Loudoun Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Leesburg, Virginia.
- Location
- 235 Old Waterford Road, Northwest, Leesburg, Virginia 20176
- CMS Provider Number
- 495275
- Inspections on file
- 19
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Loudoun Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Facility staff failed to assess and supervise two residents with significant risks, resulting in one resident sustaining serious injuries from an unsupervised fall on the patio and another causing a fire after unsupervised smoking. The care plans did not address these risks, hazardous materials were found in a resident's room, and staff did not consistently monitor or document the use of safety devices or interventions.
The facility did not ensure that effective communication training was completed for five direct care staff, including CNAs, an RN, an LPN, and the director of rehab. Review of records and staff interviews confirmed that required training was not documented or completed as per facility policy, and this was acknowledged by the administrator and DON.
Facility staff failed to notify physicians and responsible parties when a resident's prescribed medication was unavailable, when a new medication was started for another resident, and when a third resident repeatedly refused scheduled medications. Documentation and staff interviews confirmed that required notifications and progress note entries were not made in these cases, despite facility policy and expectations.
Facility staff did not obtain required criminal background checks for six contracted construction workers, instead accepting foreign background checks without confirming if they met regulatory standards. The facility was unable to provide documentation of proper screening as required by policy.
Staff failed to administer a prescribed Lidocaine patch as ordered for a resident with hemiplegia and moderate cognitive impairment, with eMARs showing repeated instances of the medication not being given and lacking proper documentation. Additionally, staff did not monitor or document vital signs every two hours as ordered for another resident with fever and risk of fluid deficit, despite care plan interventions. Interviews revealed inconsistent practices and understanding among staff regarding medication availability and vital sign monitoring.
Annual performance reviews were not completed for three CNAs hired within the past year. The HR assistant identified staff due for review and provided forms to unit managers, but the reviews were not documented or completed as required. The facility's training policy also lacked information on performance reviews.
Staff failed to cover clean resident laundry while transporting it on the second floor, as observed on two occasions. A laundry aide confirmed the carts should have been covered, in accordance with facility policy, but were not during these instances. The administrator and DON were notified of the issue.
Required behavioral health training was not completed for four staff members, including a CNA, RN, director of rehab, and dietary aide. Review of facility records and staff interviews confirmed the absence of documentation for this training, despite policy requirements and an identified increase in patients with behavioral health needs.
Two residents with cognitive and physical impairments did not receive dignified care during mealtimes, as staff failed to wash hands before meals, provided feeding assistance while standing, and delayed meal service for one resident. The CNA involved acknowledged these actions were not dignified, and facility policies requiring respect and proper hygiene were not followed.
Staff failed to provide timely incontinence care for two residents with severe cognitive impairment and total incontinence, resulting in prolonged periods without checks or care. In both cases, staff interviews confirmed that incontinence care should be provided every two hours, and that failure to do so constitutes neglect. Facility administration was made aware of these findings.
Facility staff did not conduct or document required criminal background checks for six contract workers, accepting foreign background checks without verifying regulatory compliance. Additionally, staff failed to report and investigate an allegation of financial exploitation involving a resident, as required by facility policy, and could not provide evidence of reporting to the state agency or conducting an internal investigation.
Facility staff did not report an allegation of financial exploitation involving a resident to the State Agency as required, despite being informed of concerns by the resident's family and initiating contact with APS. The facility was unable to provide evidence of the required report to the SA, in violation of its own policy.
Facility staff did not conduct an internal investigation after a resident's family member reported possible financial exploitation by an acquaintance. Although the resident denied the allegation and APS was contacted, the facility failed to follow its policy requiring immediate investigation and documentation of such reports.
A resident with Parkinson's disease and alcoholism was discharged without a clear or comprehensive plan, as the facility failed to specify a discharge date or destination and did not address the resident's ongoing alcohol abuse in the discharge planning. The social services team was minimally involved until the last days, and the discharge location was not clearly documented, resulting in a lack of evidence for a safe and orderly transition.
A resident was discharged without receiving a notice that included the required discharge date or destination. The discharge notice, prepared under the direction of a former administrator, omitted these details despite facility policy requiring them. Staff interviews confirmed the omissions were intentional, and there was no record of when the resident received the notice.
Facility staff did not follow the comprehensive care plan for a resident with severe cognitive impairment, failing to provide scheduled showers, incontinence care, and frequent vital sign monitoring as ordered. Documentation was incomplete or marked as 'not applicable' without evidence of resident refusals, and staff interviews confirmed that care and refusals should have been properly recorded.
Facility staff did not update the comprehensive care plan for a resident after the resident stopped using a voice amplifier, despite the care plan and physician's orders still referencing its use. The resident, who had moderate cognitive impairment and muscle weakness, declined further use of the device after trying it in therapy. Staff interviews confirmed the device was no longer in use, but the care plan was not revised as required by facility policy.
Facility staff did not consistently provide scheduled showers and incontinence care to two dependent residents, as evidenced by missing or incomplete documentation and staff interviews. One resident with hemiplegia and Parkinson's disease missed a scheduled bath, while another resident with dementia and schizophrenia had multiple missed showers and incontinence care episodes, with no refusals documented. Staff reported concerns about hygiene and persistent urine odor, and administrative staff were informed of these findings.
Two residents with severe cognitive impairment and total incontinence did not receive timely incontinence care over a period of several hours. Staff failed to check or change incontinence briefs as required, and communication breakdowns between shifts contributed to the deficiency. When care was eventually provided, one resident was found with a saturated and soiled brief, and both cases involved inadequate handoff information between CNAs.
Staff failed to store a nebulizer mask in a sanitary manner for a resident with pneumonia and moderate cognitive impairment, repeatedly leaving it uncovered on the bedside table. For another resident with severe cognitive impairment and respiratory issues, the facility did not implement pulmonology recommendations to titrate oxygen to maintain SpO2 above 92% or encourage use of incentive spirometry, with no evidence of related orders or documentation. These deficiencies were confirmed through observations, record review, and staff interviews.
A resident with hemiplegia and moderate cognitive impairment did not have their hands washed before eating, received feeding assistance while the CNA stood, and missed a scheduled bath due to insufficient CNA staffing. Staffing schedules and staff interviews confirmed that the LTC unit was short staffed on multiple occasions, leading to unmet care needs as documented in the resident's care plan.
A resident with Parkinson's disease and a history of alcoholism was discharged without a safe and comprehensive plan, as facility staff failed to specify a discharge location, address ongoing alcohol dependency, or ensure coordination of necessary social services. The discharge process lacked clear communication, and the social worker was not fully informed of the resident's needs, resulting in an incomplete and unsafe discharge arrangement.
Expired biologicals and medical supplies, including IV start kits, dressings, rubbing alcohol, hydrogen peroxide, and Foley catheters, were found in both a nursing unit storage closet and the central supply area. A family member raised concerns about expired supplies, and staff interviews revealed that while the central supply coordinator was responsible for rotating and removing expired items, nurses relied on this process and did not routinely check non-medication supplies for expiration. The facility's policy lacked specific guidance on disposing of expired supplies.
During a meal service, pureed snow peas were served with pod fibers and a chopped, non-smooth consistency, making them unpalatable and not in accordance with dietary guidelines for pureed diets. The dietary manager acknowledged the error, noting that snow peas may not be suitable for pureeing and that the food did not meet the required smooth, lump-free consistency.
A fire occurred when a resident discarded a lit cigarette into a trash can on the facility's patio, causing damage to a glass door. Staff extinguished the fire and secured the resident's smoking materials, but the incident was not reported to the state agency as required by regulations. The administrator later acknowledged that the fire should have been reported.
A physician documented a recommendation for a CIWA protocol assessment for a resident with a history of alcohol dependence and other medical issues, despite facility staff not being trained to perform such assessments. No evidence of the assessment was found in the clinical record, and both the DON and the physician later confirmed the recommendation was made in error, resulting in an inaccurate medical record.
Two contracted staff members, a dietary aide and a housekeeper, did not receive required training on the facility's QAPI program because they did not attend the standard orientation where this education is provided. Facility policy mandates QAPI training for all staff, but documentation confirming completion for these employees was not available.
Two CNAs did not complete the required 12 hours of annual in-service training, as confirmed by the education coordinator and a review of facility records. The facility policy mandates this annual training, but documentation for these staff members was not present.
A resident with severe cognitive and physical impairments did not receive six prescribed doses of Macrobid for a UTI, as documented by multiple blanks on the MAR. Despite clear physician orders, only one dose was given, and staff interviews confirmed the medication was not administered as required. The resident was subsequently hospitalized with septic shock from E. coli bacteremia, and the facility's medication policy lacked documentation on administering medications per orders.
Staff did not update the comprehensive care plan for a resident who was prescribed antibiotics for a UTI, despite facility policy and staff acknowledgment that such changes should be reflected in the care plan. The omission was confirmed through record review and staff interviews.
The facility failed to implement and develop comprehensive care plans for several residents. A resident with dysphagia was not provided a pureed diet as ordered, while another resident with PTSD and incontinence had no care plans addressing these issues. Additionally, a resident using side rails lacked a corresponding care plan. Staff interviews confirmed these deficiencies.
The facility's kitchen operations were found to be unsanitary, with issues such as debris and grease buildup in sinks and warmers, unlabeled and improperly stored food, and a malfunctioning dishwashing machine with inadequate temperatures. Staff were unaware of proper procedures, and facility policies on sanitation and food storage were not followed.
Facility staff failed to conduct regular bed inspections for four residents, with the last inspection dated April 2022. Despite the facility's policy requiring evaluations to minimize entrapment risks, no assessments were conducted since then. Interviews revealed that general maintenance was performed, but it did not include bed safety assessments. The issue was noted during a survey, with residents observed in bed with side rails up, indicating potential entrapment risks.
A resident was not assessed for the self-administration of a medicated mouthwash, despite having a perfect BIMS score and a physician's order. The resident kept the medication at her bedside and took it on outings. Interviews with staff revealed a lack of documentation and awareness regarding the assessment process, which is required by facility policy. The DON confirmed the absence of the assessment and decided to remove the medication from the resident's bedside.
A resident's advance directive and POA documents were not maintained in their clinical record as required. Although the resident had assigned their daughter as POA, the documents were missing from both electronic and paper records. The director of social services later found the documents in the admissions office, highlighting a lapse in the facility's process for handling such critical documents.
A resident was discharged from a Medicare-covered stay with benefit days remaining, but the facility failed to provide a timely advance beneficiary notice of non-coverage. The notice, which should have been given within 48 hours of discharge, was not signed until over two months later. The director of nursing acknowledged this delay as a concern.
Facility staff failed to protect a resident's medical privacy by posting signs with sensitive information above the resident's bed, visible to visitors. An LPN confirmed that such information is usually placed inside a closet door to maintain confidentiality. This action violated the facility's policy on resident rights to secure and confidential records.
A resident was found with blood-stained sheets and underpad, which were not changed promptly, violating the facility's policy for a clean, homelike environment. An LPN and a CNA acknowledged the need for linen changes and the unsanitary conditions.
The facility failed to provide necessary clinical information to receiving hospitals during the discharge of two residents, leading to a deficiency. One resident was transferred emergently without documentation of care plan goals and advance directives, while another was sent with stroke-like symptoms without evidence of clinical documents being provided. The facility's policy requires such information to ensure continuity of care, but it was not followed.
The facility staff failed to maintain accurate MDS assessments for three residents. A resident did not receive the required BIMS and mood interviews, while two residents were inaccurately coded as having restraints due to automatic system triggers. These errors were linked to the social services department's oversight and the computer system's coding process.
A resident requiring a neck stabilizing collar did not have this need included in their baseline care plan. Despite orders for the collar to be worn at all times, there were no instructions for skin checks or cleaning, which are crucial to prevent skin issues. Facility staff acknowledged the oversight, noting the importance of including such interventions in the care plan.
A resident's care plan was not reviewed or revised to include the use and self-administration of a medicated mouthwash, despite the resident's cognitive ability to manage her medication. The facility's policy requires care plans to be updated under certain conditions, but this was not done, as confirmed by an LPN.
Two residents in the facility did not receive care according to professional standards. One resident did not have a prescribed wound treatment administered, as indicated by a blank treatment administration record. Another resident wearing a neck stabilizing collar lacked orders for necessary skin checks and device cleaning, which were not documented in the care plan. These deficiencies were acknowledged by the facility's administrative staff.
A resident admitted with a fractured leg did not receive timely pain management due to a failure in utilizing the facility's backup medication supply. Despite a physician's order for gabapentin, the medication was not administered as scheduled, as it was awaiting delivery from the pharmacy. Interviews revealed that staff did not follow the protocol of using the backup supply, leading to a lapse in care.
A resident with PTSD, anxiety disorder, and depression did not receive trauma-informed care as required. The facility's assessments and care plan lacked information and interventions related to PTSD, despite the resident's moderate impairment in decision-making. The director of social services admitted the absence of documentation and could not explain why the facility's process for addressing PTSD was not followed.
A resident with PTSD, anxiety, and depression did not receive necessary counseling services due to the facility's failure to follow up on recommendations. The resident's assessments and care plan lacked information and interventions related to PTSD. The director of social services admitted the oversight, and the facility's policies on trauma-informed care were not adequately implemented.
A resident missed doses of Aspirin and Multivitamins due to the facility's failure to reorder medications in a timely manner. An LPN noted the unavailability of these medications during administration and did not check other areas for them. Interviews revealed inconsistencies in stock medication availability, and the facility's policy on handling unavailable medications was not followed.
A resident did not receive their prescribed Aspirin and Multivitamin due to unavailability, resulting in a medication error rate of 5.88%. The LPN did not check for these medications elsewhere in the facility, and further investigation revealed discrepancies in medication management practices, with neither medication available in stock bottles or backup supply.
Failure to Prevent Accidents and Maintain a Safe Environment
Penalty
Summary
Facility staff failed to assess a resident's ability to safely spend time unsupervised on the courtyard patio and did not provide adequate supervision or a safe environment in that area. The resident, who had a history of congestive heart failure, muscle wasting, dementia, and cognitive impairment, was found unsupervised on the patio and sustained a fall resulting in a head injury, laceration requiring staples, and a cervical vertebral fracture. The resident's care plan did not address outdoor supervision, and multiple prior falls and high fall risk assessments were documented. Staff interviews revealed inconsistent understanding and documentation regarding the use of safety devices such as wander guards, and no evidence was found that the resident had been properly assessed for unsupervised outdoor access. Additionally, the facility failed to maintain a safe environment in the resident's bedroom, where a hazardous aerosol varnish spray was found. The material safety data sheet for the product indicated it was extremely flammable, hazardous, and carcinogenic, and staff acknowledged it should not have been accessible to residents. The presence of this substance in the resident's room was confirmed through observation and staff interviews. The facility also failed to provide a safe environment and adequate supervision to prevent accidents for another resident with a known history of unsupervised smoking. This resident caused a fire by discarding a lit cigarette in a trash can on the enclosed patio, resulting in property damage. Documentation and interviews indicated that the resident continued to access smoking materials and areas unsupervised, despite being identified as unsafe to smoke and having a history of wandering. The care plan and clinical record lacked appropriate interventions and monitoring for smoking-related hazards, and staff were inconsistent in their handling and storage of the resident's smoking materials.
Failure to Provide Required Effective Communication Training to Direct Care Staff
Penalty
Summary
Facility staff failed to ensure that effective communication training was completed for five direct care staff members, including two CNAs, an RN, an LPN, and the director of rehab. Document review and staff interviews revealed that there was no evidence these employees had received the required training on effective communication, as mandated by facility policy, which specifies that direct care staff must complete at least twelve hours of annual training, including effective communication. The education coordinator confirmed that while training assignments are managed through a computerized system and in-person in-services, effective communication training had not yet been provided to these staff members, though a session was planned for the future. The deficiency was acknowledged by the administrator and the director of nursing during the survey.
Failure to Notify Physician and Responsible Party of Medication Issues and Changes
Penalty
Summary
Facility staff failed to notify physicians and responsible parties as required in three cases. In the first case, a resident with hemiplegia and moderate cognitive impairment did not receive prescribed Lidocaine patches on multiple occasions due to unavailability. The electronic medication administration records (eMARs) showed several instances where the medication was not available, but there was no documentation in the progress notes regarding these missed doses or any notification to the physician or responsible party. Interviews with staff revealed inconsistent understanding and application of the notification process, and the facility's own policy required immediate physician notification and documentation when medications were unavailable, which was not followed. In the second case, a resident with moderate cognitive impairment received a new order for Valacyclovir to treat herpes labialis. Although the medication was administered as ordered, there was no evidence in the clinical record that the resident's representative was notified of the new medication order. Staff interviews confirmed that notification of the resident representative is expected when new medications are started, but this was not documented or carried out in this instance. The third case involved a resident with severe cognitive impairment who refused multiple scheduled medications over a three-month period. The eMARs documented repeated refusals, but there was no evidence that the physician or responsible party was notified of these refusals, as required. Staff interviews indicated that notification should occur with each refusal, especially for residents unable to make their own decisions, but this was not consistently done or documented. The facility's policy required notification of changes, including medication refusals, but this was not adhered to in the resident's care.
Failure to Obtain Required Background Checks for Contracted Workers
Penalty
Summary
Facility staff failed to obtain criminal background checks to screen for abuse, neglect, exploitation, or theft for six contracted construction workers who were observed working in the facility. Despite requests for documentation, the facility was unable to provide evidence of completed criminal record background checks for these individuals, whose hire dates ranged from June 2024 to April 2025. The facility's policy requires background, reference, and credential checks for all potential employees, contracted staff, volunteers, and consultants, with documentation maintained as proof of screening. During interviews, the regional administrator stated that the general contractor reported the construction workers did not have social security numbers but could provide national background checks from Ecuador, which were accepted by the facility. However, the regional administrator was unsure if these foreign background checks met regulatory requirements. No further information or documentation was provided by the facility prior to the survey exit.
Failure to Follow Physician Orders for Medication Administration and Vital Sign Monitoring
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and vital sign monitoring. For one resident with hemiplegia and moderate cognitive impairment, staff did not administer a prescribed Lidocaine patch as ordered for myalgia. Electronic medication administration records (eMARs) showed multiple instances where the medication was not given, coded as either 'medication not available' or 'other/see progress notes.' However, there was no supporting documentation in the progress notes to explain these omissions. Interviews with nursing and supply staff revealed inconsistent understanding and documentation practices regarding medication availability, despite evidence that the facility had received regular shipments of Lidocaine patches and maintained a house supply. For another resident, staff failed to monitor and document vital signs every two hours as ordered by the physician in response to abnormal temperature readings and a fever. The resident's care plan included interventions for monitoring vital signs due to potential fluid deficit and hypernatremia. However, review of the clinical record and vital sign logs showed that vital signs were not checked or recorded at the required frequency. Interviews with nursing staff indicated a lack of recall or clarity regarding the frequency of vital sign checks for this resident. The facility's own policy on unavailable medications required immediate action and documentation when medications were not available, but this was not followed. Administrative and nursing leadership were made aware of these findings during the survey, and no further information was provided prior to exit.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
Facility staff failed to complete annual performance reviews for three certified nursing assistants (CNAs) who were hired in the previous year. Specifically, no annual performance reviews were available for CNAs hired on 11/1/23, 10/10/23, and 10/23/23. The human resources assistant reported that she generates monthly reports to identify staff due for annual reviews and provides blank review forms to unit managers, who are responsible for completing them. However, the required reviews for these three CNAs were not completed, and the facility could not provide documentation of the reviews. Additionally, the facility's policy on training requirements did not include information regarding performance reviews.
Uncovered Transport of Clean Laundry
Penalty
Summary
Facility staff failed to transport clean resident personal laundry in a sanitary manner on the second floor, as observed on two separate occasions. On both occasions, clean clothing racks were seen being pushed down hallways without being covered, contrary to facility policy which requires clean linen to be delivered on covered carts with covers down. During an interview, a laundry aide confirmed that the cart should have been covered while transporting clean laundry but admitted it was not covered during the observed instances. The administrator and director of nursing were informed of these findings, and no additional information was provided before the survey exit. No specific resident medical history or condition was mentioned in relation to the deficiency.
Failure to Complete Required Behavioral Health Training for Staff
Penalty
Summary
Facility staff failed to ensure that required behavioral health training was completed for four out of five reviewed employees, including a certified nursing assistant, a registered nurse, the director of rehab, and a dietary aide. Document review and staff interviews revealed that there was no evidence these staff members had completed behavioral health training as mandated by facility policy, which requires behavioral health content as part of annual training. The education coordinator confirmed that while training assignments are managed through a computerized system and in-person sessions, behavioral health training had not yet been provided to these staff members, despite recognizing an increased need due to more patients with behavioral issues.
Failure to Promote Resident Dignity During Feeding Assistance and Meal Service
Penalty
Summary
Facility staff failed to promote resident dignity for two residents by not adhering to proper feeding assistance protocols and timely meal service. For one resident with hemiplegia and moderate cognitive impairment, staff did not wash the resident's hands before meals and provided feeding assistance while standing, which the resident reported as uncomfortable and undignified. The same resident also experienced a significant delay in receiving her meal, having to wait approximately 25 minutes after her roommate began eating, resulting in dissatisfaction with the wait and concern about the food temperature. Staff interviews confirmed that the certified nursing assistant (CNA) involved was aware that standing while feeding and failing to wash hands before meals were not dignified practices. The CNA attributed these lapses to short staffing and the need to assist multiple residents during mealtimes. Facility policies require residents to be treated with respect and dignity and to receive necessary services to maintain personal hygiene and nutrition, which were not followed in these instances. A second resident, who had severe cognitive impairment and required supervision or touching assistance with self-care, was also observed receiving feeding assistance from a CNA who stood next to the bed rather than sitting. The CNA acknowledged that this was not a dignified approach. Facility administrative staff were made aware of these findings, and no additional information was provided prior to the survey exit.
Failure to Provide Timely Incontinence Care Results in Neglect
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents with severe cognitive impairment and total incontinence. For one resident with dementia, continuous observation over a four-hour and seventeen-minute period revealed that neither nursing nor CNA staff checked or performed incontinence care. When care was finally attempted, the resident was found with a saturated incontinence brief containing both urine and feces, some of which was dried on the skin. Staff interviews confirmed that incontinence care should be provided every two hours, and that failure to do so constitutes neglect. In the case of another resident with a history of stroke and severe cognitive impairment, a similar period of observation showed that no incontinence care was provided by staff. When a CNA attempted to offer care, the resident refused, but the CNA acknowledged that care should still be offered every two hours regardless of refusals. Staff interviews reiterated the expectation for two-hour checks and identified lack of such care as neglect. Both incidents were brought to the attention of facility administration, including the administrator, director of nursing, and regional administrator. No additional information or corrective actions were provided prior to the survey exit.
Failure to Implement Abuse Prevention Policies and Investigate Exploitation Allegation
Penalty
Summary
Facility staff failed to implement the abuse prevention policy for six contract employees by not conducting or documenting required criminal background checks prior to their work in the facility. The contract workers, including construction workers and electricians, were hired without evidence of background checks as stipulated by facility policy. When questioned, the regional administrator acknowledged accepting foreign background checks without verifying if they met regulatory requirements, and could not confirm compliance with state or federal standards. Additionally, the facility did not follow its policy to report and investigate an allegation of resident exploitation involving one resident. The resident’s daughter raised concerns about possible financial exploitation by a friend, which was communicated to the social worker and the Ombudsman. Although Adult Protective Services (APS) was contacted and later closed the case, there was no evidence that the allegation was reported to the state agency or that an internal investigation was conducted as required by facility policy. Interviews with facility leadership confirmed that allegations of exploitation should be reported immediately to the administrator or DON, and then to the state agency and APS, followed by an internal investigation. However, the administrator was unable to provide documentation of a report to the state agency or evidence of an investigation into the exploitation allegation prior to the survey exit.
Failure to Report Alleged Resident Exploitation to State Agency
Penalty
Summary
Facility staff failed to report an allegation of resident exploitation to the State Agency (SA) after being made aware of concerns regarding a resident's finances. On 10/11/2023, the Director of Nursing informed the social worker that the resident's daughter suspected her father was being exploited financially by an unknown friend. The resident, who was alert and oriented, denied the allegations and expressed a desire for his daughter to no longer manage his bank account. The social worker contacted the Ombudsman, who advised reporting the matter to Adult Protective Services (APS), which was done. However, there is no evidence that the allegation was reported to the SA as required by facility policy. During the survey, facility management was unable to provide documentation that the report to the SA had been made, despite multiple requests. The administrator confirmed that the process should involve immediate reporting to the SA and APS, followed by an internal investigation and submission of a final report to the SA within five business days. Review of facility policy confirmed the requirement to report allegations of exploitation to the SA within specified timeframes. No documentation of such a report was found prior to the survey exit.
Failure to Investigate Allegation of Resident Exploitation
Penalty
Summary
Facility staff failed to investigate an allegation of resident exploitation involving one resident. On 10/11/23, the Director of Nursing was informed by the resident's daughter that her father might be exploited financially by an unknown friend. The resident, who was alert and oriented, denied the allegations and expressed a desire for his daughter to no longer manage his bank account. The social worker contacted the Ombudsman and Adult Protective Services (APS) as advised, and APS later closed the case after discussing the matter with the resident. However, there was no evidence that the facility conducted its own internal investigation into the allegation as required by policy. During the survey, facility management was unable to provide documentation or evidence of an internal investigation into the reported exploitation. Interviews with administrative staff confirmed that the facility's policy requires immediate reporting and investigation of such allegations, including interviews with all involved parties and thorough documentation. Despite these requirements, no investigation report or supporting documentation was found or provided prior to the survey exit.
Failure to Provide Safe and Comprehensive Discharge Planning
Penalty
Summary
Facility staff failed to provide a safe and comprehensive discharge for a resident with diagnoses including Parkinson's disease and alcoholism. The resident's clinical record documented ongoing alcohol abuse, multiple falls, unsteady gait, and unintentional weight loss. Despite these complex needs, the discharge process lacked a clear and coordinated plan, with the resident's substance abuse issues not addressed in the discharge planning. The resident was issued a 30-day notice of discharge due to nonpayment, but the notice did not specify a discharge date or destination, and there was no evidence in the record of when the resident received this notice. Interviews with facility staff revealed that the social services team was not fully involved in the discharge planning until the final days before discharge. The social worker assigned to the case was instructed by an administrative staff member to find placement for the resident, including the option of paying for a hotel stay, but expressed discomfort with this plan and attempted to find a shelter instead. The discharge plan was changed multiple times, and the final discharge location was not clearly documented. The social worker was not aware of the resident's alcohol dependency and stated that substance abuse counseling should have been included in the discharge plan, but it was not. Facility policy requires that discharge notices include the discharge date and destination, and that significant changes to the plan be communicated with updated notices. The policy also requires a post-discharge plan of care developed with the resident's participation, including orientation to the new environment and documentation of discussions with the resident or their representative. In this case, the documentation did not include a clear discharge plan, discharge location, or evidence of a safe and orderly transition, particularly in light of the resident's medical and behavioral needs.
Failure to Provide Required Discharge Documentation
Penalty
Summary
Facility staff failed to provide the required documentation for the discharge of one resident. Specifically, the discharge notice issued to the resident did not include the effective date of discharge or the discharge destination, as required by facility policy. The notice did contain information about the reason for discharge, payment instructions, appeal resources, and ombudsman contact information, but omitted key details regarding when and where the resident would be discharged. There was also no evidence in the clinical record indicating the date the resident received the discharge notice. Interviews with staff revealed that the omission of the discharge date and location was intentional, as directed by a former administrator. The social worker involved confirmed that she was instructed to leave out certain information, including the final discharge location and the actual reason for discharge. The director of social services and the current administrator were not directly involved in the discharge process and could not provide further details. Facility policy requires that discharge notices include the effective date and specific location of discharge, and that any significant changes to the discharge plan be communicated with a new notice.
Failure to Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
Facility staff failed to implement the comprehensive care plan for one resident with severe cognitive impairment and total dependence on staff for activities of daily living (ADLs). The care plan required staff to provide scheduled showers, incontinence care, and frequent monitoring of vital signs. Documentation revealed that showers were not provided on multiple scheduled dates across several months, with records marked as 'not applicable' or indicating the task was not completed. There was no evidence in the clinical record that the resident refused showers on those dates, and staff interviews confirmed that showers should have been provided and refusals documented if they occurred. In addition to missed showers, the resident's care plan required incontinence care and skin inspections with each episode and every shift. However, ADL documentation showed gaps where incontinence care was not recorded as provided on several shifts, with entries either left blank or marked 'not applicable.' Again, there was no documentation of refusals for incontinence care, and staff interviews confirmed the expectation that care and refusals should be documented in the electronic medical record. The care plan also included an intervention to monitor vital signs every two hours due to a history of poor intake, hypernatremia, and recent fever. Despite a physician's order for vital signs every two hours, the clinical record showed that vital signs were not documented at the required frequency, with only sporadic entries over the relevant period. Staff interviews confirmed that vital signs were to be monitored and documented as ordered. The facility's policy on care plan revisions did not provide guidance on implementing the care plan, and administrative staff were made aware of these concerns during the survey.
Failure to Revise Care Plan After Discontinuation of Special Equipment
Penalty
Summary
Facility staff failed to revise the comprehensive care plan for a resident following the discontinued use of a voice amplifier. The resident, who was admitted with diagnoses including muscle weakness and had moderate cognitive impairment as indicated by a BIMS score of 11 out of 15, had a physician's order for the use of a voice amplifier and charger to be managed by nursing staff. The care plan, last revised several months prior, still included interventions for the use of the voice amplifier, despite the resident no longer using the device. Interviews with facility staff revealed that the speech therapist confirmed the resident did not want to use the voice amplifier after trying it in therapy, and the device was not being used. The MDS coordinator acknowledged that the care plan should have been reviewed and revised to reflect this change. The facility's policy requires care plan revisions upon a resident's status change, but this was not followed in this instance, resulting in the care plan not being updated to reflect the discontinued use of the voice amplifier.
Failure to Provide Scheduled Bathing and Incontinence Care to Dependent Residents
Penalty
Summary
Facility staff failed to provide scheduled bathing and incontinence care to two dependent residents, resulting in deficiencies in activities of daily living (ADL) care. One resident, admitted with hemiplegia and Parkinson's disease, was assessed as dependent for bathing and had a scheduled shower routine documented in the care plan. However, facility records showed a missed scheduled shower, with no documentation of refusal or explanation for the omission. Interviews with staff confirmed that showers are to be documented in the electronic medical record, but the required documentation was missing for the specified date. Another resident, with diagnoses including dementia, schizophrenia, and total dependence for ADLs, was found to have multiple missed showers and incontinence care episodes over several months. ADL documentation for this resident showed entries marked as 'not applicable' or left blank on scheduled shower and incontinence care dates, with no evidence of refusals. Staff interviews revealed that the resident was rarely showered, often appeared disarrayed, and was always incontinent, requiring frequent assistance. Multiple staff members reported concerns about the resident's hygiene, including persistent urine odor and infrequent clothing changes, which were not addressed despite being reported to administration. The facility's own policy requires that residents unable to perform ADLs receive necessary services to maintain hygiene and grooming. Despite this, documentation and staff interviews confirmed that dependent residents did not consistently receive scheduled showers or incontinence care, and there was a lack of proper recordkeeping to justify missed care. Administrative staff were made aware of these findings during the survey, but no further information was provided prior to exit.
Failure to Provide Timely Incontinence Care for Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents who were both severely cognitively impaired and always incontinent, as documented in their most recent MDS assessments. For one resident with dementia, continuous observation over a period of more than four hours revealed that no nurse or CNA checked or provided incontinence care. When care was eventually attempted, the resident was found with a saturated incontinence brief containing both urine and feces, some of which was dried on the skin. The process of providing care was further complicated by improper transfer techniques and lack of effective communication between CNAs. For the second resident, who had a history of stroke and was also severely cognitively impaired and always incontinent, a similar period of observation showed no incontinence care was provided. The assigned CNA confirmed that care should be offered every two hours and acknowledged not being informed about the resident's care status from the previous shift. When care was offered, the resident refused, and the CNA stated that refusals were frequent but that care should still be offered regularly. Interviews with CNAs revealed a lack of communication during shift changes regarding which residents had received incontinence care. Both CNAs acknowledged the importance of regular incontinence checks and the potential for skin breakdown if residents are left wet or soiled for extended periods, but neither had received adequate handoff information from the previous shift. The findings were communicated to facility administration, with no additional information provided prior to survey exit.
Failure to Provide Safe and Appropriate Respiratory Care and Follow Pulmonology Recommendations
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for two residents. For one resident with a history of pneumonia and moderate cognitive impairment, staff did not store the nebulizer mask in a sanitary manner. Observations on multiple occasions revealed the mask was left uncovered on the bedside table, contrary to facility expectations that it should be stored in a plastic bag labeled with the date, time, and resident name. This failure was confirmed by staff interviews. For another resident with severe cognitive impairment and a history of altered respiratory status and pneumonia, the facility did not implement pulmonology consult recommendations. These recommendations included titrating oxygen to maintain SpO2 above 92% and encouraging the use of incentive spirometry or a flutter valve for pulmonary toileting. The clinical record did not show evidence of orders or documentation for incentive spirometry, nor consistent monitoring or titration of oxygen as recommended. Oxygen use and monitoring were not documented after a certain date, despite ongoing recommendations and changes in the resident's condition. Staff interviews confirmed that recommendations from pulmonology consults were expected to be communicated and implemented, but in this case, orders for incentive spirometry were not placed, and oxygen saturation monitoring was not consistently performed. The facility's policy addressed oxygen administration but did not provide guidance on incentive spirometer use. The deficiencies were brought to the attention of facility administration and nursing leadership.
Failure to Provide Sufficient Nursing Staff and Meet Resident Care Needs
Penalty
Summary
Facility staff failed to maintain sufficient nursing staff to meet the needs of a resident with hemiplegia and moderate cognitive impairment. On one occasion, the resident did not have their hands washed before eating, and feeding assistance was provided while the CNA stood rather than sat, which made the resident uncomfortable. The CNA responsible stated that the unit was short staffed, requiring them to hurry and manage multiple tasks, including delivering trays and feeding residents, which contributed to the observed deficiencies in care. Review of staffing schedules and interviews with staff confirmed that the LTC unit was not consistently staffed according to facility requirements. On the day in question, a CNA was reassigned between units due to staffing shortages, resulting in the LTC unit being left short staffed. The staffing coordinator acknowledged that short staffing can affect resident care and described efforts to cover call outs, but also confirmed that the unit was not fully staffed during the shift in question. Additionally, the resident did not receive a scheduled bath as documented in their care plan. Review of the point of care documentation showed a missed shower, and staff interviews confirmed that the evening shift was short staffed, making it difficult to provide proper care. The facility's assessment indicated that staffing decisions should be based on resident needs and unit requirements, but the observed staffing levels did not meet these standards, resulting in unmet care needs for the resident.
Failure to Provide Safe Discharge Planning and Medically Related Social Services
Penalty
Summary
Facility staff failed to provide medically related social services for one resident, specifically by not developing a safe discharge plan. The resident in question had a history of Parkinson's disease and alcoholism, with multiple clinical notes documenting ongoing alcohol abuse, aggressive behavior, and repeated intoxication upon returning from outings. Despite these documented issues, the discharge planning process did not adequately address the resident's substance abuse or ensure a safe and stable discharge destination. The discharge process was marked by a lack of clear communication and coordination among facility staff. The social worker assigned to the case was instructed by an administrative staff member to find placement for the resident due to nonpayment, with the facility offering to pay for a few nights in a hotel if necessary. The social worker expressed discomfort with discharging the resident to a hotel and attempted to find a shelter, eventually locating one in an adjacent state. However, the discharge notification letter provided to the resident did not specify a discharge date or destination, and there was no evidence in the record of when the resident received this notice. The social worker also reported being kept out of the loop until the final days of discharge planning and was unaware of the resident's alcohol dependency, which was not addressed in the discharge plan. Interviews with facility staff, including the director of social services and the administrator, confirmed that the discharge plan lacked essential details such as the discharge location and did not address the resident's ongoing substance abuse issues. The facility's own job descriptions for social services staff emphasize the importance of comprehensive discharge planning, including assessment of medical, social, and emotional needs, and coordination of community resources. In this case, the discharge plan did not meet these standards, as there was no clear evidence of a safe and appropriate discharge arrangement or follow-up for the resident's substance abuse.
Expired Biologicals and Medical Supplies Found in Storage Areas
Penalty
Summary
Facility staff failed to discard expired biologicals in both a second-floor nursing unit storage closet and the central supply storage area. During an observation, multiple expired medical supplies were found, including IV start kits, oil emulsion dressings, isopropyl rubbing alcohol, hydrogen peroxide, and Foley catheters, all with expiration dates that had passed. These items were stored on shelves and were available for use. A family member expressed concerns about expired supplies following a change in the medical supplier. Staff interviews revealed that the central supply coordinator was responsible for ordering, restocking, and rotating supplies, and claimed to check supply rooms twice daily and remove expired items during restocking, particularly on Fridays. Nurses on each unit also had access to the central supply room and were expected to check for expired items, but in practice, they relied on the central supply staff to manage expiration checks for most items except medications. The facility's policy on clinical supplies outlined procedures for maintaining supply levels and reordering but did not provide guidance on the disposal of expired supplies. During interviews, staff acknowledged that expired items found in the storage areas should not have been available for use. The administrator and director of nursing were informed of these findings, and no further information was provided prior to the survey exit.
Pureed Food Served with Improper Consistency
Penalty
Summary
Facility staff failed to provide pureed food in a form that met the individual needs of residents during a dinner service. During test tray observations, pureed snow peas were served with pod fibers present, and the consistency was not smooth but appeared chopped. The food was tasted by the dietary district manager and two surveyors, who confirmed the presence of pod fibers and found the food unpalatable. The dietary manager acknowledged that snow peas may not be suitable for pureeing and that regular peas should have been substituted. The facility's policy requires pureed food to be blended to a smooth, lump-free consistency, which was not achieved in this instance. The dietary manager stated that the pureed food is typically prepared using a Robot Coupe blender to achieve a pudding-like consistency, but on the day in question, the pureed snow peas were not properly prepared and were served to residents. The issue was identified after the food had already been served, and the dietary manager admitted that the error occurred due to being busy and not catching the mistake. The facility's policy and diet consistency guidelines were not followed, resulting in the deficiency.
Failure to Report Fire Incident to State Agency
Penalty
Summary
Facility staff failed to report a fire incident that occurred on the interior patio, which was caused by a resident discarding a lit cigarette into a trash can, despite the facility being a smoke-free environment. The fire resulted in damage to the glass door at the entrance of the patio. Staff responded by removing the resident from the area, extinguishing the fire with a fire extinguisher, and securing the resident's cigarettes and lighter. Documentation in the resident's clinical record confirmed the sequence of events and the staff's immediate actions to address the fire and resident safety. Despite these actions, the incident was not reported to the state agency as required by state regulations. Interviews with staff and the administrator revealed that the decision not to notify the fire department or the state agency was based on internal guidance and the belief that the situation was under control. The administrator acknowledged that the fire should have been reported to the state agency, in accordance with both state law and facility policy, but this was not done.
Inaccurate Clinical Record Due to Erroneous Physician Documentation
Penalty
Summary
Facility staff failed to maintain an accurate clinical record for one resident when the attending physician erroneously documented a recommendation for a CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol assessment, which facility staff are not trained to perform. The resident in question had a history of debility, alcohol dependence, Parkinson's disease, worsening weakness, unsteady gait, unintentional weight loss, and multiple falls. The physician's progress note indicated a plan to place the resident on the CIWA protocol due to suspected alcohol withdrawal, despite conflicting reports about the resident's last alcohol use. A review of the resident's clinical record did not show any evidence that CIWA assessments were performed following the physician's documentation. During interviews, the DON confirmed that facility staff do not perform CIWA assessments, and the attending physician acknowledged that the recommendation was a mistake, stating that such assessments are not typically conducted in LTC facilities. The facility's policy requires that documentation in the medical record be accurate, relevant, and complete, which was not met in this instance.
Failure to Provide QAPI Training to Contracted Staff
Penalty
Summary
Facility staff failed to ensure that two contracted employees, a dietary aide and a housekeeper, received mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program. Both employees were hired in early April 2023, but there was no evidence provided that they had completed the required QAPI training. According to the education coordinator, QAPI education is typically provided during orientation; however, these contracted staff members did not attend the facility's orientation. The facility's policy requires that all staff receive training on the elements and goals of the QAPI program as part of their annual training requirements. This deficiency was identified through staff interviews and review of facility documentation.
Failure to Ensure Annual CNA Training Compliance
Penalty
Summary
Facility staff failed to ensure that two certified nursing assistants (CNAs) completed the required 12 hours of annual in-service training, as mandated by facility policy. Both CNAs were hired in late October and early November, and a review of their records did not show evidence of completed annual training. The education coordinator, a registered nurse, confirmed during interviews that these CNAs had not fulfilled the annual training requirement and explained that she is responsible for assigning and tracking training completion through computerized software, with reports submitted to the administrator and director of nursing. The facility's policy clearly states that a minimum of twelve hours of annual training is required for CNAs, but documentation for these two staff members was lacking.
Failure to Administer Prescribed Antibiotic for UTI
Penalty
Summary
Facility staff failed to administer six prescribed doses of the antibiotic Macrobid to a resident who was being treated for a urinary tract infection (UTI). The resident, who had a complex medical history including Dentatorubral-pallidoluysian atrophy (DRPLA), metabolic encephalopathy, benign prostatic hyperplasia, dysphagia, and dementia, was dependent on staff for all activities of daily living and was severely impaired in decision-making. Despite a physician order for Macrobid to be given twice daily for five days, only one dose was documented as administered, with multiple blanks on the medication administration record (MAR) indicating missed doses. Clinical records and staff interviews confirmed that the antibiotic was not given as ordered. The nurse practitioner and director of nursing acknowledged that the resident should have received the full course of antibiotics, and the infectious disease nurse practitioner stated that the medication order was incorrectly entered as a one-time dose rather than a routine medication. The MARs for July and August showed no documentation of administration for the majority of the prescribed doses. Staff interviews further clarified that a blank on the MAR indicated the medication was not given. As a result of the missed antibiotic doses, the resident's condition deteriorated over several days, culminating in a hospital admission for septic shock due to E. coli bacteremia originating from the untreated UTI. The resident exhibited fever, altered mental status, hypoxia, and required intensive care, including broad-spectrum IV antibiotics and pressors. The facility's medication and treatment order policy did not provide documentation related to administering medications per physician orders, and no further information was provided prior to the survey exit.
Failure to Update Care Plan for UTI Treatment
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for a resident who was being treated for a urinary tract infection (UTI). A physician's order was issued for Macrobid to treat the UTI, but the resident's care plan, last updated several months prior, did not reflect this new diagnosis or the prescribed treatment. Clinical record review confirmed the absence of updated documentation in the care plan regarding the UTI and its management. Interviews with both a registered nurse and the director of nursing confirmed that the care plan should have been updated to address the antibiotic treatment for the UTI. The facility's own policy requires care plans to be reviewed and updated when there is a significant change in a resident's condition, such as the onset of a UTI requiring antibiotics. Despite this, the care plan was not revised to include the new treatment, and this deficiency was acknowledged by facility leadership during the survey.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for Resident #8, who was admitted with diagnoses including dysphagia and Parkinson's disease. The care plan required a mechanically altered diet with pureed food, but during an observation, the resident was served a meal that did not meet the pureed consistency requirement. Interviews with the resident and staff confirmed that the meal did not adhere to the prescribed diet, indicating a failure to implement the care plan as ordered by the physician. For Resident #5, the facility staff did not develop or implement a care plan addressing PTSD-related care and incontinence. Despite the resident's diagnoses of anxiety disorder, depression, and PTSD, there was no documentation or care plan interventions for PTSD. Additionally, the resident, who was occasionally incontinent for urinary and frequently incontinent for bowel, had no care plan addressing incontinence care, despite having an indwelling catheter. Interviews with staff revealed a lack of awareness and documentation regarding the resident's needs and care requirements. Resident #63's care plan failed to address the use of side rails, despite a physician's order allowing their use for bed mobility. The resident, who was severely cognitively impaired, was observed with side rails in place, but the care plan did not reflect this intervention. An interview with the regional MDS consultant confirmed that the use of side rails should have been included in the care plan, indicating a deficiency in care planning for this resident.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the kitchen, as observed during a survey. The three-compartment sink was found to contain loose debris and grease residue, and the dietary manager acknowledged that it needed cleaning. The plate warmer and standing food warmer were also observed to have crumbs, grease buildup, and sticky handles, indicating a lack of cleanliness. Additionally, the stove had a significant amount of crumbs and grease buildup. In the walk-in freezer, opened and unlabeled bags of broccoli and cookies were found, and the walk-in refrigerator floor was littered with food peelings and trash. The dry storage area had a split bag of cereal with flakes scattered on the shelves and floor, and the bag was unlabeled. The facility's dishwashing machine was not functioning properly, with wash temperatures recorded at 140 and 159 degrees Fahrenheit, and rinse temperatures between 116 and 140 degrees Fahrenheit, which were below the required levels for effective sanitation. A dietary aide was unaware of the necessary temperatures for the dishwashing machine, and the regional dining services director acknowledged the issue and planned to address it. The facility's policies on dishwashing machine use and food storage were reviewed, revealing requirements for proper training, temperature monitoring, and food labeling, which were not adhered to, contributing to the deficiencies observed.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility staff failed to conduct regular bed inspections for four residents, as observed during a survey. The last documented bed inspection was dated April 2022, and no subsequent inspections were conducted to assess the risk of entrapment, despite the facility's policy requiring such evaluations. This lapse was identified for residents who were observed in bed with bilateral side rails up, indicating a potential risk for entrapment. Interviews with the facility's administrative staff, including the administrator, revealed that while general maintenance was performed by an external company, it did not include specific assessments for bed safety and entrapment risks. The facility's policy mandates regular inspections to minimize the possibility of resident entrapment or injury, but this was not adhered to, as evidenced by the lack of inspections since April 2022. The issue was brought to the attention of the facility's administration, including the director of nursing and regional director of operations, but no further information was provided before the survey exit.
Failure to Assess Resident for Self-Administration of Medicated Mouthwash
Penalty
Summary
The facility staff failed to assess a resident for the self-administration of a medicated mouthwash, which was prescribed by the resident's oncologist. The resident, who was not cognitively impaired as indicated by a perfect score on the BIMS assessment, had a bottle of Dexamethasone oral solution on her bedside table. She reported taking it with her on outings, which she did almost daily. Despite the physician's order for the medication, there was no documented assessment in the clinical record or comprehensive care plan regarding the resident's ability to self-administer the mouthwash. Interviews with facility staff, including an LPN and an RN, revealed a lack of awareness and documentation regarding the assessment for self-administration of the medicated mouthwash. The facility's policy requires an interdisciplinary team to determine if self-administration is clinically appropriate and safe, but this process was not followed. The director of nursing confirmed the absence of the assessment and decided to remove the medication from the resident's bedside.
Failure to Maintain Advance Directive Documentation
Penalty
Summary
The facility staff failed to implement advance directive requirements for a resident, identified as Resident #6. The clinical record review revealed that the resident had advance directives and had assigned their daughter as the power of attorney (POA). However, the advance directive and POA documents were not found in the resident's clinical record, both electronic and paper. During an interview, the director of social services stated that these documents are typically obtained upon admission and either uploaded into the electronic record or given to the medical records clerk. The documents were eventually located in the admissions office, dated March 8, 2021, but were not initially available in the resident's clinical record as required by the facility's policy.
Failure to Provide Timely Advance Beneficiary Notice
Penalty
Summary
The facility staff failed to issue a timely advance beneficiary notice of non-coverage for Resident #75, who was discharged from a Medicare-covered Part A stay with benefit days remaining. The resident was discharged on September 23, 2023, but the notice was not signed until November 29, 2023. According to the facility's director of nursing, the notice should have been provided within 48 hours of the discharge date. This delay in providing the notice was identified as a concern during the survey.
Failure to Protect Resident's Medical Privacy
Penalty
Summary
The facility staff failed to protect the clinical information privacy of a resident, identified as Resident #246, by posting sensitive medical information in a visible location. Observations on multiple occasions revealed that signs containing the resident's medical diagnosis of difficulty swallowing and specific feeding instructions were placed above the resident's bed. These signs were visible to all visitors, including those of the resident's roommate, thereby compromising the resident's privacy. During an interview, an LPN acknowledged that the placement of these signs did not protect the resident's medical privacy. The LPN noted that such instructions are typically placed inside a resident's closet door to maintain confidentiality. The facility's policy on Resident Rights was reviewed, which states that residents have the right to secure and confidential personal and medical records. Despite this policy, the facility staff did not adhere to it, resulting in a breach of privacy for Resident #246.
Failure to Maintain Clean Linens for Resident
Penalty
Summary
The facility staff failed to provide a clean and homelike environment for Resident #247, as observed during a survey. On two separate occasions, the resident was found lying in bed with dried red/black spots, identified as blood stains, on the sheet and underpad. A Licensed Practical Nurse (LPN) acknowledged the presence of blood stains and the need to change the linens, noting that the resident is a bleeder. A Certified Nursing Assistant (CNA) confirmed that the sheets should be changed and the nurse notified if blood is present, emphasizing that the soiled linens were neither sanitary nor homelike. The facility's policy on maintaining a homelike environment includes ensuring clean and sanitary bed linens, which was not adhered to in this instance.
Failure to Provide Clinical Information During Resident Transfers
Penalty
Summary
The facility staff failed to provide necessary clinical information to the receiving hospital upon the discharge of two residents, leading to a deficiency. For Resident #73, the facility did not send clinical documents such as care plan goals, advance directives, and current orders when the resident was emergently transferred to a hospital. The facility's policy requires that such information be documented and sent to ensure continuity of care, but there was no evidence that this was done. The administrative staff and the unit manager acknowledged that the facility does not retain evidence of clinical information being sent unless a nurse writes a progress note. Similarly, for Resident #24, the facility did not provide evidence of sending required clinical documents to the hospital when the resident was transferred with stroke-like symptoms. The progress note indicated the resident's condition and the need for emergency evaluation, but there was no documentation of clinical information being sent. The facility's policy mandates the provision of necessary information to support a successful discharge, but the Acute Care Document Transfer Checklist was found to be blank. The director of nursing confirmed the lack of evidence for the transfer of clinical documents.
Inaccurate MDS Assessments and Coding Errors
Penalty
Summary
The facility staff failed to maintain a complete and accurate Minimum Data Set (MDS) assessment for three residents. For Resident #72, the staff did not attempt the Brief Interview for Mental Status (BIMS) and mood interviews during the quarterly MDS assessment with an Assessment Reference Date (ARD) of 11/1/23. Despite the resident being coded as able to understand verbal content, the interviews were not conducted. The social services department, responsible for these interviews, did not see the resident within the seven-day ARD period, leading to the interviews being coded as not assessed. For Resident #78, the facility inaccurately coded the resident as having a restraint on the admission MDS assessment with an ARD of 10/6/23. The clinical record indicated a physician's order allowing the use of siderails or a mobility bar for bed mobility if needed. However, the MDS assessment documented the bed rail as a physical restraint used daily. This coding error was due to the automatic triggering of bed rail use as restraints in the computer system, which the nurses were unaware of. Similarly, Resident #80 was inaccurately coded as having a restraint on the admission MDS assessment with an ARD of 9/18/23. The resident's clinical record also included a physician's order for siderail use if needed, but the MDS assessment incorrectly documented the bed rail as a physical restraint. The same issue with the computer system's automatic coding of bed rail use as restraints was identified, contributing to the inaccurate assessment.
Failure to Include Neck Collar in Baseline Care Plan
Penalty
Summary
The facility staff failed to develop a complete baseline care plan for a resident, identified as Resident #246, who required a neck stabilizing collar. Observations on multiple occasions confirmed that the resident was wearing the collar, yet the baseline care plan, dated the same day as the order for the collar, lacked any information regarding its use. The clinical record review revealed an order for the collar to be worn at all times, but there were no accompanying orders for skin checks or collar cleaning, which are essential to prevent skin breakdown and infection. Interviews with facility staff, including the regional MDS coordinator and an LPN, highlighted the oversight. The MDS coordinator acknowledged that the baseline care plan should have included interventions related to the collar, such as skin integrity, pain management, and positioning. The LPN emphasized the importance of removing the collar twice daily for cleaning and skin assessment to prevent complications. Despite these acknowledgments, the baseline care plan did not address these critical care needs, and the facility's policy on person-centered care planning was not adhered to, as it mandates the development of a baseline care plan within 48 hours of admission to meet the resident's immediate needs.
Failure to Update Care Plan for Self-Administration of Medication
Penalty
Summary
The facility staff failed to review and revise the care plan for a resident regarding the use and self-administration of a medicated mouthwash. The resident, who was not cognitively impaired as indicated by a perfect score on the BIMS, was observed with a bottle of Dexamethasone oral solution on her bedside table. She reported that her oncologist had ordered the medication and that she takes it with her on outings, which she does almost daily. Despite this, the comprehensive care plan did not address the use and self-administration of the medicated mouthwash. Additionally, there was no documentation in the clinical record of an assessment for the self-administration of the medicated mouthwash. An LPN confirmed that such a situation should be addressed in the resident's care plan, as it is essential for planning the resident's care. The facility's policy requires care plans to be reviewed and updated under specific circumstances, including quarterly assessments and significant changes in the resident's condition. However, this was not adhered to in the case of the resident in question.
Deficiencies in Wound Care and Device Management
Penalty
Summary
The facility staff failed to administer a prescribed treatment for a wound on the shoulder of a resident who was not cognitively impaired, as indicated by a BIMS score of 15 out of 15. The physician's order dated 11/2/2023 required the wound to be cleansed with normal saline, patted dry, and a hydrocolloid applied three times a week and as needed. However, the treatment administration record for 11/7/2023 was left blank, indicating the treatment was not performed. This issue was acknowledged by the director of nursing, who confirmed that blanks in the treatment administration record suggest the treatment was either not given or completed. Another resident was observed wearing a neck stabilizing collar without evidence of skin checks or device cleaning, as there were no orders for these actions in the resident's clinical record. The baseline care plan also lacked information regarding the collar. An LPN stated that the collar should be removed at least twice daily for cleaning and skin assessment to prevent skin breakdown and infection. The absence of these orders and care plan details was brought to the attention of the facility's administrative staff, including the administrator and director of nursing.
Failure in Pain Management for Resident
Penalty
Summary
The facility staff failed to implement a complete pain management program for a resident who was admitted with a fractured left upper leg. The resident, who was cognitively intact, expressed concerns about not receiving pain medication in a timely manner during the initial days after admission. A physician's order for gabapentin, prescribed for neuropathy, was not administered as scheduled on one occasion. The medication administration record indicated that the medication was not given due to awaiting delivery from the pharmacy, despite the availability of gabapentin in the facility's backup medication supply. Interviews with facility staff revealed that the admitting nurse is responsible for entering medication orders into the computer system, which are then sent to the pharmacy. If a medication is due and has not arrived, nurses are expected to obtain it from the backup supply. However, in this case, the backup supply was not utilized as required, leading to a lapse in the resident's pain management. The facility's policy on pain management emphasizes the provision of pain management services consistent with professional standards and the resident's care plan, which was not adhered to in this instance.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility staff failed to provide trauma-informed care for a resident diagnosed with PTSD, anxiety disorder, and depression. The resident was moderately impaired in making daily decisions, as indicated by a score of 10 out of 15 on the BIMS. Despite these diagnoses, the social service assessments and trauma screen assessments conducted on various dates did not include any information related to PTSD. Additionally, the care plan dated 5/11/23 lacked interventions and accommodations for PTSD. During an interview, the director of social services acknowledged the absence of documentation and stated that the facility's process for admitting someone with PTSD involves identifying behaviors and symptoms indicative of PTSD and then care planning for any exhibited mood or behaviors. However, she could not explain the lack of documentation prior to the survey entrance. The facility's policy on Trauma Informed Care outlines the need for staff training on screening tools and assessments to identify trauma triggers, but this was not reflected in the care provided to the resident.
Failure to Provide PTSD Services for Resident
Penalty
Summary
The facility staff failed to provide medically related social services for a resident diagnosed with PTSD, anxiety disorder, and depression. The social worker did not follow up on a recommendation for counseling services, and there was no evidence of any such recommendation being made. The resident was assessed as moderately impaired in making daily decisions, scoring 10 out of 15 on the BIMS. Despite these assessments, the social service assessments and trauma screen assessments did not include information related to PTSD, and the care plan lacked interventions and accommodations for PTSD. During an interview, the director of social services acknowledged the absence of documentation and stated that the facility should have provided services for the resident's PTSD. The facility's job description for the social services director and the policy on Trauma Informed Care outlined responsibilities that were not fulfilled, such as gathering information on the resident's mental status and making referrals for mental health services. The interdisciplinary team was expected to be trained on trauma-informed care, but there was no evidence of this being implemented for the resident in question.
Failure to Ensure Timely Medication Reordering
Penalty
Summary
The facility staff failed to ensure the timely reordering of medications for a resident, resulting in a missed dose of Aspirin and Multivitamins. On the morning of 11/28/23, an LPN was observed preparing medications for the resident and noted that both Aspirin and Multivitamins were unavailable, as the medication cards were empty. The LPN did not check other areas in the facility for these medications and did not administer them to the resident. The resident's medication administration record indicated that the medications were not given due to unavailability from the pharmacy. Interviews with facility staff revealed inconsistencies in the availability of stock medications. One LPN stated that neither Aspirin nor Multivitamins were available in the facility's backup supply or stock bottles, while the director of nursing claimed they were available in stock bottles on each medication cart. A subsequent check of the medication cart confirmed the absence of these medications in stock bottles. The facility's policy on handling unavailable medications was not followed, as the LPN did not thoroughly search for the medications or ensure they were reordered in a timely manner.
Medication Administration Error Due to Unavailable Medications
Penalty
Summary
The facility staff failed to administer medications at an error rate of less than five percent during a medication administration observation for a resident. Specifically, the resident did not receive their prescribed Aspirin and Multivitamin on the observed date, resulting in two errors out of 34 total opportunities, leading to a medication administration error rate of 5.88%. The LPN responsible for administering the medications acknowledged that the medications were not available and stated they would need to be requested from the pharmacy, which would deliver them the following day. The LPN did not check for the availability of these medications elsewhere in the facility. Further investigation revealed discrepancies in the facility's medication management practices. Interviews with staff indicated that medications should be reordered when only a few doses remain, and that certain medications should be available in stock bottles on each medication cart. However, it was found that neither Aspirin nor Multivitamins were available in stock bottles or the facility's backup medication supply. The administrative staff was informed of these concerns, but no further information was provided before the survey exit.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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