These incidents were confirmed through interviews, clinical record review, and facility documentation, highlighting failures in following medication administration protocols.
Staff served pureed food that lacked flavor and was not palatable, as confirmed by the dietary manager, who stated that no seasoning was added in the kitchen and only salt and pepper packets were available for residents who could have them. No salt substitute was provided for those on salt-restricted diets unless brought by family.
Staff failed to maintain sanitary food preparation practices, including not fully covering facial hair while plating meals, not changing gloves after handling kitchen equipment before touching food, and serving chicken salad at an unsafe temperature to a resident. The dietary manager confirmed these actions did not meet required standards.
Facility staff did not inform a resident or their representative about the risks, benefits, or alternative treatments for lorazepam, an anti-anxiety medication, despite a physician's order for its use. Documentation and staff interviews confirmed that this required information was not provided, contrary to facility policy.
Facility staff failed to promptly notify a resident's representative when the resident experienced vomiting and was placed on contact precautions, and also did not notify a physician when another resident complained of neck pain and requested medical attention after a chemical burn. Despite facility policy requiring prompt notification of changes in condition, staff did not inform the appropriate parties in these cases.
A resident with severe cognitive impairment experienced a fall, and although the incident was documented and appropriate immediate actions were taken, staff failed to review or revise the resident's comprehensive care plan as required by facility policy. There was no documentation to show that the care plan was updated or reviewed following the fall.
A resident with respiratory failure was observed receiving oxygen via nasal cannula without a physician's order in place at the time of administration. The order for continuous oxygen was documented only after the resident had already begun receiving therapy, as confirmed by the unit manager.
On a day when only one nurse was present to care for 54 residents, multiple residents did not receive timely or complete medication administration due to staffing shortages. The nurse on duty contacted a nurse practitioner for guidance but was told to use her own judgment, resulting in medications being given late or omitted without individualized physician input or documentation.
On a day when only one nurse was present to care for 54 residents, several residents experienced delays in receiving their scheduled medications. Staff interviews confirmed that two nurses were required for the shift, but only one was available, leading to late administration of multiple medications for residents with complex medical needs.
Staff failed to include the facility name on daily nurse staffing sheets for three days, as required by facility policy. The scheduler responsible for posting the information was unaware of the requirement, and administrative staff were informed of the deficiency during the survey.
The facility staff failed to maintain sanitary garbage areas, as observed with an open trash compactor door and two open trash bin lids, allowing access to pests. Interviews with maintenance staff confirmed that these should be kept closed, in line with the facility's policy on food-related garbage disposal.
The facility failed to maintain a comprehensive infection control program and implement effective practices. The infection control program lacked a systematic surveillance system, relying only on Antibiotic Timeout forms, which were inadequate for tracking infections. Additionally, a nurse improperly handled medications by picking up a dropped pill with bare hands and administering it to a resident, contrary to proper infection control practices.
The facility staff failed to promote resident dignity for four residents. A resident was left in soiled clothing after vomiting, another waited 11 minutes for lunch while others at the table were served, a third was left in a wheelchair all night without assistance, and a fourth was told to void in her brief. These incidents highlight a lack of dignified care and service provision.
The facility failed to provide written notification of hospital transfers to residents, their representatives, and the Ombudsman for five residents. Transfers were due to urgent medical needs, but notifications were missed, partly due to staff absence. The facility's process for notifying the Ombudsman was not consistently followed.
The facility staff failed to implement comprehensive care plans for residents, leading to deficiencies in diabetes management, fluid restriction monitoring, anticoagulant therapy, and wound care. Residents experienced missed medication doses, inadequate assistance with activities of daily living, and incomplete documentation of care provided.
Facility staff failed to provide adequate ADL care for four residents, leading to deficiencies in their care. A resident was left in soiled clothing for hours after vomiting, while another had missing documentation for incontinence care. Two other residents experienced inadequate toileting and mobility assistance, with gaps in care documentation. These incidents highlight a pattern of inadequate care and documentation for dependent residents.
The facility staff failed to provide appropriate care and services for several residents, including missed medication doses, improper insulin administration, and lack of necessary assessments. These deficiencies reflect inadequate adherence to physician orders and documentation, impacting resident well-being.
The facility failed to provide adequate care for pressure injuries for three residents, leading to deficiencies in treatment. A resident under hospice care did not receive prescribed treatments, and family members reported concerns about repositioning and care. Another resident with an unstageable pressure ulcer did not have treatments documented over several months. A third resident with a skin tear did not receive prescribed wound treatments, as confirmed by an LPN. Documentation failures contributed to these deficiencies.
The facility staff failed to provide respiratory care services per physician orders for two residents. One resident with COPD did not receive required respiratory assessments, and another with obstructive sleep apnea did not have their CPAP mask cleaned as ordered. An LPN confirmed that professional standards were not followed when physician orders were not adhered to.
Two residents experienced inadequate pain management due to the facility's failure to adjust scheduled pain medication despite frequent use of as-needed opioids. Both residents reported high pain levels, and staff interviews revealed that the facility's pain management policy was not effectively implemented.
The facility failed to provide adequate dialysis care for five residents, including missed treatments, lack of communication with dialysis centers, and improper monitoring of fluid restrictions. Staff interviews revealed systemic issues in transportation arrangements, documentation, and communication processes.
The facility failed to provide adequate nursing staff during the night shift for two residents on multiple occasions. Despite the requirement for one licensed nurse and two CNAs, the unit was often staffed with only one CNA due to call-outs, affecting the care of residents with a census of 25 to 30. The staffing shortfall was confirmed by the staff scheduler and the DON, highlighting a breach in the facility's staffing policy.
Two residents in the facility were not properly administered and monitored for anticoagulant therapy. One resident experienced delays in receiving Enoxaparin injections, while another was not monitored for adverse reactions to Apixaban, despite being severely cognitively impaired. Interviews with an LPN confirmed that professional standards were not followed, and the facility's administration was informed of these deficiencies.
The facility failed to provide palatable and appropriately heated meals to residents, as reported by several residents and confirmed by a meal test tray. Residents described the food as cold and lacking flavor, with one resident noting weight loss due to the poor quality. The dietary manager acknowledged the issues with the food's taste and temperature.
The facility failed to ensure CNAs completed the required 12 hours of annual in-service training. Three CNAs had incomplete training hours, with one completing only 10 hours, another 4.5 hours, and the third 2.75 hours. The administrator and DON acknowledged the issue, noting the recent use of a computer software for training and the need for a system to ensure compliance.
The facility failed to ensure call light accessibility for two residents, leaving them unable to alert staff when needed. Additionally, a resident's request for grab bars was not assessed or documented, indicating a lack of communication and assessment of resident needs.
Facility staff failed to notify physicians and responsible parties of changes in condition or treatment for three residents. One resident's medication change was not communicated, another missed dialysis without physician notification, and a third resident's fall was not reported to their responsible party. Interviews confirmed these notifications should have occurred per facility policy.
A resident was discharged from a Medicare-covered stay without timely receiving a beneficiary notice of non-coverage. The notice, which should inform the resident of potential out-of-pocket costs, was signed by the discharge planner well before the resident's discharge but not by the resident until the day of discharge. This delay violated the facility's policy requiring timely notice to allow informed decision-making. The issue was later reported to the facility's administrator and DON.
A facility failed to maintain a complete and accurate MDS assessment for a resident. The admission assessment had incomplete sections in Cognitive Patterns, with dashes documented instead of required information. Despite the resident being coded as usually understood, the necessary interviews were not conducted. The MDS coordinator confirmed the oversight, and the facility's use of the RAI manual was noted. Administrative and clinical staff were informed of the findings.
The facility failed to include critical therapies in baseline care plans for two residents. One resident, admitted with fractures and hypertension, was on anticoagulation therapy, but the care plan lacked monitoring interventions. Another resident, with obstructive sleep apnea, required CPAP therapy, which was also omitted from the care plan. Staff interviews confirmed these omissions, despite facility policy requiring such inclusions.
The facility staff failed to update comprehensive care plans for three residents, leading to deficiencies in care. One resident's plan did not include the use of grab bars, another's lacked treatment for a skin condition, and a third's was not revised after a fall. These omissions indicate a lack of thorough documentation and care planning by the interdisciplinary team.
Facility staff failed to follow professional standards for medication administration and order clarification for three residents. A resident had conflicting insulin orders without clarification, another received medications outside the prescribed timeframe, and a third had unclear prn pain medication orders, leading to potential confusion in administration. The facility's policies did not adequately address these issues.
Two residents in a facility did not receive consistent urinary catheter care as required by their care plans and physician orders. One resident, under hospice care, had multiple missed catheter care instances, while another resident with a suprapubic catheter experienced similar lapses. Staff interviews indicated that catheter care was supposed to be documented in the eTAR, but several dates showed missing entries, suggesting care was not consistently provided.
A resident at risk for significant weight gain did not receive physician-ordered daily weight monitoring, with several days missing documentation. Additionally, the facility failed to conduct a quarterly nutritional assessment between December 2023 and May 2024, despite the resident's significant weight gain. The facility's policy requires comprehensive nutritional evaluations, but these were not adhered to, as confirmed by the dietician and missing records.
A resident was observed with raised bed rails without a documented safety assessment. The facility failed to conduct necessary evaluations by PT and OT to determine the resident's need and ability to use side rails safely. The Director of Nursing confirmed the absence of such assessments in the resident's clinical records.
The facility failed to provide adequate physician oversight for four residents, leading to deficiencies in pain management and diabetes care. Two residents experienced frequent use of prn pain medications without proper assessment or adjustment to scheduled pain management. Additionally, two residents lacked timely orders for blood sugar checks and insulin upon admission, highlighting lapses in medication reconciliation and care management.
Two residents in the facility did not receive their prescribed medications as ordered. A resident with multiple sclerosis did not receive Avonex on the scheduled days, with a 10-day gap between doses, due to the family's failure to bring the medication and lack of facility communication. Another resident did not receive Meclizine for vertigo on two occasions because it was not available in the facility's pharmacy system. Staff interviews revealed confusion about medication responsibilities, and the facility's policy on unavailable medications was not followed.
A resident continued to receive Ramelteon at a higher dose than recommended due to the facility's failure to ensure a physician reviewed and acted upon a pharmacy recommendation. The recommendation to taper the medication was initially made on 5/20/24 but was not addressed until 8/23/24, following a repeated recommendation. The DON was unaware of the delay, despite facility policy requiring timely physician review.
A resident was kept on an unnecessary psychoactive medication at a higher dose for three months due to the facility's failure to address a pharmacy recommendation for gradual dose reduction. The Director of Nursing was unaware of why the recommendation was not timely addressed, and the issue was discussed with the facility's administrative and clinical staff.
The facility failed to maintain safe and sanitary conditions in food storage and preparation areas. Sugar was left exposed, pots and pans were stored on dirty shelves, and an ice scoop was improperly stored. The sanitizer solution was below recommended levels, and the dishwasher operated at insufficient temperatures. Coleslaw was served at unsafe temperatures, and watermelon was found spoiled and unlabeled.
The facility staff failed to maintain a sanitary environment in the kitchen, with visible debris and stains on the floor under various equipment and in the dry goods storage room. The dietary manager acknowledged the need for regular cleaning and had requested housekeeping assistance for stain removal, as per facility policy.
Failure to Resolve Resident Grievances Regarding Linen Shortages
Penalty
Summary
Facility staff failed to resolve ongoing grievances regarding shortages of washcloths and towels, as voiced by residents during council meetings in 10 out of 11 months reviewed. Multiple residents reported delays in receiving care, such as getting out of bed or attending breakfast, due to insufficient linen supplies. Residents also noted that the facility had stopped using disposable wipes for incontinence care, increasing the demand for washcloths and towels. Resident council meeting minutes and grievance forms repeatedly documented complaints about linen shortages, with some months lacking evidence of follow-up or resolution. Interviews with residents, CNAs, and other staff confirmed that linen shortages were a persistent issue, leading to delays in bathing, bed changes, and other personal care activities. Staff reported that when linens ran out, they had to request more from the laundry, which sometimes resulted in residents waiting for care. Observations of linen closets and the laundry area revealed low quantities of towels and washcloths relative to the number of beds on each unit. The LTC ombudsman corroborated these findings, stating that residents consistently complained about linen shortages and that her own spot checks found linen closets empty at times. Facility documentation showed that orders for additional linens were placed periodically, but the problem persisted over several months. Staff and management interviews indicated that some believed the shortages were due to hoarding or disposal of soiled linens, but audits and room checks did not substantiate widespread hoarding. Despite efforts to monitor and restock linens, the facility did not make prompt or effective efforts to resolve the residents' grievances, as required by policy.
Failure to Document PRN Psychotropic Duration and Non-Pharmacological Interventions
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medication use. Specifically, for a resident with schizophrenia, the physician's order for prn (as needed) lorazepam did not include documentation of the intended duration of use, as required by facility policy. The nurse practitioner continued the prn lorazepam order without specifying the duration, and there was no documentation from the physician or nurse practitioner regarding how long the prn medication should be used. Additionally, the clinical record and medication administration records showed that lorazepam was administered on several occasions without evidence that non-pharmacological interventions were attempted prior to giving the medication. Staff interviews confirmed that non-pharmacological interventions should be individualized and attempted before administering prn lorazepam, and that such attempts should be documented in the progress notes. However, no such documentation was found for the dates when lorazepam was given.
Failure to Administer Medications Within Required Timeframes
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards of practice for four residents, as evidenced by medication administration records and staff interviews. For each of these residents, multiple medications were not given within the facility's policy of 60 minutes before or after the scheduled time. The medications involved included treatments for conditions such as seasonal allergies, spinal stenosis, high cholesterol, rhabdomyolysis, muscle spasms, high blood pressure, increased eye pressure, seizure-like activity, pain, arthritic pain, and constipation. For one resident, medications such as pseudoephedrine, baclofen, azelastine, simvastatin, and magnesium oxide were administered several hours after their scheduled times. Another resident experienced delays in receiving hydralazine, carvedilol, and brimonidine tartrate, with administration occurring up to several hours late. A third resident did not receive levetiracetam and Tylenol at the scheduled time, with both being administered six hours late. The fourth resident had tramadol, diclofenac gel, and Miralax administered outside the required time window. Interviews with nursing staff confirmed that medications should be administered within one hour before or after the scheduled time to ensure proper dosing and avoid overmedication. The facility's own policy also requires medications to be given within 60 minutes of the scheduled time. These findings were communicated to the facility administrator, and no additional information was provided prior to the survey exit.
Failure to Provide and Document Personal Hygiene ADL Care
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically personal hygiene, to one resident who was unable to perform these tasks independently. Review of the resident's ADL records for March and May 2025 showed that personal hygiene tasks such as combing hair, brushing teeth, and washing/drying face and hands were not documented as provided on several day and evening shifts, as indicated by blank spaces in the records. Interviews with a CNA confirmed that personal hygiene should be performed and documented every shift, and the facility's policy requires assistance with ADLs for residents unable to perform them independently. The administrator was made aware of the concern, and no further information was provided prior to exit.
Failure to Prevent Significant Medication Errors
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. On one occasion, fluorouracil 5% cream, prescribed for application to a skin cancer lesion on the chest, was instead applied to the resident's neck. This resulted in redness and a burning sensation, requiring subsequent treatment with hydrocortisone. The error was confirmed by both the resident and the LPN involved, and the pharmacist explained that the medication should only be applied to the specific lesion due to its cell-killing properties. Additionally, there were three separate incidents where Debrox ear drops were administered into the resident's eye instead of the ear. Each time, the resident experienced burning and discomfort, and the errors were documented in facility reports. The pharmacist clarified that Debrox is intended solely for ear use and can cause significant irritation if placed in the eye. The reports indicated that the errors occurred due to confusion between medication containers and a failure to properly check medication labels before administration. A further deficiency was identified when Baclofen, a muscle relaxant prescribed for muscle spasms and spinal stenosis, was administered several hours later than scheduled. Facility policy requires medications to be given within one hour of the scheduled time, and both nursing and pharmacy staff confirmed the importance of timely administration for this medication. The resident's clinical record and medication administration audit confirmed the late administration, and staff interviews acknowledged the deviation from protocol.
Unseasoned Pureed Food Served Without Palatability Consideration
Penalty
Summary
Facility staff failed to ensure that food served on one of three observed units was palatable, as required by facility policy. During a survey, a test tray containing pureed fish, pureed broccoli, mashed potatoes, whole broccoli florets, and a whole fish fillet was sent to the unit and food temperatures were taken, all of which were within safe ranges. However, after tasting the pureed items, the dietary manager acknowledged that the pureed food lacked flavor and was not palatable. The dietary manager also confirmed that no seasoning was added to the food in the kitchen, and that only salt and pepper packets were supplied on the units for residents who were allowed them. No salt substitute was provided for residents on salt-restricted diets unless supplied by the resident's family. These findings were communicated to the administrator and director of clinical services.
Food Preparation and Sanitation Deficiencies in Kitchen
Penalty
Summary
Facility staff failed to prepare and serve food in a sanitary manner in one of two facility kitchens. During observation, a cook was seen plating lunch trays with a beard and mustache, but only the beard was covered, leaving the mustache exposed. The cook acknowledged that both beard and mustache should be covered to prevent hair from falling into food but was unaware his mustache was not covered at the time. Another staff member was observed cooking fish filets and handling them with the same gloves used to operate the deep fry baskets, and admitted she should not have touched the resident's food with her hands after handling equipment. Additionally, a container of chicken salad was found on an accessory table with a temperature of 53 degrees, above the required holding temperature of 41 degrees or lower. Despite this, a sandwich was made from the chicken salad and served to a resident. The dietary manager confirmed that all facial hair should be covered, gloves should be changed before handling food, and food should not be served if it is above the safe holding temperature. The administrator and director of clinical services were made aware of these findings.
Failure to Inform Resident of Medication Risks, Benefits, and Alternatives
Penalty
Summary
Facility staff failed to inform a resident or the resident's representative about the risks, benefits, and alternative treatments associated with the use of lorazepam, an anti-anxiety medication. A physician's order was present for lorazepam to be administered as needed for anxiety, sleeplessness, seizure activity, or shortness of breath, but there was no documentation in the clinical record indicating that the required information was provided to the resident or their representative. Staff interviews confirmed that such information should be communicated, including details about targeted behaviors, side effects, and alternative treatments, but this was not done in this case. The facility's own policy states that residents have the right to be fully informed in advance about care and treatment, but this was not followed for the resident in question.
Failure to Notify Physician and Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to promptly notify the resident representative when a resident experienced vomiting and was placed on contact precautions. Review of the clinical record showed that the resident was placed on contact isolation due to vomiting, but there was no documentation that the resident's representative was informed of this change in condition. Interviews with staff confirmed that notification should have occurred, and facility policy required prompt notification of changes in a resident's condition to the resident, physician, and representative. In another instance, staff did not notify the physician when a resident complained of burning and pain to the neck and repeatedly requested that the on-call physician be contacted for treatment. The resident, who was cognitively intact, reported that a chemotherapy cream had been mistakenly applied to the neck, resulting in a chemical burn. Despite the resident's insistence and repeated requests for hydrocortisone cream and for the on-call physician to be contacted, the nurse assessed the area, found no visible irritation, and decided not to call the on-call provider, instead placing the request in the nurse practitioner communication book for follow-up the next day. Progress notes documented the resident's ongoing complaints and the nurse's repeated assessments, which did not reveal visible signs of injury. Staff interviews indicated that the protocol was to call the on-call provider for medication needs or acute symptoms, and that it was the resident's right to have the provider contacted upon request. The facility's policy required prompt notification of changes in condition, but this was not followed in these cases.
Failure to Review or Revise Care Plan After Resident Fall
Penalty
Summary
Facility staff failed to review or revise the comprehensive care plan for one resident following a fall incident. The resident, who had a diagnosis including dementia and was severely cognitively impaired as indicated by a low BIMS score, experienced a fall that was documented in both nursing notes and a fall investigation. The documentation showed that the resident was found on the floor, was alert and oriented, sustained no injuries, and appropriate notifications and protocols were followed at the time of the incident. Despite the fall and the facility's policy requiring care plan review and updating after significant changes in a resident's condition, there was no evidence that the comprehensive care plan was reviewed or revised following the incident. The MDS coordinator confirmed that although the care plan was reviewed, there was no documentation to support this, and the care plan itself did not reflect the fall event. The administrator and director of clinical services were made aware of these findings.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
Facility staff failed to provide appropriate respiratory care for one resident by not obtaining a physician's order for oxygen therapy prior to administration. The resident was admitted with diagnoses including respiratory failure and was assessed as cognitively intact. During an observation, the resident was found to be receiving oxygen at three liters per minute via nasal cannula. At the time of the observation, there was no documented physician's order for the oxygen therapy being administered. The physician's order for continuous oxygen at three liters per minute by nasal cannula was only created later that same day, after the resident had already been observed receiving oxygen. This lapse was confirmed by the unit manager, who acknowledged that no order was present at the time of the surveyor's observation.
Failure to Provide Individualized Physician Oversight During Medication Administration
Penalty
Summary
Facility staff failed to provide physician services for three residents by not ensuring individualized physician oversight and response to a nurse's inquiry regarding medication administration. On a specific date, only one nurse was present on a unit with 54 residents, instead of the scheduled two nurses. The nurse on duty reported being unable to administer medications as scheduled due to the overwhelming workload and the absence of a second nurse. The nurse attempted to seek guidance from a nurse practitioner, who stated she could not provide orders for all residents and advised the nurse to use her own judgment and critical thinking. No individualized physician direction was documented for the affected residents. For the residents involved, clinical records showed that multiple medications, including those for allergies, spinal stenosis, nasal congestion, rhabdomyolysis, muscle spasms, high blood pressure, increased eye pressure, pain, and constipation, were administered late or not at all. Medication administration audit reports confirmed that scheduled doses were significantly delayed, and in some cases, medications ordered to be given three times a day were omitted because the late administration would have resulted in doses being too close together. The nurse on duty made decisions about which medications to administer based on her own judgment without specific physician input for each resident. Interviews with staff, including the nurse, nurse practitioner, pharmacist, and administrator, confirmed the lack of individualized physician response and documentation regarding the medication administration issues. The facility's policy required the attending physician to participate in assessment, care planning, and to provide consultation or treatment when called by the facility. However, this process was not followed, resulting in a failure to ensure that residents were under appropriate physician care during the incident.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Medication Administration
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of residents on the [NAME] unit during the day shift on 12/25/24. On that day, only one nurse was present to care for 54 residents, despite facility policy and staff statements indicating that two nurses are required for this shift. The night shift nurse, who had already worked 16 hours, remained until approximately 9:30 a.m. but did not provide resident care or administer medications between 7:00 a.m. and 9:30 a.m., instead attempting to find coverage for the absent second nurse. As a result of the staffing shortage, several residents experienced delays in the administration of their scheduled medications. For example, one resident with orders for pseudoephedrine, baclofen, azelastine, and magnesium oxide received these medications several hours after their scheduled times. Another resident with orders for hydralazine and brimonidine tartrate also received medications later than scheduled. A third resident with orders for tramadol and Miralax experienced similar delays in medication administration. Interviews with staff confirmed that only one nurse was present during the day shift, and the nursing scheduler was unable to verify the intended schedule for that day due to limitations in the scheduling system. The administrator was made aware of the concern, and the facility's policy states that sufficient numbers of staff with the necessary skills and competency are to be provided in accordance with resident care plans and the facility assessment. No further information was presented prior to exit.
Incomplete Nurse Staffing Information Posted
Penalty
Summary
Facility staff failed to post complete daily nurse staffing information for three consecutive days, as required. Specifically, the daily nurse staffing sheets for the reviewed dates did not include the facility name, which is a required element according to the facility's own policy. During an interview, the scheduler responsible for posting the nurse staffing information acknowledged that the facility name was missing from the sheets and stated she was unaware that this information was required. The deficiency was confirmed through observation, staff interviews, and review of facility documents. Administrative staff were made aware of these findings during the survey.
Improper Garbage Disposal Practices
Penalty
Summary
The facility staff failed to maintain the garbage areas in a sanitary manner, as observed with one trash compactor and two trash bins. During an observation, the side door of the trash compactor was found open with multiple bags of trash inside. Additionally, two outside trash bins were observed with their lids open, also containing multiple bags of trash. Interviews with the regional director of maintenance and the maintenance director confirmed that the doors and lids should be kept closed to prevent animal access. The facility's policy on food-related garbage and refuse disposal requires that garbage containing food waste be stored in a manner inaccessible to pests. This policy was not adhered to, leading to the deficiency.
Inadequate Infection Control Program and Practices
Penalty
Summary
The facility staff failed to maintain a comprehensive infection control program and implement effective infection control practices. A review of the facility's infection control program for the year 2023 revealed the absence of a systematic surveillance system. The only documentation available was a binder containing multiple Antibiotic Timeout forms for various residents, which was insufficient for tracking and identifying clusters of infections. During an interview, the infection control nurse, who was not employed at the facility during 2023, confirmed that the existing documentation was inadequate for identifying infection control challenges. The facility's policy on infection prevention and control emphasized the need for surveillance tools to recognize infections, record their frequency, and detect outbreaks, but no further information was provided before the survey exit. Additionally, a registered nurse failed to implement proper infection control practices while preparing and administering medications to a resident. The nurse was observed dropping a tablet on the medication cart, picking it up with bare hands, and placing it in a medication cup with other pills. Upon realizing the tablet was incorrect, the nurse used a finger to hold the remaining pills while discarding the wrong one, then continued to administer the medications to the resident. An LPN later stated that dropped pills should be discarded, and if a pill needs to be removed from a cup, all pills should be discarded and re-poured, or gloves should be used. The facility lacked a specific policy regarding this concern, and no further information was provided before the survey exit.
Failure to Promote Resident Dignity in Care and Services
Penalty
Summary
The facility staff failed to provide care and services in a manner that promoted resident dignity for four residents. For Resident #96, the staff did not treat him with dignity after he vomited. Despite calling out for help, the resident was left in soiled clothing and bed linens for several hours, which made him feel dirty and humiliated. The incident was not documented in the resident's clinical record, and the staff involved did not ensure the resident was cleaned up promptly. Resident #31 experienced a lack of dignity during meal service. While other residents at the same table were served lunch, Resident #31 was left waiting for 11 minutes before receiving food. The dietary manager acknowledged that all residents at the same table should be served simultaneously to avoid such situations. The facility's policy on food and nutrition services did not address the importance of a dignified dining experience. For Resident #67, the staff failed to provide necessary ADL assistance during the night shift. The resident, who was dependent on staff for personal care, was left sitting in a wheelchair all night without being assisted to bed or cleaned up. The progress notes did not document any attempts to provide care or the resident's refusal of care. Additionally, Resident #157 reported that staff instructed her to void in her brief, which she found embarrassing and undignified. The staff allegedly told her they were going on break and could not assist her at that time, leading to her being left in wet clothing.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility staff failed to provide written notification of facility-initiated hospital transfers to residents, their representatives, and the Ombudsman for five residents. For Resident #52, the staff did not provide a written notice to the resident's representative for a hospital transfer due to shortness of breath and chest heaviness. The Discharge Planner/Social Worker admitted to not sending the notification due to being out with COVID. The facility's policy requires notification to be made as soon as practicable before transfer or discharge, especially in cases of urgent medical needs. Resident #69 was transferred to the hospital due to tachycardia and confusion, but the facility failed to provide written notice to the resident's representative and the Ombudsman. The Discharge Planner/Social Worker again cited absence due to COVID as the reason for the oversight. The transfer list used by the facility did not include residents who went to the emergency room and returned the same day, leading to missed notifications. For Resident #22, the facility did not provide written notice to the Ombudsman for a hospital transfer following a nosebleed. Similarly, Resident #45 did not receive written notification for multiple transfers, and the Ombudsman was not notified for some of these transfers. Resident #11's transfer to the emergency department also lacked notification to the Ombudsman. Interviews with staff revealed that the facility's process for notifying the Ombudsman was not consistently followed, particularly when the Discharge Planner was absent.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility staff failed to develop and implement comprehensive care plans for several residents, leading to multiple deficiencies. For one resident with diabetes, the staff did not adhere to the scheduled times for blood sugar monitoring and insulin administration as per physician orders. The blood sugar levels were often checked after meals, which could result in inaccurate insulin dosing. Additionally, there was a failure to administer insulin and antibiotics as ordered, with no documentation provided for missed doses. Another resident, who was at risk for malnutrition and on a fluid restriction due to end-stage renal disease, did not have their fluid intake monitored as per the care plan. The medication administration record showed gaps in documentation, indicating that the fluid restriction was not consistently implemented. Similarly, a resident on anticoagulant therapy reported missing doses of their medication, Xarelto, despite the medication being available in the facility's pharmacy system. The facility also failed to provide necessary assistance with activities of daily living for a resident who was severely impaired and dependent on staff for care. The documentation did not reflect the care provided, and there were reports of the resident being left in soiled clothing and not repositioned regularly. Additionally, there were deficiencies in wound care management for residents with pressure injuries and skin tears, as treatments were not documented as completed on multiple occasions. These failures highlight significant lapses in the implementation of care plans and documentation practices within the facility.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care for four residents, leading to deficiencies in their care. Resident #96 experienced an incident where he vomited and was left in soiled clothing and bed linens for several hours. Despite calling for assistance, the staff did not clean him up until much later, and there was no documentation of the incident in his clinical record. This oversight indicates a failure to adhere to the facility's policy on providing proper daily personal attention and care. Resident #108's care was compromised due to missing documentation of incontinence care, bathing, and dressing on specific dates. The resident, who was dependent on staff for these activities, did not have evidence of care provided in the facility's records. Interviews with staff revealed that incontinence care should be documented in the Point Click Care system, but this was not done consistently, leading to gaps in the resident's care documentation. Residents #32 and #67 also experienced deficiencies in their ADL care. Resident #32 reported being left wet and not changed in a timely manner, with documentation showing multiple dates where assistance with toileting was not recorded. Similarly, Resident #67 was left in a wheelchair overnight without being assisted back to bed, and there was a lack of documentation for care provided on several dates. These incidents highlight a pattern of inadequate care and documentation for residents who are dependent on staff for their daily living activities.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to provide appropriate care and services to promote the highest level of well-being for several residents. For Resident #157, the staff did not obtain blood sugars as ordered by the physician, leading to insulin being administered at inappropriate times, potentially affecting the resident's blood sugar levels. Additionally, insulin and antibiotic medications were not administered as ordered, with no documentation provided for the missed doses. This lack of adherence to physician orders and documentation requirements indicates a significant lapse in medication management and monitoring. Resident #34 experienced missed doses of Xarelto, a medication used to prevent blood clots, due to the medication not being on hand, despite being available in the facility's pharmacy system. The facility's policy on unavailable medications was not followed, as there was no evidence of notification to the attending physician or responsible party. This oversight in medication availability and communication further highlights the facility's failure to ensure residents receive necessary medications as prescribed. Other residents, including Resident #114, #113, #108, #112, #117, and #53, also experienced deficiencies in care. These included failures in administering medications, conducting necessary assessments, and obtaining appropriate orders upon admission. The facility's inability to adhere to physician orders, document care accurately, and ensure medication availability and administration reflects a broader issue of inadequate care and oversight, impacting the well-being of multiple residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide adequate care and services to promote the healing of pressure injuries for three residents, leading to deficiencies in their treatment. Resident #67, who was severely impaired in making daily decisions and under hospice care, did not receive the prescribed treatments for pressure injuries on multiple occasions. The resident's family member expressed concerns about the lack of regular repositioning and the application of prescribed creams, which were not consistently documented in the electronic treatment administration record (eTAR). Resident #111 also experienced a lack of proper treatment for a pressure injury. The resident had an unstageable pressure ulcer on the sacrum, and the facility failed to document the completion of the prescribed treatments on several dates over a four-month period. Interviews with nursing staff revealed that wound care was supposed to be documented on the eTAR, but there were multiple instances where this was not done, indicating a failure to provide the necessary care. Resident #116, who was severely cognitively impaired and dependent on staff for daily activities, did not receive the prescribed wound treatments for a skin tear on the right shin. The medication administration record (MAR) showed missing evidence of wound treatments on several dates over three months. An LPN confirmed that if there was no documentation of wound care on the TAR, it was not performed. The facility's policy required documentation of treatments, but this was not adhered to, resulting in a deficiency in care.
Failure to Provide Respiratory Care Services per Physician Orders
Penalty
Summary
The facility staff failed to provide respiratory care services per physician orders for two residents. Resident #108, who was admitted with diagnoses including coronary artery disease, COPD, hyponatremia, and asthma, did not receive the required respiratory assessments as per physician orders. The treatment administration record (TAR) for May 2024 showed missing documentation for respiratory assessments on specific shifts. An LPN confirmed that the evidence of respiratory assessments should be on the TAR and acknowledged that professional standards were not followed when physician orders were not adhered to. Similarly, Resident #407, admitted with conditions such as a fracture, obstructive sleep apnea, asthma, and paroxysmal atrial fibrillation, did not have their CPAP mask cleaned as ordered by the physician. The nursing task administration record for August 2024 lacked evidence of CPAP cleaning for a specified period. The resident confirmed that no one was cleaning the mask due to their inability to do so because of a broken bone. An LPN confirmed that the evidence of CPAP mask cleaning should be on the TAR and acknowledged that professional standards were not followed when physician orders were not adhered to.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility staff failed to implement a complete pain management program for two residents, leading to deficiencies in their care. Resident #96, who has no cognitive impairment and requires assistance with activities of daily living, expressed concerns about frequently needing to request pain medication. Despite receiving 51 doses of as-needed Oxycodone for breakthrough pain related to multiple sclerosis, the resident's pain levels remained high, ranging from 6 to 9. The attending physician and nurse practitioner acknowledged that the frequent use of as-needed medication indicated a need for adjustment in the resident's scheduled pain management, which was not done. Similarly, Resident #72 also experienced inadequate pain management. This resident received 49 doses of as-needed Oxycodone or Percocet, with pain levels primarily between 7 and 10. The attending physician and nurse practitioner recognized that the frequent administration of as-needed medication suggested the need for a change in the resident's scheduled pain medication. However, no adjustments were made to address the resident's ongoing pain. Interviews with facility staff, including a licensed practical nurse and the nurse practitioner, revealed that the facility's pain management policy was not effectively implemented. The staff acknowledged that frequent requests for as-needed pain medication should have prompted a reassessment and adjustment of the residents' scheduled pain management. The facility's policy emphasizes a multidisciplinary approach to pain management, including monitoring and modifying interventions as necessary, which was not adequately followed in these cases.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care and services for five residents, leading to multiple deficiencies. For one resident, the facility staff did not ensure transportation to a scheduled dialysis session, resulting in a missed treatment. The staff was unable to locate the necessary contact information for transportation, and there was no backup plan in place to address the issue. Additionally, the facility did not maintain proper communication with the dialysis center, as evidenced by the lack of pre and post-dialysis review forms and communication records. Another resident experienced a similar lack of communication with the dialysis center. The facility failed to provide documentation of communication with the dialysis center for scheduled treatments. Interviews with staff revealed that necessary paperwork, such as medication lists and face sheets, was not consistently sent with residents to the dialysis center. This lack of communication and documentation was a recurring issue for multiple residents, indicating a systemic problem within the facility's processes. Furthermore, the facility did not adequately monitor and document physician-ordered fluid restrictions for residents undergoing dialysis. In one case, the facility's medication administration records showed missing or incorrect documentation of fluid intake, and staff interviews revealed confusion about the documentation process. This failure to implement and monitor fluid restrictions was noted for multiple residents, highlighting a significant deficiency in the facility's care for residents requiring dialysis.
Inadequate Night Shift Staffing for Residents
Penalty
Summary
The facility failed to provide adequate nursing staff for two residents during the night shift on multiple occasions. For one resident, the facility did not meet the required staffing levels on several nights in September and October 2023, with only one licensed nurse and one CNA present, despite the unit having a census of 25 to 30 residents. The staff scheduler and the director of nursing both confirmed that the unit should have a minimum of one licensed nurse and two CNAs on the night shift, based on the staffing grid provided by corporate and the unit's acuity and census. However, due to call-outs, the unit was often left with insufficient staff. Similarly, another resident experienced inadequate staffing on a specific night in August 2023, with only one licensed nurse and one CNA on duty for a unit with 26 residents. The staff scheduler and the director of nursing reiterated the staffing requirements, which were not met on this occasion. The facility's policy states that staffing should be sufficient to meet the needs of all residents according to their care plans, but this was not adhered to, leading to the deficiency.
Failure to Administer and Monitor Anticoagulant Therapy
Penalty
Summary
The facility staff failed to ensure that two residents were free from unnecessary medications due to improper administration and monitoring of anticoagulant therapy. Resident #113, who was admitted with fractures and hypertension, was prescribed Enoxaparin Sodium Injection to be administered every 12 hours. However, the medication administration record (MAR) showed multiple instances of delayed administration, with times significantly deviating from the prescribed schedule. The baseline care plan did not include any focus or interventions related to anticoagulation therapy, and the facility's medication administration policy, which emphasizes the 5 Rights, was not adhered to. Resident #26, admitted with diagnoses including congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease, was on anticoagulant therapy for atrial fibrillation. The comprehensive care plan required monitoring for adverse reactions to the anticoagulant therapy, but the medication administration record-treatment administration record (MAR-TAR) showed no evidence of such monitoring. The resident was severely cognitively impaired, as indicated by a BIMS score of 03 out of 15, and was dependent on staff for most activities of daily living. Interviews with an LPN revealed that the facility did not follow professional standards for medication administration and monitoring, as evidenced by the lack of adherence to physician orders and the facility's own medication administration policy. The facility's administrative staff, including the administrator and director of nursing, were made aware of these findings, but no further information was provided prior to the survey exit.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility staff failed to serve palatable food at an appetizing temperature for five residents. Residents reported that the food was often cold and lacked flavor. One resident mentioned losing weight due to the poor quality of the food, while another stated that the food was not suitable even for a pet. The residents involved were cognitively intact or moderately impaired, as indicated by their BIMS scores, and were able to express their dissatisfaction with the meals provided. A meal test tray conducted with the dietary manager revealed that the food did not have a palatable flavor or appetizing temperature. The ground pork was found to be bland and not warm enough, the coleslaw was overly vinegary, and the pureed pork and vegetables were also bland and not at the desired temperature. The facility's policy requires that food be served at a safe and appetizing temperature, but this standard was not met, as evidenced by the observations and resident interviews.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility staff failed to ensure that certified nursing assistants (CNAs) completed the required in-service training hours. Specifically, three out of five CNA records reviewed showed deficiencies in meeting the 12-hour annual training requirement. CNA #3, hired on May 19, 2022, completed only 10 hours of training. CNA #4, hired on June 22, 2022, completed 4.5 hours, and CNA #5, hired on March 24, 2023, completed 2.75 hours. During an interview, the administrator and the director of nursing acknowledged the issue and mentioned the recent implementation of a computer software for training, indicating a need for a system to ensure compliance with training requirements. The facility's policy mandates no less than 12 hours of annual in-service training per employment year or as required by state law.
Failure to Ensure Call Light Accessibility and Assess Resident Needs
Penalty
Summary
The facility staff failed to accommodate the needs of three residents by not ensuring that call lights were accessible. For Resident #92, who was admitted with diagnoses including congestive heart failure, Parkinson's disease, and dementia, the call light was found coiled behind the headboard, out of reach. Despite the resident's severe cognitive impairment and need for supervision, the call light was not accessible, as confirmed by a CNA who later clipped it to the bedspread. The facility's policy required call lights to be within easy reach, but this was not adhered to. Resident #50, who was severely impaired in making daily decisions and required substantial assistance, also had issues with call light accessibility. Observations showed the call light on the floor and later clipped to a pillow, out of reach. Interviews with staff confirmed that the call light should be within reach to allow residents to alert staff when needed. However, the call light was not consistently placed within reach, compromising the resident's ability to communicate needs. For Resident #91, the facility failed to assess the need for grab bars, despite the resident's request and history of slipping off the bed. There was no documented assessment or physician order for grab bars, and the care plan did not include them. The director of therapy was unaware of the resident's request, indicating a lack of communication and assessment regarding the resident's needs. The facility's failure to assess and provide necessary accommodations for these residents highlights deficiencies in meeting individual resident needs.
Failure to Notify of Changes in Condition and Treatment
Penalty
Summary
The facility staff failed to notify the physician and/or the resident's representative of a change in condition or treatment for three residents. For one resident, the staff did not document any discussion or notification regarding a change in medication. The physician's progress note did not mention the addition of Sacubitril-Valsartan, and there was no evidence of communication with the resident or their responsible party about this change. Interviews with facility staff confirmed that such notification should have occurred, as per the facility's policy. Another resident missed a scheduled dialysis treatment because transportation did not arrive, and the facility staff failed to notify the physician. The nurse's notes indicated attempts to contact the transportation company and the dialysis center, but there was no documentation of notifying the physician about the missed treatment. An interview with a unit manager confirmed that the provider and responsible party should be informed if a resident misses dialysis. For a third resident, the facility staff did not notify the responsible party after the resident experienced a fall. The clinical record lacked documentation of any notification to the responsible party following the incident. Interviews with facility staff revealed that the responsible party should have been informed, but the notes and care plan did not reflect this communication. The facility's administrative and clinical leadership were made aware of these findings, but no further information was provided before the survey's conclusion.
Failure to Timely Issue Beneficiary Notice of Non-Coverage
Penalty
Summary
The facility staff failed to issue a beneficiary notice of non-coverage in a timely manner for a resident, identified as Resident #257. The resident was discharged from a Medicare-covered Part A stay with benefit days remaining on 5/22/24. However, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, which informs the resident that Medicare may not cover certain services and that they may have to pay out of pocket, was signed by the discharge planner on 5/14/24 but not by the resident until 5/22/24. This delay in obtaining the resident's signature did not comply with the facility's policy, which requires the notice to be provided within forty-eight hours of the last anticipated covered day. During an interview, the discharge planner, identified as OSM #4, admitted to discussing the notice with the resident on 5/14/24 but failed to obtain the resident's signature at that time. OSM #4 speculated that the papers might have been left in the resident's room, leading to the delay. The issue was brought to the attention of the facility's administrator and director of nursing on 8/27/24. The facility's policy emphasizes the importance of providing the notice in a timely manner to allow residents or their representatives enough time to make informed decisions about their care and financial responsibilities.
Incomplete MDS Assessment for a Resident
Penalty
Summary
The facility staff failed to maintain a complete and accurate Minimum Data Set (MDS) assessment for one resident in the survey sample. The MDS assessment, specifically the admission assessment with a reference date of 5/7/23, contained inaccuracies in Section C - Cognitive Patterns. The section for the resident interview and the staff interview were left incomplete, with dashes documented instead of the required information. Additionally, under item C0100, which determines if a Brief Interview for Mental Status should be conducted, a dash was also documented. This was despite the resident being coded as usually understood and usually understands, indicating that the interview should have been completed. During an interview with RN #6, the MDS coordinator, it was revealed that the social worker typically completes Section C, although RN #6 sometimes does it. RN #6 was not employed at the facility at the time of the assessment but confirmed that the staff interview should have been conducted if the resident could not do the interview. The facility uses the Resident Assessment Instrument (RAI) manual to complete MDS assessments. The RAI Manual, Version 1.18.11, specifies that if the resident interview was not conducted within the look-back period, item C0100 must be coded as 'Yes,' and the standard no information code (a dash) should be entered in the resident interview items. The staff assessment for mental status items should not be completed if the resident interview should have been conducted but was not done. The administrative and clinical staff were made aware of these findings, but no further information was provided before the exit.
Failure to Include Critical Therapies in Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans for two residents, which led to deficiencies in monitoring critical therapies. Resident #113, who was admitted with fractures and hypertension, was prescribed anticoagulation therapy with Enoxaparin Sodium Injection. However, the baseline care plan did not include any focus or interventions related to this therapy, despite the resident's need for monitoring due to the medication's potential side effects. Interviews with facility staff confirmed that the baseline care plan should have included this information, but it was omitted. Similarly, Resident #407, admitted with a fracture, obstructive sleep apnea, asthma, and paroxysmal atrial fibrillation, required CPAP therapy as per physician orders. The baseline care plan for this resident also failed to include any focus or interventions related to CPAP use or monitoring. Staff interviews revealed an understanding that such therapies should be included in the baseline care plan, yet this was not done. The facility's policy mandates that baseline care plans should address immediate care needs based on orders, services, medications, and treatments, which was not adhered to in these cases.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for three residents, leading to deficiencies in their care. For one resident, the care plan did not include the use of grab bars, which were ordered by the physician and used by the resident for independent bed mobility. Despite the presence of grab bars being documented in the physician's orders and a risk assessment, the care plan was not updated to reflect this, leaving a gap in the documentation of the resident's needs and the interventions required. Another resident's care plan was not updated to include treatment for a non-pressure related skin condition. The physician had ordered Nystatin cream for the resident's skin redness, but the electronic treatment administration record (eTAR) showed multiple instances where the treatment was not documented as completed. The care plan only mentioned the potential for skin integrity impairment due to incontinence, without addressing the specific treatment for the skin condition, indicating a lack of comprehensive care planning. A third resident experienced a fall, but the care plan was not reviewed or revised following the incident. The existing care plan documented the resident's risk for falls and included various interventions, but there was no update after the fall to address any new needs or changes in the resident's condition. Interviews with staff revealed that the interdisciplinary team was responsible for updating care plans, but this was not done in this case, resulting in an incomplete care plan that did not reflect the resident's current situation.
Medication Administration and Order Clarification Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for three residents, leading to deficiencies in medication administration and order clarification. For Resident #157, there were two conflicting physician orders for insulin administration documented in the medication administration record (MAR) simultaneously. Despite nurses noting the duplicate order, no action was taken to clarify or discontinue the incorrect order, as confirmed by RN #5 during an interview. The facility's medication administration policy did not address handling duplicate orders, contributing to the oversight. Resident #34 experienced a delay in receiving medications as per physician orders. The resident reported not receiving Metformin and Seroquel at the scheduled times, with documentation showing administration occurred significantly later than prescribed. The facility's policy allows for a one-hour window around the scheduled time for medication administration, but this was not adhered to, resulting in the resident receiving medications outside the acceptable timeframe. For Resident #72, the facility staff did not clarify two as-needed orders for pain medication, leading to potential confusion in administration. The resident's MAR showed frequent administration of both Oxycodone and Percocet without clear parameters for when each should be used. LPN #5 acknowledged the lack of specific guidelines for administering these medications based on pain levels, indicating a gap in the facility's protocol for managing prn orders. The absence of clarification could lead to inconsistent pain management for the resident.
Deficient Catheter Care for Two Residents
Penalty
Summary
The facility staff failed to provide adequate urinary catheter care for two residents, leading to deficiencies in care. Resident #67, who was severely impaired in making daily decisions and under hospice care, did not receive catheter care on multiple occasions between June and August 2024. The resident's family expressed concerns about the care provided, noting uncertainty about the specific catheter care being administered. The facility's comprehensive care plan and physician orders required catheter care every shift, but the electronic treatment administration record (eTAR) showed missed care on several dates. Similarly, Resident #24, who was cognitively intact, also experienced lapses in catheter care from June to July 2024. The resident had a suprapubic catheter and reported that staff changed the catheter when it leaked and emptied the bag daily. However, the resident was unsure about the regularity of catheter care. The care plan and physician orders specified catheter care every shift, but the eTAR indicated that care was not documented on several dates. Interviews with facility staff, including a CNA and an RN, revealed that catheter care was supposed to be provided every shift as per physician orders, and documentation in the eTAR was meant to evidence the completion of care. However, the lack of documentation suggested that care was not consistently provided. The facility's administrative and clinical leadership were informed of these concerns, but no further information was provided before the survey exit.
Failure to Monitor Resident's Weight and Conduct Nutritional Assessments
Penalty
Summary
The facility staff failed to adhere to physician orders for daily weight monitoring for a resident identified as being at risk for significant weight gain. The resident reported that she was supposed to have daily weights taken, but if she did not go to the scales herself, no staff would assist her. The physician's order, dated July 12, 2024, required daily weights to monitor for significant weight gain, yet there were missing entries on the medication administration record for several days in July 2024. The comprehensive care plan also highlighted the resident's risk for nutritional status alteration and the need for daily weight monitoring. Additionally, the facility staff did not complete a quarterly nutritional assessment for the resident between December 6, 2023, and May 1, 2024. The resident's clinical chart showed a significant weight gain, which was noted in a nutritional assessment on December 6, 2023, but no follow-up assessment was conducted until May 1, 2024. The facility's policy required quarterly assessments, and the dietician confirmed that an assessment should have been completed if the resident triggered for weight gain in December 2023. The facility's policy on nutritional assessments mandates a comprehensive evaluation of each resident's nutritional status, risk factors, and preferences. However, the facility failed to conduct the required assessments and follow physician orders, as evidenced by the lack of documentation and missed weight recordings. The administrative and clinical staff were informed of these deficiencies, but no further information was provided before the survey exit.
Failure to Assess Resident for Safe Use of Bed Rails
Penalty
Summary
The facility staff failed to perform a safety assessment for the use of side rails for Resident #93. On August 27, 2024, the resident was observed sitting up in bed with both quarter side rails raised while eating breakfast. A review of the resident's clinical record, including assessments, physician orders, and care plan, showed no evidence of an assessment for the need or safe use of side rails. On August 28, 2024, the Director of Nursing confirmed the absence of a safety assessment for the resident's use of side rails. Further interviews revealed that before a resident's bed is equipped with side rails, assessments by physical therapy and occupational therapy are required to determine the resident's ability to use the side rails safely and the necessity of the side rails. However, these assessments were not completed for Resident #93, and no orders were entered into the system by PT or OT.
Deficiencies in Pain Management and Diabetes Care
Penalty
Summary
The facility staff failed to provide adequate physician oversight for the care of four residents, leading to deficiencies in pain management and diabetes care. For two residents, the facility physician and nurse practitioner did not properly assess the frequent use of as-needed (prn) pain medications. One resident expressed concern about having to frequently request pain medication, and the medication administration record showed high usage of prn pain medication with pain levels ranging from 6 to 9. Interviews with the attending physician and nurse practitioner revealed that adjustments to the resident's scheduled pain medication were necessary but not made, indicating a lack of proactive management. Similarly, another resident also experienced frequent administration of prn pain medications, with pain levels primarily between 7 and 10. The attending physician and nurse practitioner acknowledged the need for adjustments to the resident's pain management regimen, yet no changes were implemented. Both cases highlight a failure to transition residents from prn to scheduled pain management, which could have alleviated the need for frequent requests for pain relief. In addition to pain management issues, the facility failed to identify and address the need for blood sugar checks and insulin administration for two residents upon admission. One resident's spouse raised concerns about the absence of orders for blood glucose monitoring and insulin, which were only addressed after the resident had been in the facility for over 24 hours. Another resident also lacked orders for blood sugar checks and insulin until the responsible party notified the facility. These oversights in medication reconciliation and timely implementation of necessary medical orders demonstrate a significant lapse in the facility's admission process and ongoing care management.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility staff failed to provide a physician-ordered medication, Avonex, for timely administration to Resident #96, who was being treated for multiple sclerosis. Despite the resident's cognitive ability to make daily decisions and his reliance on staff assistance for activities of daily living, the medication was not administered on the scheduled Saturdays in August 2024. Instead, it was given on subsequent Tuesdays, resulting in a 10-day gap between doses. The facility did not communicate with the pharmacy or the family regarding the medication's availability, and the staff were unsure of the protocol if the family did not bring the medication. Resident #34 also experienced a failure in medication administration, as the facility did not ensure the availability of Meclizine, prescribed for vertigo. The medication was not available on two documented occasions, and the facility's onsite pharmacy system did not have Meclizine in stock. The nursing staff indicated that they would contact the pharmacy and check the backup system if a medication was unavailable, but there was no evidence of notifying the provider or the resident's responsible party when the medication was not found. Interviews with various staff members, including the LPN, registered pharmacist, and director of nursing, revealed a lack of clarity and communication regarding the responsibility for obtaining and administering medications. The facility's policy on unavailable medications requires notifying the attending physician and explaining the circumstances, but there was no documentation of such actions being taken. The facility's administrative staff were made aware of these findings, but no further information was provided before the survey exit.
Failure to Address Pharmacy Recommendation for Medication Tapering
Penalty
Summary
The facility staff failed to ensure that a physician reviewed and acted upon a pharmacy recommendation for a resident during the monthly pharmacy regimen review. On 5/20/24, a pharmacy note indicated that the resident was receiving Ramelteon 8 mg every night for hypnotic therapy, which exceeded the manufacturer's recommended duration of use. The pharmacy recommended considering a gradual tapering of the medication to ensure the resident was on the lowest dose possible or to assess the continued need for the medication. However, the physician did not review or address this recommendation, and the resident remained on the higher dose for an additional three months. The issue was identified when the pharmacy repeated the recommendation on 8/12/24, and the physician subsequently decreased the dose to 4 mg on 8/23/24. During an interview, the Director of Nursing stated that pharmacy forms are provided to the provider for review and sign-off, but she was unaware of why this particular recommendation was not addressed in a timely manner. The facility's policy requires that if the attending physician does not respond within 30 days, the medical director should review the recommendations and document any actions taken. Despite this policy, the deficiency was not addressed until the second recommendation was made.
Failure to Address Pharmacy Recommendation for Psychoactive Medication
Penalty
Summary
The facility staff failed to ensure that a resident was free of an unnecessary psychoactive medication. The resident was prescribed Ramelteon, an oral tablet for insomnia, at a dose of 8 mg to be taken every night at bedtime. A pharmacy recommendation dated six days after the initial prescription advised a gradual tapering of the medication to ensure the resident was on the lowest dose possible or to assess the continued need for the medication. However, the physician did not review or address this recommendation, resulting in the resident remaining on the higher dose for an additional three months. The issue was identified during a survey, and the Director of Nursing acknowledged receiving the pharmacy forms and providing them to the provider for review. However, she was unaware of why the recommendation was not addressed in a timely manner. The deficiency was discussed with the facility's administrative and clinical staff, including the Administrator, Director of Nursing, Director of Clinical Operations, Regional Director of Clinical Operations, Regional Director of Operations, and Assistant Director of Nursing. No further information was provided by the end of the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to maintain safe and sanitary conditions in the kitchen and nourishment areas, as observed during a survey. In the kitchen's dry goods storage room, a container of sugar was found with its lid open, exposing the contents to potential contamination. Additionally, pots and pans were stored on a shelf with visible stains and food debris, compromising their cleanliness. An ice scoop was improperly stored on a cart beside the ice machine instead of being placed in a sanitary holder or bag. Further deficiencies were noted in the facility's dishwashing and food preparation processes. The sanitizer solution in the three-compartment sink was tested and found to be at 170 ppm, below the manufacturer's recommended range of 272-700 ppm, indicating improper sanitization of kitchenware. The dishwasher was observed operating at temperatures below the manufacturer's minimum requirement of 120 degrees Fahrenheit, with readings between 114 and 118 degrees, which could affect the effectiveness of dish sanitization. The facility also failed to maintain proper food storage and serving temperatures. Coleslaw was served at 69 degrees Fahrenheit, above the safe serving temperature of 40 degrees, posing a risk for bacterial growth. In the grace unit nourishment room, a container of watermelon was found without a date label, and the contents appeared mushy and emitted an unpleasant odor, suggesting spoilage. These observations highlight significant lapses in food safety and sanitation practices within the facility.
Sanitation Deficiency in Kitchen Area
Penalty
Summary
The facility staff failed to maintain a sanitary environment in the kitchen, as observed on two separate occasions. Black and brown debris were visible on the floor under the three-compartment sink, under shelves, under the dishwasher, and in a gap between the stove and ovens. Additionally, similar debris and stains were noted on the floor in the dry goods storage room. During an interview, the dietary manager acknowledged that the dietary staff should sweep and mop the kitchen floors after every meal, including the areas under the sink, shelves, dishwasher, and between the stove and ovens. The dietary manager also mentioned that the stains in the dry goods storage room could not be removed by dietary staff and had requested housekeeping to strip and wax the floor. The facility's policy requires floors to be maintained in a clean, safe, and sanitary manner.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
