Lynchburg Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynchburg, Virginia.
- Location
- 5615 Seminole Avenue, Lynchburg, Virginia 24502
- CMS Provider Number
- 495105
- Inspections on file
- 28
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lynchburg Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with paraplegia, osteomyelitis, UTI, indwelling catheter, and MRSA, who was cognitively intact, frequently refused medications, treatments, hygiene, and incontinence care, and often left the facility during scheduled care times. Despite these ongoing refusals, the care plan only addressed behavioral refusals of wound treatments and medications, lacking specific interventions for missed care, hygiene, and incontinence needs. Multiple staff confirmed the absence of detailed interventions in the care plan.
Staff did not complete or document required weekly skin assessments for a resident with traumatic wounds and paraplegia over a three-week period, despite facility policy and electronic prompts. Interviews with an LPN and the DON confirmed the assessments were missed without explanation or documentation of refusal.
A resident with multiple complex medical conditions did not receive eleven scheduled doses of gabapentin for pain management due to pharmacy delivery delays and staff not accessing the back-up medication supply, despite facility protocols requiring such actions. Staff interviews and documentation confirmed the missed doses and the breakdown in communication and procedure.
Staff failed to consistently document whether nightly dressing changes were performed or refused for a resident with multiple complex medical conditions, as shown by blank spaces on the treatment administration record for several dates. Facility leadership could not provide evidence for most of the undocumented treatments.
Staff did not follow infection control protocols during dressing changes for a resident on enhanced barrier precautions, including failing to sanitize surfaces, not using a clean barrier for supplies, omitting hand hygiene between glove changes, and not wearing required gowns. Interviews confirmed these actions were inconsistent with facility policy.
Facility staff did not notify a resident's responsible party when the resident experienced a significant change in condition and was transferred to the hospital. Despite the resident's complex medical history and the facility's policy requiring notification, staff failed to inform the responsible party at the time of the event, and this omission was confirmed through interviews and record review.
A resident with multiple complex medical conditions was found to be living in a room that was not clean or homelike, as reported by a family member and confirmed by the DON and housekeeping supervisor. The room had an unmade bed, trash on the floor, and sticky floors, despite facility policy requiring daily cleaning and maintenance. The assigned housekeeper had not performed the required cleaning tasks, resulting in the room not meeting facility standards.
A resident with multiple complex medical conditions experienced a change in condition that led to a hospital transfer. The nurse on duty assessed the resident, provided interventions, and communicated with facility staff, but failed to document any assessments, interventions, vital signs, or communications related to the event, contrary to facility policy and professional standards.
A resident with multiple complex medical conditions was transferred to the hospital due to a change in condition, but staff failed to document assessments, interventions, and communications related to the event. The nurse involved acknowledged not recording vital signs, provider notifications, or the transfer decision, resulting in an incomplete clinical record in violation of facility policy.
The facility failed to implement a bed safety program, affecting all residents across three units. The maintenance director installed bedrails on a resident's bed without a maintenance work order, and the facility could not provide evidence of inspections. The bed management binder lacked inspection records, and the facility did not adhere to its Bed System Audits policy, which required annual audits referencing safety guidelines.
The facility failed to accommodate residents' dining preferences by using the main dining room as a storage area, affecting socialization and meal experiences. Residents expressed dissatisfaction with the prolonged inaccessibility of the dining room, which had been closed for about three months.
The facility failed to provide residents with quarterly trust account statements and limited their access to funds, affecting all 140 residents with trust accounts. Residents reported not receiving statements and expressed concerns about restricted access to their funds, which was limited to two hours on weekdays with no weekend access. The facility's policies required quarterly statements and reasonable weekend access, but these were not adhered to, resulting in a deficiency.
The facility failed to update care plans for several residents, leading to deficiencies in care. One resident's plan lacked interventions to prevent a traumatic ex-boyfriend from entering, despite staff awareness. Another resident's plan did not reflect a fall or bed rail use, and a third resident's mental health screening was inaccurately documented. Additionally, a resident's care plan omitted heel protectors for skin integrity, which were not in use due to lack of documentation.
The facility staff failed to follow physician orders for several residents, leading to deficiencies in care. A resident with severe cognitive impairment did not have heel protectors applied as ordered, resulting in skin issues. Another resident's feeding tube was not anchored, and incorrect medication dosages were administered to a resident. Additionally, a resident did not receive ted hose due to a supply issue, and a lab test was incorrectly conducted for another resident. These issues were acknowledged by the facility's administration.
The facility failed to provide trauma-informed care for several residents, as care plans lacked identification of trauma triggers and specific interventions. Residents with histories of abuse and anxiety reported triggers such as rude staff, loud noises, and medical procedures, but these were not addressed in their care plans. Interviews revealed staff were unaware of the need to include trauma and PTSD considerations in care plans.
The facility failed to provide therapeutic diets as ordered for four residents. Three residents did not receive meals in the correct consistency, and one resident did not receive a prescribed nutritional supplement. The unit manager confirmed these issues, and the dietary manager could not explain the oversight. The facility's policy requires diets to be offered as ordered by the physician, which was not followed.
The facility staff failed to maintain sanitary conditions in food storage and preparation areas. In the main kitchen, out-of-date and unsealed food items were found, and equipment was not properly cleaned. Flies were present due to a non-functioning air curtain. On the West unit, an opened supplement lacked proper labeling. Facility policies on food storage and equipment maintenance were not followed.
The facility failed to maintain effective pest control, with flies observed in the dining/day room and kitchen during meal preparation. The air curtain meant to prevent insect entry was not functioning automatically, and the dietary manager confirmed it was not routinely used during meal prep. A resident was seen with flies landing on them while eating. The assistant maintenance director was unaware of the fly issue, and the pest control report did not address the non-functional air curtain or targeted fly treatment.
The facility staff failed to distribute meal trays in a manner that upheld residents' dignity, affecting several residents. During a lunch meal, a resident was left without food while another resident's meal was improperly placed between two others, leading to confusion and tampering. A CNA was unaware of the missing meal tray, and an LPN removed a tray to correct food consistency, leaving a resident without food. The situation was reviewed with facility leadership.
A resident's dignity was compromised as the facility failed to provide adequate and season-appropriate clothing. The resident, who had been at the facility for five years, expressed dissatisfaction with the ill-fitting clothes provided, which were not suitable for the season. Despite having a trust account with substantial funds, these were not used to purchase appropriate clothing. The social services assistant was unaware of the issue until informed by the surveyor, and no immediate action was taken to address the resident's clothing needs.
A resident remained in a facility after skilled services ended without receiving an Advanced Beneficiary Notice (ABN), which would have allowed them to decide on continuing services and assuming financial responsibility. Despite ongoing discharge discussions and the resident's indecision, the facility did not provide the necessary notice, contrary to policy and CMS guidelines.
Two residents experienced deficiencies in their environment and equipment maintenance. A resident's closet was missing a door for months, despite being noted during daily rounds. Another resident's wheelchair was dirty and in disrepair, with torn arm cushions and debris. Staff interviews revealed a lack of action to address these issues, highlighting failures in maintaining a homelike environment and clean equipment.
Two residents were involved in a physical altercation resulting in injuries, but the facility failed to report the incident to the state survey agency and other required authorities. Despite documentation of the event and staff intervention, the facility did not adhere to its policy of immediate reporting of abuse incidents.
A resident with bilateral hand contractures did not have a comprehensive care plan addressing their condition. Observations showed the resident was non-verbal and lacked splints or palm protectors. Interviews revealed the resident was previously on occupational therapy, and palm guards were recommended. However, no splint devices were found, and the care plan did not reflect the resident's needs. Care plan coordinators confirmed the plan should include contractures, and the issue was acknowledged in a meeting with facility staff.
The facility staff failed to follow professional standards for three residents. A resident's pressure ulcer dressing was not dated or initialed, another wore Tubi grips without a physician's order, and a third was not positioned correctly during tube feeding, risking aspiration. These deficiencies were confirmed by staff and observed during the survey.
The facility failed to provide activities that met the psychosocial needs and preferences of residents. A resident was left in a dark room without entertainment, despite a care plan for one-on-one activities. Another resident was not invited to activities, leading her to stay in her room. The activity schedule was not followed, and changes were not communicated, resulting in dissatisfaction among residents.
A resident with a stage three sacral pressure ulcer did not receive timely treatment interventions, as the facility staff delayed implementing treatment orders for seven days after the ulcer was identified. Despite the presence of a wound assessment report from a clinic, the facility's physician orders were not documented until a day later, and treatments began the following day. The inconsistency in weekly skin assessments further highlighted the deficiency.
Two residents in the facility were found to have inadequate foot care, with one having toenails extending 3/4 of an inch past the toes and another with extremely long, curling toenails and dry skin. The facility relied on a podiatrist for nail care, but both residents were not on the podiatry list for 2024, and the podiatry contract lacked details on visit frequency and resident coverage.
A resident with bilateral hand contractures was observed without necessary splints or palm protectors, despite previous therapy recommendations. Facility staff, including a therapy director and LPN, confirmed the absence of these devices, and the resident's care plan did not address the contractures or use of palm guards. This indicates a deficiency in implementing contracture management interventions.
A facility failed to provide emergency suction equipment at the bedside for a resident with a tracheostomy. The resident confirmed the absence of the device, which is necessary for breathing. A nurse also verified the lack of equipment and intended to set it up. Facility policy mandates the availability of such equipment, but it was not followed.
A resident with ESRD missed two dialysis treatments due to transportation issues related to a COVID-19 diagnosis. The facility failed to arrange alternative transport and did not ensure proper communication with the dialysis center regarding the resident's care during dialysis sessions. Essential information was missing from communication forms, and staff interviews revealed a lack of coordination and awareness in handling the situation.
A resident in a persistent vegetative state was provided with bed rails without attempting alternatives or assessing entrapment risks. The facility's documentation inaccurately indicated the resident could use the rails as an enabler, despite being non-verbal and fully dependent on staff. The facility also failed to provide necessary documentation for the installation and safety of the bed rails, contributing to the deficiency.
A resident missed doses of Xanax due to the facility's failure to ensure medication availability. Despite efforts by staff to fax prescriptions to the pharmacy, the medication was not restocked, and the pharmacy required a new prescription for emergency access. The facility's policy on medication unavailability was not effectively implemented, resulting in the resident missing scheduled doses.
An opened Fiasp insulin pen was found without a date indicating when it was opened, contrary to facility policy and manufacturer guidelines. An LPN confirmed that insulin pens should be dated upon opening. The facility's policy requires a 'date opened' sticker and specifies an expiration date of 30 days from opening unless otherwise stated by the manufacturer, which in this case is 28 days.
A resident with protein-calorie malnutrition and moderate cognitive impairment did not receive the complete meal as specified on her meal ticket. The meal tray was missing several items, including a pork chop and black-eyed peas, which were confirmed through observation and staff interviews. The dietary manager acknowledged the issue but could not explain the missing items.
A resident with diabetes and obesity was not provided with side salads as requested, despite expressing a preference for fresh fruits and vegetables. The dietary manager cited a corporate menu change as the reason for discontinuation, although fresh produce was available in the kitchen. The VP of operations acknowledged the resident should be allowed a side salad.
The facility staff failed to maintain accurate clinical records for three residents, including inconsistent documentation of a sacral wound, incomplete mental health screening records, and incorrect documentation of ted hose application. These deficiencies highlight issues in record-keeping and adherence to treatment protocols.
A resident with an ESBL urinary tract infection was removed from contact isolation without obtaining a negative urinalysis after completing antibiotic therapy. The facility's protocol requires a negative urine culture before discontinuing isolation, which was not followed. The infection preventionist and LPN confirmed the oversight, and no follow-up urine culture results were found in the resident's records.
Failure to Develop Comprehensive Care Plan for Noncompliant Resident
Penalty
Summary
Facility staff failed to develop a comprehensive care plan addressing all of a resident's needs, specifically for a resident with paraplegia, osteomyelitis, urinary tract infection, indwelling catheter, and MRSA. The resident was cognitively intact and had a significant change in status as indicated by the most recent MDS. Clinical record review and staff interviews revealed that the resident frequently refused medications, treatments, hygiene, and incontinence care, and would often leave the facility for extended periods, missing scheduled treatments and medications. Despite documentation of the resident's noncompliance and refusals in various records and staff interviews, the care plan only addressed behaviors related to rejecting wound treatments and medications, without including specific interventions for missed treatments or medications, or for hygiene and incontinence care. Multiple staff, including the LPN, CNA, physician, wound care nurse practitioner, and MDS coordinator, confirmed the lack of detailed interventions in the care plan. The issue was acknowledged by the MDS coordinator and presented to the DON, with no additional information provided before the exit conference.
Failure to Complete Required Weekly Skin Assessments
Penalty
Summary
Facility staff failed to follow professional standards of care regarding skin assessments for one resident with significant risk factors, including traumatic wounds, paraplegia, and immobility. The resident's care plan required regular skin assessments to prevent further skin breakdown. Clinical records showed that weekly skin assessments were documented for several weeks, but there were no assessments recorded for three consecutive weeks. There was no documentation explaining the absence of these assessments or any indication that the resident refused them during this period. Interviews with the LPN unit manager and the DON confirmed that weekly skin assessments were required by facility policy and should have been prompted by the electronic health record system. Both staff members were unable to provide an explanation for the missing assessments, and no additional information was provided during the survey regarding the lapse. The facility's policy specified that skin assessments must be completed at least every seven days for all residents, but this was not followed in the case of the resident in question.
Failure to Administer Physician-Ordered Medication Due to Pharmacy and Staff Oversight
Penalty
Summary
Facility staff failed to administer gabapentin as ordered by the physician for a resident with multiple complex diagnoses, including traumatic wounds, pneumothorax, paraplegia, vertebra fractures, neurogenic bladder/bowel, spinal stenosis, and emphysema. The resident, who was cognitively intact, reported that several doses of gabapentin were missed over several days, and the clinical record confirmed that eleven scheduled doses were not given between 10/17/25 and 10/21/25. Documentation indicated that the medication was placed on hold due to pharmacy delivery issues, and staff interviews revealed delays in obtaining the required prescription and problems with fax communication to the pharmacy after new equipment was installed. The facility's protocol for omitted medications required staff to check the back-up supply (Omnicell), contact the provider for alternatives if the medication was unavailable, and notify the pharmacy regarding the medication's expected arrival. Despite gabapentin being available in the back-up supply, nurses did not access it, resulting in the missed doses. The deficiency was confirmed through resident and staff interviews, clinical record review, and facility policy documentation.
Incomplete Documentation of Resident Treatments on TAR
Penalty
Summary
Facility staff failed to ensure a complete and accurate clinical record for one of two residents reviewed, as evidenced by missing staff initials on the treatment administration record (TAR) for multiple dates. The resident involved had diagnoses including paraplegia, osteomyelitis, urinary tract infection, an indwelling catheter, and MRSA, and was noted to be cognitively intact on the most recent significant change MDS. Review of the TAR for August 2025 revealed blank spaces where staff did not indicate whether nightly dressing changes to the left heel and sacral wound were performed or refused on several dates. When questioned, facility leadership was unable to provide evidence for most of the missing documentation, except for one instance where the treatment was refused by the resident.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Facility staff failed to follow infection control practices during dressing changes for a resident with multiple wounds and a urinary catheter, who was under enhanced barrier precautions. During an observed dressing change, the registered nurse and certified nurse aide washed their hands and donned gloves, but the nurse did not sanitize the over-bed table or use a barrier before placing dressing supplies. The nurse also failed to perform hand hygiene between glove changes, placed supplies directly on the resident's bed linens without a barrier, and did not use gowns as required by enhanced barrier precautions. The nurse was unclear about the requirements for personal protective equipment and hand hygiene, despite facility policy and signage indicating the need for gowns, gloves, and hand hygiene at specific points during wound care. Interviews with the nurse, unit manager, and director of nursing confirmed that the facility's policies required the use of gowns and gloves for residents on enhanced barrier precautions, a clean field for supplies, and hand hygiene between glove changes. The observed practices did not align with these policies, as the nurse did not consistently use a clean barrier, failed to perform hand hygiene at required times, and did not wear a gown during high-contact care activities. These deficiencies were confirmed through staff interviews and review of facility policies.
Failure to Notify Responsible Party of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify the responsible party of a resident's change in condition and subsequent transfer to the hospital. The resident, who was cognitively intact and had multiple complex diagnoses including end-stage liver disease, sepsis, MRSA, hepatic encephalopathy, and acute kidney failure, experienced a significant change in condition characterized by low blood pressure and altered mental status. Nursing staff assessed the resident and, following instructions from the on-call nurse manager, arranged for emergency transport to the hospital. However, there was no documentation or evidence that the resident's responsible party was notified of the change in condition or the transfer at the time it occurred. Interviews with the DON and nursing staff confirmed that the responsible party was not informed prior to or during the transfer, and the responsible party later reported not receiving any notification. The facility's policy required notification of the responsible party in the event of a significant change in condition, but this was not followed or documented in the clinical record. The deficiency was identified through staff interviews, clinical record review, and facility policy review, with no additional information provided by facility leadership during the survey.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for one resident, as evidenced by observations and staff interviews. The resident, who had multiple complex medical diagnoses including end-stage liver disease, MRSA, sepsis, and alcohol-induced dementia, was assessed as cognitively intact. On a specific date, the resident's family member reported concerns regarding the cleanliness of the resident's room, noting that the bed was unmade, trash was on the floor, and the floor was sticky. The DON confirmed these concerns and took steps to have the room cleaned at that time. Further investigation with the housekeeping supervisor revealed that the assigned housekeeper had reported the room as cleaned, but upon inspection, the room did not meet cleanliness standards. The supervisor, along with two housekeepers, observed the same issues reported by the family member. Facility policy required daily cleaning of resident rooms, including mopping, trash removal, and bathroom cleaning, but these procedures were not followed in this instance. The deficiency was confirmed through staff interviews and review of facility policy.
Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to follow professional standards of quality by not documenting assessments, interventions, or communications regarding a resident's change in condition and subsequent transfer to the hospital. The resident, who had a complex medical history including end-stage liver disease, sepsis, MRSA, hepatic encephalopathy, and other serious conditions, experienced altered mental status and declining oxygen saturation. Although the nurse on duty assessed the resident, applied oxygen, and attempted to contact the provider before notifying the nurse manager and arranging for hospital transfer, none of these actions or the vital signs taken were recorded in the clinical record. Interviews with the DON, the nurse involved, and the regional nurse consultant confirmed that the expected standard was to document all assessments, changes in condition, and significant events such as hospital transfers at the time they occur. The nurse admitted to not documenting any of the events, including vital signs, communications, or the transfer itself, and did not consider making a late entry. Facility policy and professional nursing standards both require timely and complete documentation of such events, which was not followed in this instance.
Incomplete Documentation of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident who was transferred to the hospital following a change in condition. The resident, who had multiple complex diagnoses including end-stage liver disease, sepsis, MRSA, hepatic encephalopathy, and other serious conditions, was assessed as cognitively intact. On the date of the incident, the clinical record lacked documentation regarding the resident's change in condition, assessments performed, interventions implemented, and communications that led to the hospital transfer. The only nursing note present was entered after the transfer, stating the resident had been sent to the emergency department on the prior shift. Interviews with the DON and the nurse who cared for the resident during the incident confirmed that no documentation was made regarding the vital signs, attempted provider communication, or the decision to transfer the resident. The nurse stated he assessed the resident multiple times, noted declining oxygen saturation and blood pressure, and communicated with the on-call nurse manager, who instructed him to send the resident to the hospital. However, none of these actions were documented in the clinical record, and the nurse did not consider making a late entry. Facility policy required documentation of assessments and provider notifications for significant changes in condition, which was not followed in this case.
Failure to Implement Bed Safety Program
Penalty
Summary
The facility staff failed to implement a comprehensive bed safety program, affecting all residents across three units. During an interview, the maintenance director revealed that he had installed bedrails on a resident's bed approximately two months prior but could not provide a maintenance work order for this task. The facility was unable to produce evidence of any inspection conducted on the resident's bed and bedrails. The regional director of clinical services admitted to the survey team that the bed safety program documentation was incomplete. Upon reviewing the facility's bed management binder, the surveyor found a bed inventory listing dated April 2023, which included bed frame model numbers but lacked any indication of actual inspections. The facility's policy on Bed System Audits required annual audits of each bed, referencing safety guidelines such as the FDA's Seven Zones of Entrapment and the Hospital Bed Safety Workgroup guidelines. However, there was no evidence that these audits were performed, indicating a failure to adhere to the facility's own safety protocols.
Dining Room Inaccessibility Due to Storage Use
Penalty
Summary
The facility failed to accommodate the residents' preference to dine in the dining room, affecting multiple residents across three units. During an initial tour, it was observed that the main dining room was being used as a storage area, preventing residents from using it for meals. This issue was confirmed during a resident council meeting where eight residents expressed their dissatisfaction with the dining room being closed for an extended period. Residents reported missing the social interaction that dining together provided and expressed frustration over the dining room being inaccessible for about three months. Interviews with residents revealed their disappointment and the negative impact of not having a communal dining space. Residents expressed feelings of isolation and a desire for socialization that the dining room previously facilitated. The facility's director of nursing and regional director of clinical services acknowledged the issue and mentioned plans to remove the stored items from the dining room. However, throughout the four-day survey, the dining room remained inaccessible to residents, and no additional information was provided to resolve the deficiency.
Failure to Provide Trust Account Statements and Access
Penalty
Summary
The facility staff failed to provide residents with quarterly statements of their trust accounts and did not allow residents to readily access their trust funds, affecting all 140 residents with trust accounts. During interviews, multiple residents reported not receiving any statements regarding their trust accounts and expressed concerns about limited access to their funds, which was restricted to two hours on weekdays with no weekend access. Observations confirmed the restricted banking hours, and the front office assistant and business office manager acknowledged the changes, citing reasons such as managing funds better and staffing challenges. The facility's policy required quarterly statements to be issued to residents or their designated representatives, but there was no evidence that Resident #14 received such a statement. Additionally, the facility's policy on banking hours stipulated that residents should have access to their funds for a reasonable time on weekends, which was not being adhered to. The business office manager admitted that the facility did not consult with residents before changing the banking hours and did not provide a copy of the notification letter to the surveyor. The facility's failure to comply with its policies and federal regulations resulted in a deficiency noted by the surveyors.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for several residents, leading to deficiencies in care. For one resident, the care plan was not updated to include specific interventions to prevent an ex-boyfriend, who was a source of trauma, from entering the facility. Although staff were aware and had measures in place, such as posting the ex-boyfriend's picture at the reception desk, these interventions were not documented in the care plan. This oversight was acknowledged by the staff, including the LPN unit manager and the social worker, who confirmed that the care plan should have been updated to reflect these interventions. Another resident's care plan was not revised to reflect a fall and the use of bed rails. The resident, who was non-verbal and had multiple diagnoses including a persistent vegetative state, experienced a fall that was documented in nursing notes but not in the care plan. The care plan also failed to mention the use of bed rails, which had been consented to by the resident's father. The RN care plan coordinator acknowledged the need for updating the care plan to include interventions for falls and safety measures like bed rails. Additionally, a resident with mental health diagnoses had a care plan that inaccurately stated the completion of a Level II PASRR, which was halted due to the resident's primary diagnosis of dementia. The facility administration was unaware of this until the survey team requested the documentation, which was then obtained from the department of behavioral health. Furthermore, another resident's care plan did not include the intervention of heel protectors for skin integrity, despite a physician's order. Observations revealed the resident was not wearing the heel protectors, and the LPN was unaware of the order due to a lack of documentation in the treatment administration record.
Failure to Follow Physician Orders in LTC Facility
Penalty
Summary
The facility staff failed to follow physician orders for several residents, leading to deficiencies in care. For Resident #66, who had severe cognitive impairment and was on hospice care, the staff did not apply heel protectors as ordered. Observations showed the resident lying in bed without the protectors, which were found on the bedside dresser. The LPN was unaware of the order due to a lack of documentation requirement, resulting in the resident's heels showing signs of dry, peeling skin and a dark area on the right heel. Resident #159, who had intact cognition and a feeding tube, did not have the tube anchored as ordered. The resident confirmed the absence of an anchor, and the RN mistakenly believed the balloon holding the tube in place was the anchor. The RN later found the anchors but was previously unaware of their availability. This oversight was acknowledged by the facility's administration. For Resident #99, an incorrect dosage of acetaminophen was administered. The LPN gave two tablets of acetaminophen ER 650 mg instead of the ordered 325 mg tablets, citing nervousness and unfamiliarity with being observed as reasons for the error. Additionally, Resident #149 did not receive ted hose as ordered due to a supply issue, and Resident #92 did not have the correct lab test conducted, as a uric acid level was obtained instead of the required valproic acid level. These deficiencies were presented to the facility's administration without further information provided before the survey's conclusion.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility staff failed to provide trauma-informed care for several residents, as evidenced by the lack of identification of trauma triggers and the absence of specific interventions in the care plans. For instance, one resident with a history of physical abuse and domestic violence reported increased anxiety when staff were rude or raised their voices. Despite this, the care plan did not identify any triggers or interventions related to trauma-informed care. Similarly, another resident with a history of trauma from an alcoholic father and a traumatic divorce also had no triggers or trauma-informed interventions noted in their care plan. Another resident with a history of gun violence and substance abuse reported being bothered by loud noises and violence on television. However, their care plan only included general interventions such as having familiar staff and referring to psychiatric services, without addressing specific triggers or providing trauma-informed care strategies. Additionally, a resident with anxiety and major depressive disorder identified medical procedures and being held down as triggers, yet their care plan lacked any reference to these triggers or related interventions. Furthermore, a resident with a history of sexual assault and suicidal ideation had a care plan that did not address their trauma or identify triggers that could increase their fears or anxiety. The facility's policy on trauma-informed care emphasized the importance of identifying symptoms, triggers, and coping mechanisms, but this was not reflected in the care plans reviewed. Interviews with facility staff revealed a lack of awareness and understanding of the need to address trauma and post-traumatic stress disorder in care plans, contributing to the deficiency.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility staff failed to provide therapeutic diets as ordered by the physician for four residents in a survey sample of 33 residents. For three residents, the kitchen did not provide the appropriate diet consistency. One resident, who was supposed to receive chopped meats, was given a whole pork chop, which was not in the prescribed chopped consistency. Two other residents, who required pureed diets, received meals that were not of the correct pureed consistency. Additionally, one of these residents was supposed to receive double portions, which were not provided. The unit manager confirmed these discrepancies and noted previous communication with the kitchen regarding similar issues. Another resident, who had experienced weight loss, did not receive a nutritional supplement as ordered. During breakfast, the resident's meal tray was missing a health shake that was prescribed to prevent malnutrition and promote weight maintenance. The unit manager and kitchen staff were informed, and the shake was subsequently provided. The dietary manager was unable to explain why the shake was not initially included. The facility's policy on therapeutic diets states that diets should be offered as ordered by the physician or designee, but this was not adhered to in these instances.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility staff failed to store, prepare, and serve food in a sanitary manner in the main kitchen and on the West unit. During an inspection of the main kitchen, several issues were identified, including out-of-date and unsealed food items in the walk-in refrigerator and freezer. Specifically, a package of sliced turkey was past its use-by date, and another package lacked a manufacturer's label. Additionally, a carton of thickened cranberry cocktail was opened without a label indicating when it was opened, and a box of pasteurized eggs was stored beyond its use-by date. The walk-in freezer contained unsealed bags of frozen sausage patties and French fries. Stainless prep pans were stored nested and wet, and the bench-mounted can opener was dirty with accumulated debris. Flies were observed in the kitchen during meal preparation, and the air curtain over the exit door did not activate automatically, contributing to the presence of flies. On the West unit, an inspection of the nutrition/snack refrigerator revealed an opened carton of Med Pass supplement without a label indicating when it was opened. The LPN interviewed was unsure of how long the supplement had been opened, as it lacked a label. The facility's policies on food storage, ware washing, and equipment maintenance were not adhered to, as evidenced by the improper storage and labeling of food items, the cleanliness of kitchen equipment, and the non-functioning air curtain. These findings were reviewed with the facility's administrator, director of nursing, and regional nurse consultants, with no further information provided before the end of the survey.
Pest Control Deficiency Due to Non-Functional Air Curtain
Penalty
Summary
The facility staff failed to maintain effective pest control, as evidenced by the presence of flies in the [NAME] unit dining/day room and the main kitchen during food preparation. During an observation on 9/9/24, flies were seen near the handwashing sink and convection ovens in the kitchen while lunch was being prepared. The air curtain positioned over the exit door, which was intended to prevent flying insects from entering, did not activate automatically when the door was opened. The dietary manager confirmed that the air curtain had to be manually turned on at the breaker box and was not routinely used during meal preparation. Additionally, multiple flies were observed in the [NAME] unit day room while residents were eating lunch, with flies landing on a resident seated in a wheelchair. The assistant maintenance director, when interviewed, stated that a pest control vendor treated the facility monthly but was unaware of the fly issue in the day room. The pest control report from 8/28/24 documented treatment for ants and fruit flies but did not mention the non-functional air curtain or targeted treatment for flies in the kitchen or dining room. This deficiency was discussed with the facility's administration and nursing staff, but no further information was provided before the survey concluded.
Failure to Maintain Resident Dignity During Meal Distribution
Penalty
Summary
The facility staff failed to distribute meal trays in a manner that upheld the residents' dignity, affecting several residents on one of the three units. During a lunch meal observation, a resident was served her meal and began eating while another resident at the same table was left without food. Additionally, a meal tray was placed between two residents for another resident who was not present. This led to confusion and improper meal distribution, as one resident removed coffee from the unattended tray, and another resident removed the lid from the plate of food. The situation was further complicated when a CNA was the only staff member remaining in the dining room, assisting another resident, and was unaware of the missing meal tray for one of the residents. An LPN was asked to verify the consistency of pureed foods and subsequently removed a resident's tray to correct the consistency, leaving the resident without food. The meal tray for the resident was eventually found on the meal cart and served after a significant delay. The resident whose tray was initially placed between the two other residents arrived later to find his meal had been tampered with. These events were reviewed with the facility administrator, director of nursing, and corporate staff.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility staff failed to uphold the dignity of a resident, identified as R99, by not ensuring he had adequate and season-appropriate clothing. R99, who has been residing at the facility for five years, expressed dissatisfaction with the clothing provided to him, which were ill-fitting and not suitable for the season. He reported having to wear the same clothes for several days due to limited options, which made him feel neglected. Observations confirmed that R99 had a limited wardrobe consisting of winter clothes, and the available pants did not fit him properly. Despite having a resident trust account with substantial funds, these were not utilized to purchase appropriate clothing for him. Interviews with the social services assistant (SSA) revealed a lack of awareness regarding R99's clothing situation. The SSA mentioned a process for assisting residents in obtaining clothes, including checking for personal funds and unclaimed clothing, and expressed willingness to help purchase clothes if necessary. However, the SSA was unaware of R99's needs until informed by the surveyor. Despite discussions with facility administration and corporate staff, no immediate action was taken to address R99's clothing needs, as he was observed wearing the same clothes over several days without any intervention from the facility staff.
Failure to Issue Advanced Beneficiary Notice
Penalty
Summary
The facility staff failed to issue an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident #107, who remained in the facility after skilled services ended. This oversight was discovered during a survey sample review of three residents for beneficiary notices. The resident transitioned from a Medicare Part A reimbursed stay to self-pay without being provided the necessary ABN, which would have allowed the resident to make an informed decision about continuing skilled services and assuming financial responsibility. The facility's documentation and staff interviews revealed that the resident was initially expected to discharge shortly after skilled services ended. However, the resident remained in the facility for several months beyond the anticipated discharge date. Despite progress notes indicating ongoing discussions about discharge plans and the resident's uncertain intentions regarding staying or leaving, the facility did not issue an ABN. The Corporate Social Worker and Discharge Planner acknowledged the oversight, attributing it to the resident's history of indecision and the assumption that he would eventually discharge. The facility's policy on issuing ABNs, as well as CMS guidelines, emphasize the importance of providing these notices to residents transitioning from Medicare-covered skilled services to non-covered services. The failure to issue an ABN to Resident #107 was a significant lapse in protocol, as it deprived the resident of the opportunity to make an informed choice about their care and financial obligations. The facility's staff, including the director of social work and discharge planning, recognized the importance of ABNs in ensuring residents' rights to choose their care options, yet this understanding was not applied in this case.
Deficiencies in Resident Environment and Equipment Maintenance
Penalty
Summary
The facility staff failed to provide a homelike environment for Resident #99, as the resident's closet was missing a door. This issue was observed during a visit to the resident's room, where it was confirmed that the closet had been without a door since the resident moved into the room. Interviews with staff, including a certified nursing assistant and other employees, revealed that the missing door had been noted during daily rounds for approximately two months, but no action had been taken to resolve the issue. The unit manager acknowledged the absence of the door, citing plans to install new ones, while the regional director of clinical services expressed that the situation was unacceptable. Resident #55's wheelchair was found to be dirty and in disrepair, with torn arm cushions and debris on the support bars and wheels. The resident, who has multiple diagnoses including cerebral infarction and dementia, was observed in this condition in the day room. Interviews with staff, including a licensed practical nurse and the housekeeping supervisor, indicated that routine cleaning of resident equipment was the responsibility of third shift aides and nurses, but the wheelchair had not been maintained. The housekeeping supervisor acknowledged the need for cleaning and repair but was uncertain about who could address the arm cushion issue. These findings were discussed with the facility's administration and nursing staff, but no further information was provided before the end of the survey.
Failure to Report Resident Altercation
Penalty
Summary
The facility staff failed to report an incident of abuse involving two residents to the state survey agency and other required officials. The incident occurred when one resident physically assaulted another, resulting in a black eye and other injuries. Despite the altercation being documented in the facility's records, there was no evidence that the incident or the investigation results were reported to the necessary authorities, including adult protective services and law enforcement. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed. The altercation was described in detail by both the involved residents and staff witnesses. The incident began with a verbal disagreement over a loud television, escalating to physical violence where one resident punched the other multiple times. Staff intervened to separate the residents, and medical attention was provided for the injuries sustained. However, the facility's failure to report the incident as required by their abuse policy constitutes a significant deficiency in their compliance with regulatory obligations.
Failure to Address Hand Contractures in Resident Care Plan
Penalty
Summary
The facility staff failed to develop a comprehensive resident-centered care plan for a resident with bilateral hand contractures. Observations conducted over two days revealed that the resident was non-verbal and had bilateral hand contractures, yet was not provided with splints or palm protectors. Interviews with the therapy director and unit manager indicated that the resident had previously been on occupational therapy caseload, and palm guards were recommended to prevent pressure and moisture in the hands. However, during the survey, no splint devices were found in the resident's room, and the care plan did not address the resident's hand contractures or the use of palm guards. Further interviews with care plan coordinators confirmed that the care plan should reflect the resident's individualized care needs, including the presence of contractures. The clinical record review corroborated that the care plan was not comprehensive, as it failed to address the resident's bilateral hand contractures. During an end-of-day meeting with the facility administrator, director of nursing, and corporate staff, it was acknowledged that the care plan was incomplete and did not meet the resident's needs.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for three residents, leading to deficiencies in care. For Resident #268, the staff did not date or initial the dressing on a pressure ulcer, despite facility policy requiring this practice. The resident, who was cognitively intact, reported that dressing changes were not performed daily as ordered. The dressing was observed to be clean and intact, but the lack of dating and initialing was confirmed by a licensed practical nurse (LPN), who acknowledged the oversight. Resident #134 was observed wearing Tubi grips on both lower extremities without a physician's order, which is against the facility's policy requiring verification of physician's orders. This was confirmed by both an LPN and the regional director of clinical services. Additionally, Resident #49, who was receiving nutrition through a gastronomy tube, was found lying flat in bed during tube feeding, contrary to the physician's order to keep the head of the bed elevated to prevent aspiration. This oversight was confirmed by an LPN, and the facility's policy on enteral feeding did not address the necessary positioning during feeding.
Failure to Provide Scheduled and Personalized Activities
Penalty
Summary
The facility staff failed to provide activities that met the psychosocial well-being and preferences of several residents, including Resident #92 and Resident #121. Resident #92 was observed multiple times sitting alone in a dark room without any personal possessions or entertainment options, such as a television or radio. The resident had a history of removing televisions from the wall, but there were no progress notes documenting these incidents. Despite having a care plan that required one-on-one activities, the resident's activity attendance was primarily limited to receiving snacks or beverages, indicating a lack of engagement in meaningful activities. Resident #121 reported that she used to attend activities but was no longer invited or assisted by staff, leading her to stay in her room with a doll she referred to as a baby. Her activity preferences, as recorded in assessments, included listening to music, going outside, and participating in religious services. However, her care plan focused on one-on-one activities, which were not consistently provided. The activity staff acknowledged that Resident #121 did not attend group activities and that they relied on nursing staff to assist residents in getting to activities. The facility's activity programming was inconsistent with the posted schedule, as observed during the survey. Activities listed on the calendar, such as courtyard social and music bingo, were not conducted as scheduled, and no changes were made to inform residents of any alterations. The activity director admitted that activities were sometimes changed based on the preferences of residents in the dayroom without notifying others. This lack of communication and adherence to the activity schedule resulted in residents, like Resident #149, expressing dissatisfaction with the activities offered and the lack of interaction and socialization opportunities.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility staff failed to implement timely interventions for the care and treatment of a pressure ulcer for one resident. The resident, who was cognitively intact, had a stage three sacral pressure ulcer identified, but no treatment orders were implemented until seven days after the ulcer was first noted. The resident's diagnoses included pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of the rectum, and anemia. Weekly skin assessments were inconsistent, with some assessments documenting the presence of the ulcer and others not, despite the wound showing signs of improvement. A wound assessment report from a wound clinic documented the presence of the stage three pressure ulcer and provided treatment orders. However, the facility's physician orders for treatment were not documented until a day after the wound clinic's report, and treatments were not started until the following day. The director of nursing and a nurse consultant confirmed the lack of treatment orders prior to this date. The deficiency was presented to the facility's administration, but no additional information was provided before the exit conference.
Deficient Foot Care for Residents
Penalty
Summary
The facility staff failed to provide adequate foot care for two residents, leading to deficiencies in maintaining good foot health. For one resident, the surveyor observed toenails extending approximately 3/4 of an inch past the toes, indicating a lack of nail care. The LPN confirmed the need for toenail care, and the unit manager mentioned that nail checks are typically done every two weeks. However, the resident was not on the podiatry list for any month in 2024, and the assistant director of nursing noted that the podiatrist would sometimes mark residents as 'refused' when he was unable to see them, suggesting a gap in care coordination. Another resident was found to have extremely long toenails curling under the toes and dry, crusty skin on the soles of the feet. The regional director of clinical services confirmed the need for nail care and noted that the facility had been relying solely on the podiatrist for toenail care. This resident was also not on the podiatry list for 2024, and the facility's podiatry contract did not specify the frequency of visits or the number of residents to be seen, indicating a lack of structured foot care management.
Failure to Implement Contracture Management Interventions
Penalty
Summary
The facility staff failed to implement necessary interventions for a resident with bilateral hand contractures, leading to a deficiency in care. The resident, who was non-verbal, was observed multiple times without the required splints or palm protectors, which are essential to prevent the worsening of contractures. Despite previous occupational therapy recommendations for the use of palm guards and a splint schedule, these devices were not in use during the observations. The therapy director confirmed that the resident had been on therapy caseload previously and had tolerated palm guards well, but no such devices were found in the resident's room during the survey. Interviews with facility staff, including a therapy director, LPN, and unit manager, revealed a lack of awareness and implementation of the necessary interventions for the resident's condition. The unit manager mentioned that the family sometimes takes the palm guards home for cleaning, but no palm guards were present during the survey. Additionally, a review of the resident's care plan showed no mention of hand contractures or the use of palm guards, indicating a gap in the care planning process. The facility's policy on contracture management was not effectively followed, as evidenced by the absence of splints and palm guards for the resident.
Lack of Emergency Suction Equipment for Resident with Tracheostomy
Penalty
Summary
The facility staff failed to ensure that emergency suction equipment was available at the bedside for a resident with a tracheostomy, identified as Resident #159. During an observation, it was noted that there was no suctioning device present in the resident's room, which is necessary for the care of a tracheostomy. Resident #159, who has a cognitive score indicating intact cognition, confirmed the absence of the suctioning device and acknowledged the need for the tracheostomy to breathe. A registered nurse also confirmed the lack of suctioning equipment and stated that she would set it up. The facility's policy requires that emergency sterile tracheostomy equipment be available at the bedside, but this was not adhered to in this instance.
Failure to Provide Dialysis and Ensure Communication
Penalty
Summary
The facility failed to provide physician-ordered dialysis services and failed to communicate care provided during dialysis treatment for a resident with end-stage renal disease (ESRD) and other medical conditions. The resident missed two scheduled hemodialysis treatments due to transportation issues related to a COVID-19 diagnosis. Despite the dialysis center confirming the resident could attend dialysis, the transport company refused to take the resident due to COVID-19, and no alternative transportation arrangements were made. Consequently, the resident was sent to the hospital for evaluation and dialysis treatment. The facility also failed to ensure proper communication between the dialysis center and the nursing facility regarding the resident's status and care during dialysis sessions. On two occasions, the dialysis communication forms lacked essential information, including pre- and post-dialysis vital signs, medications administered, and occurrences during dialysis. Notably, the administration of Benadryl during a dialysis session was not communicated to the facility, and the nursing staff did not follow up with the dialysis center to obtain the missing information. Interviews with facility staff, including the LPN, NP, transportation scheduler, and DON, revealed a lack of awareness and coordination in arranging transportation for COVID-19 positive residents and ensuring complete communication with the dialysis center. The facility's policy required the use of dialysis communication forms to document and share information, but this was not consistently followed, leading to incomplete documentation and communication gaps.
Failure to Assess Alternatives and Risks Before Bed Rail Use
Penalty
Summary
The facility staff failed to attempt alternatives before implementing the use of bed rails for a resident in a persistent vegetative state, identified as Resident #49 (R49). The staff applied bed rails without assessing the risk of entrapment, which is a necessary step before their use. The resident had a history of a fall, and the facility did not explore other options or conduct a thorough risk assessment before deciding on bed rails. The resident's care plan did not indicate that the resident could assist with daily activities, and the bed rails were not used as an enabler, contrary to what was documented. The clinical record review revealed that R49 had multiple diagnoses, including persistent vegetative state and cerebral palsy, and was non-verbal and unable to respond to stimuli. Despite this, the facility's documentation inaccurately indicated that the resident could use the bed rails as an enabler. Interviews with staff, including a certified nursing assistant and the regional director of clinical services, confirmed that R49 was entirely dependent on staff for care and could not use the bed rails independently. The facility's maintenance director also failed to provide documentation of the installation of the bed rails or the manufacturer's user manual, which are necessary for ensuring proper installation and safety. The facility's policy required maintenance and nursing to collaborate on bed system audits to ensure compatibility and safety, but this was not adequately followed. The facility was unable to provide evidence of a maintenance work order or the manufacturer's specifications for the bed rails, indicating a lack of proper documentation and adherence to safety protocols. These oversights contributed to the deficiency identified during the survey, as the facility did not ensure the safe and appropriate use of bed rails for R49.
Medication Unavailability Leads to Missed Doses
Penalty
Summary
The facility staff failed to ensure the availability of a prescribed medication for a resident, leading to missed doses. The resident, who was cognitively intact, reported missing doses of her anti-anxiety medication, Xanax, which was prescribed to be administered twice daily. The medication was not available for administration on two occasions, as documented in the resident's medication administration record. Nursing notes indicated that the medication was not available from the back-up supply, and the pharmacy was notified but did not provide the medication or a code for emergency access. Interviews with facility staff, including an LPN and the unit manager, revealed that the prescription had been faxed to the pharmacy twice in the week prior to the missed doses. Despite these efforts, the medication was not restocked, and the pharmacy required a new prescription before providing a code for emergency access. The director of nursing was unaware of the reason for the pharmacy's delay. The facility's policy on medication unavailability required nurses to notify the provider and discuss alternatives, but this process did not result in timely access to the medication for the resident.
Failure to Label Insulin Pen with Opening Date
Penalty
Summary
The facility staff failed to label an insulin pen with the date it was opened, as observed on the West unit. During an inspection of medications stored in cart #2, an opened Fiasp (insulin aspart) FlexTouch insulin pen was found without a date indicating when it was opened. A Licensed Practical Nurse (LPN) confirmed that all insulin pens should be dated upon opening. The facility's policy requires that a 'date opened' sticker be placed on medications with a specified usable duration after opening, and the expiration date should be recorded as 30 days from opening unless otherwise specified by the manufacturer. The manufacturer's prescribing information for Fiasp indicates that the pen should be discarded 28 days after opening, whether stored at room temperature or refrigerated. This deficiency was discussed with the facility's administrator, director of nursing, and regional nurse consultants, but no further information was provided before the survey concluded.
Failure to Provide Meals According to Menu
Penalty
Summary
The facility staff failed to provide food in accordance with the menu for a resident, identified as R39, who was part of the survey sample. R39, who was admitted to the facility with a diagnosis of unspecified protein-calorie malnutrition and moderate cognitive impairment, did not receive the complete meal as specified on her meal ticket during a lunch observation. The meal ticket listed items such as mechanical advanced/chopped baked pork chop, mushroom gravy, black-eyed peas, and a magic cup, but the resident's tray only contained squash and a roll. This discrepancy was confirmed through observation and interviews with the resident and staff. Interviews with a certified nursing assistant and the dietary manager revealed that missing items from meal trays were a common occurrence. The CNA mentioned that dietary replacements were not always available, and the dietary manager acknowledged that some items, like the pork chop, might not have appeared as expected on the tray. Despite these acknowledgments, the dietary manager could not explain why the other items were missing. The issue was discussed in a meeting with the facility's regional director of clinical services, administrator, vice president of operations, and director of nursing, but no new information was provided to address the deficiency.
Failure to Provide Resident's Food Preferences
Penalty
Summary
The facility staff failed to accommodate the food preferences of a resident, identified as R69, who was not provided with side salads as requested. R69, who has diagnoses of diabetes and obesity and is cognitively intact with a score of 15, expressed concerns about the lack of side salads during an interview. The resident mentioned a preference for fresh fruits and vegetables, particularly due to their diabetic condition. The dietary manager explained that a recent change to a different seasonal menu by the corporate office resulted in the discontinuation of purchasing salad ingredients, although the kitchen had fresh produce available for meal ingredients. The vice president of operations acknowledged that the resident should be allowed to have a side salad, but no further information was provided before the exit conference.
Deficiencies in Clinical Record-Keeping and Care Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurate clinical records for three residents, leading to deficiencies in care documentation. For one resident with a sacral wound, the daily skilled progress notes and skin assessments were inconsistent, with some entries failing to document the presence of a stage three pressure ulcer. Despite a wound assessment report confirming the ulcer upon admission, the facility's records did not consistently reflect this condition, indicating a lack of proper documentation and communication among staff. Another resident's clinical record was incomplete regarding a Level II pre-admission screening for mental health. Although the resident's care plan noted the presence of a Level II PASRR, the actual documentation was missing from the chart. It was later revealed that the screening had been halted due to the resident's primary diagnosis of dementia, but this information was not initially included in the resident's records, highlighting a gap in record-keeping and communication with external agencies. Additionally, the facility staff failed to apply and document the use of ted hose for a resident as prescribed. Observations showed the resident without ted hose on multiple occasions, despite the treatment administration record indicating that the order was completed daily. This discrepancy between observed care and documented care suggests a failure in adhering to prescribed treatment protocols and accurate record-keeping.
Failure to Obtain Negative Urinalysis Before Discontinuing Isolation
Penalty
Summary
The facility staff failed to adhere to the infection prevention and control protocol for a resident diagnosed with an ESBL (Extended-spectrum beta-lactamases) urinary tract infection. The deficiency was identified when the staff did not obtain a negative urinalysis after the completion of antibiotic therapy before discontinuing contact isolation precautions for the resident. During a facility tour, it was observed that the resident had an enhanced barrier isolation sign on the room door, which was later clarified to be for a previous resident. Interviews with the LPN and the infection preventionist revealed that the protocol requires a negative urine culture before removing isolation precautions, which was not followed in this case. A review of the resident's clinical records and care plan indicated that the resident was receiving cephalexin for the ESBL infection, with the care plan noting the need for isolation due to the infection. However, no follow-up urine culture results were found in the resident's clinical records, as confirmed by the regional director of clinical services. The facility's policy on ESBL infections mandates contact precautions and a negative culture before discontinuing transmission-based precautions, which was not adhered to, leading to the deficiency.
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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