Holston Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wytheville, Virginia.
- Location
- 990 Holston Rd, Wytheville, Virginia 24382
- CMS Provider Number
- 495349
- Inspections on file
- 16
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holston Health And Rehabilitation during CMS and state inspections, most recent first.
Facility staff failed to administer ordered medications, such as insulin and Gabapentin, and did not consistently obtain or document daily weights for residents with physician orders. In one case, a resident with diabetes did not receive their bedtime insulin, resulting in a critically high blood sugar and hospital transfer. Another resident missed doses of Gabapentin despite its availability in the facility, and a third resident's daily weights were not consistently obtained or recorded, with staff signing off without performing the task.
A resident with severe cognitive impairment and a history of hip fracture experienced frequent, inadequately managed pain due to inconsistent pain assessments, lack of timely follow-up on pain interventions, and delays in adjusting pain medications. Staff did not consistently document pain levels or nonpharmacological interventions, and communication lapses led to delays in implementing new pain management orders, resulting in the resident's pain not being effectively addressed.
Staff did not provide written information or assistance regarding advance directives to multiple residents, despite facility policy requiring this. Documentation referenced an 'Advance Directive Handbook' that did not exist, and no evidence of advance directive education or offers of assistance was found.
Facility staff did not ensure that a baseline care plan was developed and provided to residents and their representatives within 48 hours of admission. Staff interviews and record reviews confirmed that baseline care plans were completed electronically but not shared or reviewed with residents or families, and key staff were unaware of the requirement to provide these plans promptly.
Staff failed to properly assess a resident after a fall resulting in a hip fracture, did not document a registered nurse's assessment at the time of a resident's death, and documented daily weights and medication administration for another resident when these actions were not performed. These deficiencies involved failures in assessment, documentation, and adherence to professional standards by nursing staff and administration.
The DON worked as a floor nurse and CNA on multiple occasions, contrary to regulations requiring the DON to serve in a full-time administrative role. Staff interviews and facility records confirmed that the DON provided direct resident care on 14 occasions, and both the DON and Administrator acknowledged this practice occurred when necessary to maintain resident care.
Staff failed to maintain accurate clinical records for two residents, including incomplete documentation of behavioral episodes for one resident and missing provider orders for lab studies performed on another. The MAR and progress notes were inconsistent with facility policy requiring thorough documentation of services and changes in resident condition.
Facility staff did not provide required behavioral health training to five sampled CNAs, as evidenced by a lack of documentation in their in-service records. Although the facility assessment and policies specified the need for such training to address the needs of residents with behavioral health conditions, only trauma-informed care training was completed by most of the CNAs. At the time of the survey, two residents with PTSD/trauma were identified as needing this level of care.
Facility staff shortages resulted in the DON and UMs frequently working floor shifts, which hindered their ability to oversee critical processes such as lab monitoring. This led to failures in timely lab test completion, communication of abnormal results, and prompt implementation of provider orders for several residents, resulting in an immediate jeopardy finding.
An LPN was employed without a valid Virginia nursing license, as required by state law. The LPN held only a single state license from West Virginia, and facility records showed no evidence of a Virginia license or a multi-state license during the period of employment. The issue was discovered after the LPN was no longer working at the facility, and the facility's hiring policy required license verification.
A resident with chronic respiratory conditions was found to have an Albuterol inhaler and over-the-counter medications in their possession without documentation of an assessment for self-administration. The resident was cognitively intact and had a provider order for Albuterol as needed, but staff failed to document administration or assess the resident's ability to self-administer medications, contrary to facility policy.
Facility staff did not notify the medical provider when a resident with multiple complex diagnoses experienced a significant change in condition, including altered mental status and hypotension, which led to a hospital transfer and ICU admission. Review of records and staff interviews confirmed there was no documentation of physician notification, despite facility policy requiring such notification in these circumstances.
Facility staff did not provide a required SNF Advanced Beneficiary Notice of Non-coverage (ABN) to a resident discharged from a Medicare Part A stay, and were unable to locate or produce any related documentation when requested by surveyors. Leadership confirmed the absence of the required notice and documentation during the survey process.
Facility staff did not provide required notifications to the ombudsman or written notices to residents and their representatives during transfers or discharges to hospitals. In several cases, residents with varying levels of cognitive impairment were transferred without proper documentation or notification, and staff interviews revealed a lack of awareness of these requirements.
Facility staff did not provide or document sufficient preparation and orientation for a resident with multiple complex diagnoses and moderate cognitive impairment before transfer to a higher level of care. The clinical record lacked required details about the transfer process, and the DON confirmed that discharge documentation was incomplete, contrary to facility policy.
Facility staff did not provide a resident and/or the resident's representative with the required written bed-hold policy notification when the resident, who had multiple serious medical conditions and moderate cognitive impairment, was transferred to a hospital. No documentation of the notification was found in the clinical record, and the DON confirmed its absence during the survey.
Staff failed to ensure accurate MDS assessments for a resident, documenting lower extremity functional impairment inconsistently with other records and without supporting documentation. The resident, who had severe cognitive impairment, was assessed as having lower extremity limitations on two MDS assessments, despite other assessments indicating no such impairment.
Surveyors found that staff failed to create and implement complete care plans for two residents—one requiring oxygen therapy and another with PTSD. For the resident on oxygen, there was no care plan addressing oxygen use despite physician orders and direct observation of oxygen administration. For the resident with PTSD, the care plan did not identify triggers or include specific interventions, and the interdisciplinary team did not address the diagnosis during care planning. Facility policy requires comprehensive, person-centered care plans, but these were not followed in both cases.
Staff did not update the care plans for two residents after changes in their clinical status. One resident's care plan continued to reference CPAP use despite discontinuation, and another's care plan listed tube feeding dependence even though the resident was no longer receiving tube feedings. Facility policy required timely care plan updates, but these were not completed.
Facility staff did not document the amount of gastric residuals when checking a resident's tube feeding residuals, despite physician orders and facility policy requiring this information. Although checks were marked as completed on the MAR, the actual amounts were missing from the clinical record, as confirmed by the DON.
Staff did not follow the physician's order for oxygen administration for a resident with chronic respiratory failure, providing oxygen at 5 LPM via nasal cannula instead of the ordered 2 LPM. The discrepancy was observed and confirmed before the order was updated to match the higher flow rate.
Facility staff did not properly assess or address trauma-informed care needs for a resident with PTSD, failing to identify or mitigate triggers such as nightmares and hallucinations in the care plan, despite ongoing symptoms and relevant diagnoses. Staff interviews and record reviews confirmed that trauma assessments and appropriate interventions were not implemented as required by facility policy.
A resident's medication and consult orders were entered by non-prescribing staff as 'Prescriber written' in the electronic record, which did not require provider signature, resulting in multiple orders remaining unsigned by the medical provider. Facility policy required provider review and countersignature for such orders, but this was not followed due to incorrect order entry.
Staff failed to accurately document the administration of controlled medications for two residents, as LPNs did not sign out Oxycodone and Gabapentin in the narcotics book at the time of preparation or after administration, contrary to facility protocols.
A resident with multiple complex diagnoses and severe cognitive impairment did not have a pharmacist's medication regimen review recommendation regarding antipsychotic use reported to or acted upon by the medical provider in a timely manner. The recommendation was not acknowledged or reviewed by the provider until several months after it was made, contrary to facility policy requiring timely physician response and documentation.
Facility staff failed to ensure residents were free from significant medication errors, including incorrect transcription and delayed administration of an IV antibiotic for a resident with a UTI, and improper administration of cardiac medications to two residents despite provider orders to hold the medications based on vital signs. These incidents involved residents with severe cognitive impairment and complex medical histories.
A surveyor observed an unattended, unlocked medication cart on a nursing unit. When approached, an LPN confirmed responsibility for the cart and locked it after being notified. Facility policy requires medication carts to be locked when out of the nurse's view.
Facility staff failed to obtain timely laboratory tests for two residents who exhibited symptoms requiring urinalysis, resulting in delays in diagnosis and treatment. In both cases, provider orders or documented plans for urinalysis were not processed or carried out as required, with staff and providers later indicating issues with order entry or follow-through. The facility's policy to process and arrange laboratory tests was not adhered to, and no further explanation was provided to surveyors.
A resident with chronic renal failure and other urological conditions experienced a significant delay in UTI treatment because abnormal urinalysis and culture results were not promptly communicated to the ordering provider. Despite repeated lab findings indicating infection, nursing staff did not notify the NP, and the NP was unaware of the results due to issues with lab integration and lack of staff communication. Facility policy requiring prompt notification of abnormal results was not followed, leading to delayed care.
A resident with multiple chronic conditions experienced a delay in receiving a chest x-ray after it was ordered to rule out a respiratory infection. Although the facility's policy and contract required 24/7 radiology services, the x-ray was not obtained for two days, and staff could not provide a reason for the delay.
An LPN failed to follow infection prevention and control practices during medication administration by stacking medication cups for two residents, carrying both into a resident's room, and not maintaining separation between medications. The LPN also handled medications and discarded items without changing gloves or sanitizing the medication cart, contrary to facility policies.
Surveyors identified that a CNA did not have documented evidence of completing required effective communication training, as outlined in the facility's assessment and training protocols. This was confirmed through review of training records and discussion with facility leadership.
Failure to Administer Ordered Treatments and Document Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and care according to provider orders, resident preferences, and goals for multiple residents. In one instance, a resident with diabetes did not receive their ordered bedtime insulin upon admission, and there was no documentation of administration. The resident subsequently experienced a critically high blood sugar level, requiring emergency intervention and transfer to the hospital. Additionally, the same resident did not have their before-meal insulin ordered for the evening meal on the day of admission, resulting in a gap in diabetic management. Another resident with a physician's order for Gabapentin to be administered at bedtime for pain did not receive the medication on two separate days, despite the medication being available in the facility's backup medication dispensing system. Documentation indicated the medication was not available from the pharmacy, but the DON later confirmed it was accessible in the Cubex system and should have been administered as ordered. The order was discontinued after several missed doses. A third resident with orders for daily weights due to congestive heart failure did not have weights consistently obtained or documented. The electronic medication administration record (eMAR) lacked a designated area for weight documentation until several months after the order was in place, and staff were signing off on weights without actually performing them. Progress notes indicated multiple refusals by the resident, but the weight record showed infrequent documentation of actual weights, and the DON confirmed that nurses were not consistently obtaining the weights as ordered.
Failure to Provide Consistent and Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with multiple complex diagnoses, including a recent right hip fracture, Alzheimer's disease, and chronic pain conditions. The resident, who had severe cognitive impairment and was frequently experiencing pain, was noted to have pain levels as high as 6 out of 10 and exhibited behaviors such as calling out, moaning, and shouting for help. Despite these signs and the care plan's directive to notify the physician of unrelieved pain, documentation showed inconsistent pain assessments, lack of follow-up on pain interventions, and delays in adjusting pain management strategies. Progress notes and provider documentation revealed that the resident continued to experience pain even after receiving PRN narcotic pain medication, with staff sometimes only placing the resident on a rounding list for future provider evaluation rather than seeking immediate intervention. Orders for pain assessment were not consistently followed, as staff simply checked off pain monitoring without documenting pain scales or nonpharmacological interventions. There was also a lack of follow-up pain assessments after medication administration, and gaps in pain medication administration were noted despite ongoing reports of pain. Communication issues further contributed to the deficiency, as there were delays in clarifying and implementing new pain medication orders, confusion regarding medication allergies, and lack of timely documentation regarding hospice involvement and medication changes. Interviews with staff and providers indicated uncertainty about expectations for pain assessment frequency and appropriate escalation when pain was not controlled. Facility policy required regular pain reassessment and documentation, but these standards were not met, resulting in inadequate pain management for the resident.
Failure to Provide Written Advance Directive Information and Assistance
Penalty
Summary
Facility staff failed to provide written information regarding the right to formulate an advance directive to 11 out of 30 sampled residents. Clinical record reviews showed that these residents had signed an acknowledgment of receipt of admission information, which included a reference to an 'Advance Directive Handbook.' However, interviews with the administrator revealed that no such handbook existed, and there was no evidence that advance directive education had been provided to the residents. The administrator also confirmed that the facility did not currently offer assistance to residents in formulating advance directives, despite this being referenced in the facility's policy. The facility's own Advance Directive policy requires that residents be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, as well as a description of the facility's policies and applicable state law. The policy also states that staff should offer assistance in establishing advance directives and document the offer and the resident's decision in the medical record. No documentation or evidence was found to show that these requirements were met for the affected residents.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to implement a process to ensure that a baseline care plan was developed for every resident within 48 hours of admission and that a summary of this care plan was provided to the resident and their representative. Clinical record reviews for seven residents showed no evidence that either the residents or their representatives received a baseline care plan. Staff interviews revealed that the MDS coordinator completed baseline care plans in the computer system but did not print, provide, or review them with residents or their families. The MDS coordinator also indicated a lack of awareness regarding the requirement to provide the baseline care plan within 48 hours of admission. The facility's policy stated that a baseline plan of care should be developed within 48 hours of admission and that a summary should be provided to the resident and their representative. However, during interviews and document reviews, it was confirmed that this process was not consistently followed. The DON was unable to find evidence that baseline care plans had been provided to residents, and the issue was discussed with facility leadership during the survey.
Failure to Follow Professional Standards in Assessment, Documentation, and Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice in several instances involving three residents. In one case, a resident with severe cognitive impairment experienced a fall resulting in a right hip fracture. The resident was found on the bathroom floor and was unable to bear weight on her right leg. Despite this, the resident was moved to a wheelchair and monitored at the nurses' station before being sent to the emergency room. Documentation did not show that a proper assessment was performed prior to moving the resident, nor was there evidence of how long the resident remained in the wheelchair before transfer. The facility's own falls management policy and staff interviews confirmed that a post-fall assessment should have been conducted before moving the resident, but this was not documented or performed. In another instance, staff failed to follow professional standards regarding the pronouncement of death for a resident with moderate cognitive impairment. The clinical record included a progress note from an LPN stating the resident had no signs of life and that the DON was notified and pronounced the resident dead. However, there was no documentation of a registered nurse's assessment at the time of death, and a late entry was made by the RN much later. Additionally, the facility could not provide a policy guiding the pronouncement of death, and the LPN's assessment and findings leading to the call to the DON were not documented in the clinical record. A third deficiency involved a resident with multiple chronic conditions, including CHF and COPD, for whom staff documented daily weights and medication administration that did not occur. The electronic medication administration record (eMAR) was initialed as if daily weights were obtained, but there was no area to document the actual weights until a later date, and the weight record showed weights were not taken daily as ordered. Staff also initialed the administration of an inhaler medication that was not available in the facility, as confirmed by progress notes and the DON. Facility policies required documentation of all services provided and that medication administration be documented immediately after administration, but these standards were not followed.
DON Served as Charge Nurse and CNA in Violation of Staffing Requirements
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse, as required. Based on staff interviews and facility document review, it was found that the DON worked as a floor nurse on nine occasions and as a certified nursing assistant (CNA) on five occasions between January and April, for a total of 14 instances. The facility has 107 certified beds with an average daily census of 98 residents. During interviews, the DON acknowledged working the medication cart at times and stated that when she or the Unit Managers were assigned to direct care duties, it was difficult to keep up with facility processes. The Administrator confirmed awareness of the issue, indicating that having the DON work on the floor was considered a last resort to ensure resident care.
Incomplete Clinical Documentation and Missing Provider Orders for Lab Studies
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident, the medication administration record (MAR) indicated two episodes of behaviors during specific shifts, but the clinical documentation did not specify what those behaviors were. Additionally, the MAR included a section for monitoring and documenting specific behaviors, which was inconsistently completed; the nurse documented 'N' for no behaviors observed, which did not clarify the nature of the behaviors previously recorded. Facility policy required documentation of all services, changes in condition, and events involving the resident, but this was not followed in this instance. For another resident, staff did not ensure that the clinical record included a provider order for laboratory studies that were performed. Although a progress note indicated that a provider requested a urinalysis due to concerns about cloudy urine, and results for both urinalysis and urine culture were present in the record, there was no formal provider order documented in the system. The DON confirmed the absence of a provider order for these laboratory studies, despite the tests being completed and results available.
Failure to Provide Behavioral Health Training to CNAs
Penalty
Summary
Facility staff failed to provide behavioral health training for all five sampled Certified Nursing Assistants (CNAs). Review of in-service training records for these CNAs showed no evidence of completed behavioral health training, with only the trauma-informed care portion being completed by four of the five CNAs. The facility's own assessment and policy documents indicated that staff should be trained in recognizing psychological distress, implementing and monitoring care plan interventions relevant to behavioral health diagnoses, and following protocols for mental disorders, trauma, and substance use disorders. The facility assessment documented that the facility regularly cares for residents with behavioral health needs, including those with PTSD/trauma and substance use disorders. At the time of the survey, the resident matrix identified two residents with PTSD/trauma. Despite this, the facility was unable to provide evidence that the sampled CNAs had received the required behavioral health training as outlined in their own policies and facility assessment.
Insufficient Licensed Nursing Staff Leads to Immediate Jeopardy
Penalty
Summary
Facility staff failed to provide sufficient licensed nursing staff to meet the needs of all residents, as required. The Director of Nursing (DON) and Unit Managers (UMs) were frequently required to work as floor nurses or CNAs due to staffing shortages, which limited their ability to monitor and maintain essential facility processes, including laboratory services. The facility's own assessment indicated an average daily census of 98 residents, and CMS Payroll Based Journal data showed a one-star staffing rating for the previous four quarters. During the survey, it was found that the facility averaged only two to three licensed nurses on night shift, below their stated goal of four per shift, and relied on agency staff and management to fill gaps. As a result of these staffing issues, surveyors identified concerns for four residents related to failures in timely laboratory test completion, communication of abnormal results to medical providers, ensuring provider response, and timely implementation of orders for abnormal results. These failures led to the identification of an immediate jeopardy situation. Both the DON and the Administrator acknowledged that the need for management to cover floor shifts contributed to the breakdown in facility processes, particularly regarding laboratory services.
Failure to Verify Valid State Nursing License for LPN
Penalty
Summary
Facility staff failed to ensure that a licensed practical nurse (LPN) employed at the facility held a valid license to practice in accordance with state laws. The LPN was hired with an active single state license from West Virginia, as verified in the employee file, but did not possess a Virginia LPN license at any point during their employment. Documentation in the employee file included a note indicating an application for a multi-state license, but there was no evidence that such a license was ever obtained. The LPN's employment spanned from early March to the end of December, with no breaks in service. Interviews with facility staff revealed that the current human resources manager was not employed at the time of the LPN's hire and described a process for license verification that would have excluded applicants with only a single state license. The administrator became aware of the licensing issue only after the LPN was no longer employed. The facility's hiring policy required verification of certifications and licenses, but no further information regarding compliance with this policy at the time of the LPN's hire was provided to the survey team.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident for self-administration of medications, despite the resident having an Albuterol inhaler in their possession. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and heart failure, was found to be cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included interventions for respiratory conditions, but there was no documentation indicating an assessment for self-administration of medications. The resident was observed keeping the inhaler in their pocket and stated they used it as needed for shortness of breath. Additionally, over-the-counter medications were found in the resident's bedside drawer, which were not on the medication list. A review of the clinical record revealed a provider order for Albuterol as needed, but there was no documentation on the medication administration record for its administration during the month in question. Facility policy required that residents be assessed by the interdisciplinary team for self-administration of medications and that unauthorized medications found at the bedside be given to the charge nurse. Despite these requirements, there was no evidence that the resident had been assessed for self-administration, and the issue was confirmed during a meeting with facility administrators.
Failure to Notify Physician of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify the medical provider of a significant change in condition for one resident, which resulted in the resident being transferred to a higher level of care. The resident had multiple complex diagnoses, including heart failure, atherosclerotic heart disease, chronic respiratory failure with hypoxia, atrial fibrillation, myocardial infarction, type 2 diabetes mellitus, cardiomyopathy, presence of a prosthetic heart valve, presence of a cardiac pacemaker, transient ischemic attack, and anxiety disorder. The resident was assessed as moderately impaired in cognition. On the evening in question, the resident experienced altered mental status, hypotension with blood pressure as low as 68/49, tachycardia, and tachypnea, leading to a transfer to the hospital and subsequent admission to the ICU for a stroke workup. A review of the clinical record and facility documentation revealed no evidence that the physician was notified of the resident's change in condition or of the transfer/discharge. The facility's policy requires nursing staff to notify the attending physician or physician on call in the event of a significant change in the resident's condition or when a transfer to a hospital is necessary. The director of nursing confirmed that there was no documentation of physician notification for this incident.
Failure to Provide Required SNF ABN Notification
Penalty
Summary
Facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification to one of three residents selected for SNF Beneficiary Notification Review. During the survey, the administrator supplied a list of Medicare beneficiaries discharged from a Medicare Part A stay with benefit days remaining, from which three residents were chosen for review. For one resident, documentation showed that the SNF ABN was not provided, with a hand-written note indicating uncertainty and inability to locate the document in the file. Interviews with the administrator confirmed that staff could not find any beneficiary documentation for this resident. The issue was discussed with facility leadership, but no further information or documentation was provided before the survey concluded.
Failure to Notify Ombudsman and Provide Written Transfer/Discharge Notices
Penalty
Summary
Facility staff failed to provide timely and appropriate notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman prior to or at the time of transfer or discharge for multiple residents. In several cases, there was no evidence that the ombudsman was notified when residents were transferred to local hospitals or higher levels of care. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman, and documentation supporting such notifications was not provided to surveyors upon request. For one resident with intact cognition, there was no documentation that the ombudsman was notified of the resident's transfer to a hospital. Another resident, who was severely cognitively impaired, was sent to an acute care hospital without evidence of ombudsman notification, and the social worker confirmed she was unaware of the notification requirement. Additionally, a resident with severe cognitive impairment was transferred to a hospital, and again, no evidence of ombudsman notification was found. In another instance, a resident and their representative did not receive written notice of the reason for transfer/discharge, nor was the ombudsman notified. The facility's own policy indicated responsibilities for informing appropriate parties of transfers or discharges, but staff interviews and document reviews showed these procedures were not followed. The survey team discussed these deficiencies with facility leadership, but no further evidence of compliance was provided before the survey exit.
Failure to Document and Prepare Resident for Safe Transfer/Discharge
Penalty
Summary
Facility staff failed to provide and document adequate preparation and orientation for a resident prior to transfer or discharge to a higher level of care. The clinical record lacked sufficient documentation to demonstrate that the resident was properly prepared or oriented for the transfer, as required by facility policy. The only progress note available for the transfer was brief and did not include necessary details about the preparation or orientation provided to the resident. The resident involved had multiple significant diagnoses, including heart failure, chronic respiratory failure, atrial fibrillation, and anxiety disorder, and was assessed as moderately cognitively impaired. The DON confirmed that the family requested the transfer due to increased confusion, but acknowledged that the nurse responsible did not accurately document the discharge process. Facility policy requires thorough documentation of all services, changes in condition, and communication with family or other staff, which was not met in this instance.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide a resident and/or the resident's representative with the facility's bed-hold policy upon the resident's transfer to a higher level of care. Specifically, for one sampled resident with multiple significant diagnoses, including heart failure, chronic respiratory failure, and cognitive impairment, there was no documented evidence that the required written notification regarding the bed-hold policy was given at the time of transfer to the hospital. A review of the clinical record confirmed the absence of this documentation, and the DON was unable to locate any evidence that the bed-hold policy had been provided. This deficiency was identified through staff interviews, clinical record review, and facility document review, and was discussed with facility leadership during the survey process.
Inaccurate MDS Assessment of Lower Extremity Range of Motion
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident, specifically regarding the assessment of lower extremity functional range of motion. The resident's MDS assessments with assessment reference dates of 2/19/25 and 11/19/24 documented impairment in both lower extremities, which was inconsistent with other MDS assessments for the same resident that indicated no functional limitations. The resident was assessed as able to make self understood and to understand others, with a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. During the survey, the Administrator-in-Training was unable to provide documentation supporting a decline in the resident's lower extremity functional range of motion as recorded in the MDS assessments. The discrepancy in the MDS documentation was identified through observation, staff interviews, and clinical record review, revealing that the assessments did not accurately reflect the resident's actual condition at the time.
Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and PTSD
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies identified during the survey. For one resident with chronic respiratory failure, morbid obesity, and obstructive sleep apnea, the clinical record and physician's orders indicated the use of oxygen therapy. Despite documentation of oxygen use in the resident's records and direct observation of oxygen administration, there was no corresponding care plan addressing oxygen usage. The MDS coordinator confirmed that oxygen usage should have been included in the care plan, and facility policy requires that care plans describe all services necessary to meet residents' needs. For another resident diagnosed with post-traumatic stress disorder (PTSD) and other significant medical and psychiatric conditions, the care plan failed to identify potential triggers for PTSD. Although the resident's diagnosis and risk for PTSD-related symptoms were documented, the care plan did not include specific interventions or triggers. Interviews with administrative staff and the administrator revealed that the interdisciplinary team did not address or discuss the resident's PTSD during care plan meetings, and staff acknowledged the lack of appropriate assessment and intervention planning for trauma-informed care. Facility policies reviewed by the surveyor emphasized the need for comprehensive, person-centered care plans developed by the interdisciplinary team, incorporating risk factors and targeted interventions based on thorough assessments. The deficiencies were discussed with facility leadership, and no additional information was provided prior to the survey team's exit.
Failure to Update Care Plans Following Changes in Resident Status
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents following changes in their clinical status. For one resident with chronic respiratory failure, morbid obesity, and obstructive sleep apnea, the care plan continued to reference CPAP use and resistance to CPAP, despite the resident no longer having a CPAP order due to ongoing refusals. The resident confirmed that the CPAP had not been picked up and was not in use, and the MDS coordinator acknowledged that the care plan should have been updated to reflect this change. For another resident with congestive heart failure, diabetes mellitus type 2, and dysphagia, the care plan indicated dependence on tube feeding, even though the resident's current physician orders reflected a regular puree diet and only maintenance flushes for the PEG tube. The MDS coordinator confirmed that the care plan should have been revised to indicate that the resident was no longer dependent on tube feedings. In both cases, the facility's policy required care plans to be updated when outcomes were not met and at least quarterly, but this was not done.
Failure to Document Tube Feeding Residual Amounts
Penalty
Summary
Facility staff failed to document the amount of gastric residuals when checking a resident's tube feeding residuals, as required by physician orders and facility policy. The resident in question had an order to check gastric residual volume prior to feeding, with instructions to hold feeding and notify the physician if the residual exceeded a specified amount. The care plan and medication administration record (MAR) both indicated that gastric residuals were to be checked three times daily, and the MAR showed that these checks were consistently performed. However, the actual amounts of gastric residuals were not documented in the resident's clinical record, despite facility policy requiring this information to be recorded. This omission was confirmed by the Director of Nursing. The resident involved had moderate cognitive impairment and was receiving enteral nutrition due to an inability to eat or drink, making accurate documentation of tube feeding residuals critical for their care.
Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with the physician's order for one resident diagnosed with chronic respiratory failure with hypoxia, morbid obesity, and obstructive sleep apnea. The resident's clinical record included a physician's order for oxygen administration via nasal cannula at 2 liters per minute (LPM) during the day shift, to be used when oxygen saturation dropped or the resident was unable to breathe. Documentation in the electronic medication administration record indicated that oxygen was administered as ordered each day. However, during surveyor observations on two separate occasions, the resident was found receiving oxygen at 5 LPM, not the 2 LPM specified in the physician's order at that time. The resident confirmed that the oxygen was supposed to be at 5 LPM, but the clinical record and orders had not been updated to reflect this until after the surveyor's inquiry. The facility's policy required verification and documentation of the physician's order and the oxygen flow rate, but this was not followed prior to the order being changed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Facility staff failed to provide appropriate trauma-informed care for one resident diagnosed with post-traumatic stress disorder (PTSD), among other medical and psychiatric conditions. The resident was cognitively intact and had a documented history of PTSD, anxiety, depression, and hallucinations. Despite this, the clinical record lacked any trauma-informed care assessments, and the comprehensive person-centered care plan did not identify or address specific triggers related to the resident's PTSD. Psychiatry progress notes indicated ongoing symptoms and identified nightmares and hallucinations as potential triggers, but these were not incorporated into the care plan interventions. Interviews with facility staff and administration revealed that the interdisciplinary team did not discuss or address the resident's PTSD during care plan meetings, and staff were not adequately educated on trauma-informed care. The facility's own policy required trauma assessment and identification of triggers, but these steps were not followed for the resident in question. The deficiency was confirmed through staff interviews, clinical record review, and facility document review, with no further relevant information provided to the survey team prior to exit.
Unsigned Provider Orders Due to Incorrect Order Entry
Penalty
Summary
Facility staff failed to ensure that medical provider orders entered into a resident's clinical record by non-prescribing staff were signed or cosigned by the ordering provider. Specifically, several medication and consult orders for a resident with intact cognition were entered by staff as 'Prescriber written' rather than as verbal or telephone orders, which in the facility's electronic record system did not require or allow for provider signature or cosignature. This resulted in the orders for medications such as pantoprazole, famotidine, and insulin, as well as a urology consult, remaining unsigned by the medical provider. Facility policies required that physician orders and progress notes be maintained in accordance with OBRA regulations and that verbal or telephone orders be reviewed and countersigned by the practitioner during their next visit. The Assistant Director of Nursing confirmed that the orders were not signed due to incorrect entry in the electronic record system, which bypassed the requirement for provider signature. The deficiency was identified through interviews, clinical record review, and facility document review.
Failure to Accurately Record Controlled Drug Administration
Penalty
Summary
Facility staff failed to maintain accurate records of controlled drugs for two of thirty sampled residents during a medication pass and pour observation. On two separate occasions, LPNs prepared and administered controlled medications—Oxycodone 5/325 mg for one resident and Gabapentin 100 mg for another—without signing the medications out in the narcotics book at the time of preparation or after administration. These actions were directly observed by the surveyor, and the facility's policy on controlled substance medication orders was reviewed, which indicated that applicable protocols are to be followed closely. No additional information was provided to the survey team prior to exit.
Delayed Medical Provider Review of Pharmacist Medication Regimen Recommendation
Penalty
Summary
Facility staff failed to ensure that a medication regimen review (MRR) completed by a licensed pharmacist was reported to and acted upon by the medical provider in a timely manner for one resident. The pharmacist completed the MRR and made recommendations regarding the resident's antipsychotic medication, specifically suggesting an evaluation and possible dose reduction of Olanzapine. However, the recommendation report was not found in the resident's clinical record, and there was no evidence that the medical provider had acknowledged or reviewed the recommendation until three months after the MRR was completed. The resident involved had multiple complex diagnoses, including hypertension, Alzheimer's disease with early onset, chronic respiratory failure, cerebrovascular disease, diabetes, epilepsy, depression, anxiety, dementia, chronic kidney disease, and schizoaffective disorder. The resident was also noted to have severe cognitive impairment. Facility policy required timely physician response to pharmacist recommendations, and documentation of review in the medical record, but these steps were not followed in this instance.
Significant Medication Errors Due to Failure to Follow Provider Orders
Penalty
Summary
Facility staff failed to ensure residents were free from significant medication errors, as evidenced by three separate incidents involving three residents. In one case, a resident with a history of urinary tract infections and severe cognitive impairment was readmitted with a hospital discharge order for IV Ceftriaxone Sodium (Rocephin) to treat an acute UTI. Instead, staff transcribed and administered Ceftazidime, not the ordered medication, and there was a delay in starting the antibiotic, with the first dose given several days after readmission. The resident never received the prescribed Ceftriaxone Sodium. In another instance, staff did not follow provider orders for the administration of Carvedilol, a medication for heart failure and hypertension, for a resident with severe cognitive impairment and multiple cardiac diagnoses. The provider's order specified to hold the medication if the pulse was less than 60, but staff administered Carvedilol on two occasions when the resident's pulse was documented as 59. A third incident involved a resident with paroxysmal atrial fibrillation and multiple myeloma, who was prescribed Metoprolol Tartrate with instructions to hold the medication if systolic blood pressure was less than 110. Staff administered the medication twice when the resident's systolic blood pressure was documented as 109, contrary to the provider's order. These events demonstrate failures in medication transcription, administration, and adherence to provider orders.
Unattended and Unlocked Medication Cart Observed
Penalty
Summary
Facility staff failed to ensure the safe and secure storage of medications and biologicals as required by professional standards. During an observation, a surveyor found an unattended and unlocked medication cart on the nursing unit. When questioned, an LPN confirmed the cart was hers and subsequently locked it after being informed of the observation. The facility's own policy requires medication carts to be securely locked at all times when out of the nurse's view. No additional information was provided to the survey team prior to their exit.
Failure to Obtain Timely Laboratory Services for Residents
Penalty
Summary
Facility staff failed to obtain timely laboratory services for two residents, resulting in deficiencies in meeting their clinical needs. For one resident with chronic kidney disease, sepsis, and a history of urinary tract infections, a nurse practitioner ordered a urinalysis to evaluate symptoms consistent with a UTI. However, there was no evidence that the urinalysis was obtained as ordered on 4/25/25. The resident continued to experience symptoms, and a new order for a urinalysis was placed four days later, with the test finally collected on 4/29/25. The resident confirmed that no urine sample was collected prior to that date, and the nurse practitioner later stated the original order did not save in the electronic system. For another resident with multiple diagnoses including diabetes, hemiplegia, and mental health conditions, a provider's progress note indicated a plan to order a urinalysis due to increased urination. However, no corresponding order was found in the medical record, and no urinalysis was conducted at that time. The provider later stated she believed she had entered the order, but it did not appear in the system. The resident subsequently developed symptoms of dysuria and abdominal pain, prompting a new urinalysis order, which later confirmed a urinary tract infection. In both cases, the facility's policy required staff to process and arrange for laboratory tests as ordered by providers. The surveyors found that the staff did not follow through with obtaining the necessary laboratory tests in a timely manner, as evidenced by the lack of documentation and delayed testing despite provider orders or documented plans. No additional information or clarification regarding these failures was provided by the facility prior to the survey exit.
Failure to Promptly Notify Provider of Abnormal Lab Results Delays UTI Treatment
Penalty
Summary
Facility staff failed to promptly notify the ordering provider of laboratory results that were outside clinical reference ranges for one resident, resulting in a delay in treatment for a urinary tract infection (UTI). The resident had significant medical conditions, including chronic renal failure stage IV, benign prostatic hypertension, and obstructive and reflux uropathy, and was assessed as having moderate cognitive impairment. Orders for urinalysis with culture and sensitivity were placed, and results indicating a UTI were available in the clinical record, but the provider was not promptly informed. Despite multiple urinalysis and culture results showing evidence of infection, there was no documentation that the provider was notified of these abnormal findings. The nurse practitioner (NP) continued to order repeat tests and was unaware of the previous positive results, as the laboratory results were not integrated into the chart in a timely manner. Nursing staff did not communicate the abnormal results to the NP, and the NP reported being unable to obtain information about the labs from staff during visits. Facility policy required nursing staff to identify and promptly communicate abnormal laboratory results to the attending physician, especially when results were problematic or the resident's clinical status was unclear. However, the policy was not followed, and the abnormal results were not conveyed to the provider, resulting in a significant delay in the initiation of appropriate treatment for the resident's UTI.
Delay in Obtaining Timely Diagnostic X-ray Services
Penalty
Summary
Facility staff failed to obtain a chest x-ray (CXR) in a timely manner for a resident with multiple significant diagnoses, including Chronic Obstructive Pulmonary Disease, Multiple Myeloma, and Paroxysmal Atrial Fibrillation. The resident, who was cognitively intact, was seen by a nurse practitioner for mild fever and chills, and a CXR was ordered to rule out respiratory infection. The order for the CXR was entered on the same day as a urinalysis, but the CXR was not performed until two days later. Interviews with the Director of Nursing and the nurse practitioner revealed that the delay was not explained by facility staff, and the nurse practitioner stated that the facility was dependent on the radiology company. Review of facility policy and the contract with the mobile imaging provider confirmed that radiology services were to be available 24/7. No additional information was provided by facility leadership to explain the delay prior to the survey exit conference.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices during medication administration on one of two nursing units. During a medication pass, an LPN was observed stacking medication cups for two different residents, carrying both into one resident's room, and administering medications without maintaining separation between the residents' medications. The LPN then proceeded to administer the other resident's medication without following appropriate infection control protocols. Additionally, the LPN was observed donning gloves to prepare medications for another resident, handling and scoring a Lasix tablet while wearing the same gloves, and discarding a half-tablet in a resident's bathroom trash can. The LPN then retrieved the pill cup from the trash, placed it on the medication cart, and discarded the medication into the sharps container without sanitizing the cart. These actions were not in accordance with the facility's infection control and hand hygiene policies, which were reviewed by the surveyor.
Lack of Documented Communication Training for CNA
Penalty
Summary
Facility staff failed to provide evidence that a Certified Nursing Assistant (CNA) received effective communication training, as required by the facility's own assessment and training protocols. During a review of the CNA's in-service training record, surveyors found no documentation indicating that effective communication training had been completed. The facility's assessment document listed communication as a necessary training topic for direct care staff, but the CNA's records did not reflect participation in such training. This deficiency was confirmed through staff interviews and document review, and was discussed with facility leadership.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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