Lynn Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Front Royal, Virginia.
- Location
- 1000 Shenandoah Avenue, Front Royal, Virginia 22630
- CMS Provider Number
- 495316
- Inspections on file
- 18
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Lynn Care Center during CMS and state inspections, most recent first.
Multiple residents experienced repeated physical abuse from other residents, primarily on a memory care unit, including being struck in the face, head, shoulder, arm, and mouth, having hair pulled, and being knocked to the floor. These altercations typically occurred in common areas while residents were wandering or seated, often when one resident became agitated about personal space or perceived a need to protect staff. Many involved residents had cognitive impairment and could not recall the events, though staff and other residents sometimes witnessed the incidents and documented assessments showing either no injury or minor findings such as bruising or redness. Despite these documented episodes and staff acknowledgment that such conduct constitutes abuse under the facility’s abuse policy, the comprehensive care plans for the abused residents did not include information about the incidents or individualized approaches to address the abuse or prevent recurrence, resulting in an immediate jeopardy determination.
Facility staff failed to provide adequate supervision to two high-risk residents, one with severe dementia and a long history of unpredictable physical aggression who repeatedly assaulted other cognitively impaired residents on the memory care unit, causing facial and eye injuries, and another with severe cognitive impairment, poor standing balance, and documented need for substantial to maximal assistance who was left alone on the toilet by a CNA and subsequently found on the bathroom floor with a hip fracture and intracranial hemorrhage, despite a care plan directing staff not to leave the resident alone in the room.
The facility failed to revise comprehensive care plans for four residents who were repeatedly abused by the same resident on a memory care unit. Facility documentation and nursing notes described multiple episodes in which one resident, who became agitated when others entered her personal space or touched staff, struck other residents in the face or mouth with her hand or objects, sometimes leaving visible marks or bruising. Although psychosocial support visits were documented and the residents often had no recall of the events, their existing care plans contained no information about these abuse incidents. Interviews with the social services director, an RN, and a unit manager LPN confirmed that care plans should be updated for any victim of abuse, and facility policy required review and updating of care plans when needs or preferences change, but this was not done for the affected residents.
Two residents did not receive multiple prescribed medications at scheduled times due to unavailability following their admissions. Staff documented that medications were on order or not available in the facility's Omnicell system, and the process for obtaining medications from an out-of-state pharmacy led to delays. Required notifications and documentation were inconsistently completed, resulting in missed doses for both residents.
Facility staff did not notify physicians or responsible parties when multiple residents missed scheduled medication doses due to unavailability, despite documentation in the MAR and progress notes indicating the medications were on order or not available. Nursing staff interviews confirmed the expectation to communicate and document such events, but records showed this was not done.
Staff failed to administer prescribed medications and supplements to two residents as ordered, documenting them as unavailable or on order from the pharmacy, even though interviews and observations confirmed that Banatrol and Ferrous Sulfate were stocked and accessible in the facility.
The facility failed to update the care plans for two residents after they were moved to a secured dementia unit. The care plans, which were outdated, did not reflect the residents' current living situations or needs. Interviews with facility staff confirmed that the care plans should have been updated, as required by the facility's policy.
A resident's physician order for compression wraps was not clarified, leading to improper application. The order lacked specificity on the type of wrap, causing confusion among LPNs, who used different wraps, some of which were not compression wraps. The facility's policy requires clarification of such orders, but this was not done.
Three residents with cognitive impairments eloped from a facility due to inadequate supervision and unsecured exits. One resident fell outside, another was found in a garden area, and a third reached a private residence. The facility's failure to secure doors and properly assess elopement risks contributed to these incidents.
Failure to Prevent and Care Plan Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, primarily on the memory care unit, over an extended period. Resident-on-resident altercations repeatedly occurred in which one resident struck, hit, pulled hair, or otherwise physically contacted another resident, often involving the same aggressor. For example, one resident repeatedly struck other residents in the face, head, shoulder, arm, and mouth, and pulled another resident’s hair while they were seated in the dining room. In many of these events, staff documented that the aggressor resident became agitated or combative, particularly when other residents were in her personal space, when she perceived staff as needing protection, or immediately after receiving care. The clinical records and final event synopses show that affected residents were typically seated in common areas such as the dining room or wandering on the memory care unit when they were struck or otherwise physically abused. In several cases, staff or other residents witnessed the incidents and separated the residents, and progress notes documented assessments showing either no visible injury or minor findings such as a small red spot on the nose, bruising to the upper lip, or a fall to the floor after being hit on the shoulder. Many of the residents involved had cognitive impairment and were unable to recall the incidents when interviewed afterward, though one resident later described being “whacked” across the face. Staff interviews acknowledged that residents on the memory care unit wander, can become easily agitated, and are especially vulnerable due to cognitive status and limited ability to communicate symptoms. Across all cited residents, the comprehensive care plans in place at the time of the incidents did not contain information related to these episodes of resident-to-resident abuse. Care plans for residents who were struck, hit, or had their hair pulled lacked any documentation of the abuse incidents or individualized approaches addressing these behaviors or the residents’ vulnerability to further altercations. This absence of care plan interventions was noted for multiple residents who experienced one or more abusive encounters, including those who were struck on more than one occasion by the same aggressor. Facility staff, including nursing and social services personnel, stated in interviews that any willful striking, hitting, smacking, or hair-pulling by one resident toward another constitutes physical abuse and that residents have the right to be free from abuse, consistent with the facility’s written abuse policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. In addition to the repeated incidents involving a primary aggressor on the memory care unit, other residents were abused by different residents who became combative when their personal space was invaded. In these cases, staff witnessed residents being hit on the arm or chest and a resident being struck on the shoulder, causing a loss of balance and a fall. Progress notes documented that affected residents were assessed and often had no recall of the negative encounters. Despite these documented events and staff recognition that such conduct constitutes abuse, the corresponding care plans for the abused residents did not reflect the incidents or any related information. The pattern of resident-to-resident physical abuse, combined with the lack of care plan documentation addressing these events, formed the basis of the cited deficiency and led to a determination of immediate jeopardy for residents on the memory care unit.
Removal Plan
- Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
- Provide follow up psychosocial support from social services to Residents #58, #94, #25, #13, #41, and #68.
- Screen all residents for evidence of abuse and neglect.
- Complete an abuse questionnaire for residents who are interviewable (BIMS score of 8 or greater).
- Complete a head to toe physical assessment for non-verbal residents or residents with a BIMS score of 7 or below.
- Address any identified concerns according to the HVHC Abuse and Neglect Policy.
- Conduct an audit of all incident reports for the last 30 days to ensure that all events meeting the reporting requirements were reported to the appropriate parties.
- Reeducate all staff of the facility/agency on the HVHC Abuse and Neglect Policy, including abuse prevention, types of abuse, abuse reporting, and the Elder Justice Act specifically pertaining to resident to resident altercations.
- Require any staff not present for the education to receive mandatory education prior to the start of their next shift.
- Prohibit staff from returning to work until the mandatory education has been completed.
- Include this training in new hire orientation as part of the new hire process.
- Require all agency staff to complete this education prior to starting work in the facility.
- Provide reeducation to facility leadership (NHA, DON, social services, activities) on abuse reporting and investigating allegations of abuse and resident altercations.
Failure to Adequately Supervise Aggressive and High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and care to prevent accidents for residents with known behavioral and fall risks. One resident with non-Alzheimer’s dementia, depression, severe cognitive impairment, and a long history of physical aggression toward others repeatedly assaulted other cognitively impaired residents on the memory care unit. Despite documented episodes of hitting, grabbing, throwing objects, wandering into other residents’ rooms, and striking residents with fists and objects, the resident continued to wander and interact with others on the unit without consistently implemented, sustained close supervision. Facility documentation showed multiple resident-to-resident altercations over many months, including incidents where the resident struck others in the face and head, sometimes causing visible injuries such as redness to an eye and bruising on the bridge of the nose. Clinical records, change-in-condition notes, and psychiatry progress notes described this resident as having recurrent, sometimes unprovoked, violent outbursts triggered by perceived threats to possessions, food, or personal space, and as being unpredictable and increasingly aggressive toward both staff and residents. Staff statements indicated that the resident could ambulate independently but required someone to walk with them due to fall risk, and that the resident had a history of hitting other residents. However, supervision practices on the memory care unit were described as having staff stationed in the common area and CNAs rounding on rooms every couple of hours, rather than continuous or 1:1 supervision for this resident despite the pattern of aggression. Nursing staff acknowledged that repeated resident-to-resident assaults constituted abuse and that repeated incidents indicated residents were not being adequately supervised. A second deficiency involved another resident with dementia, severe cognitive impairment, poor standing balance, and high fall risk who sustained a fall with serious injury. This resident’s MDS, therapy evaluations, and fall risk assessments documented substantial to maximal assistance needs for sit-to-stand and transfers, poor standing balance, impulsivity when standing, and a fall risk score above the facility’s threshold for being at risk. The resident’s care plan included an intervention instructing staff not to leave the resident alone in the room. On the night of the incident, a CNA assisted the resident onto the toilet in the resident’s bathroom, then left the resident alone on the toilet with the bathroom door closed while physically redirecting the roommate to another bathroom. When the CNA returned after this brief absence, the resident was found on the bathroom floor complaining of right hip and elbow pain, with contusions noted to the right elbow and side of the head. Hospital evaluation confirmed a right hip fracture and intracranial hemorrhage. This sequence of events demonstrates that the resident was left unsupervised during a high-risk toileting transfer despite known fall risk and documented need for close assistance, resulting in a fall and serious injury.
Removal Plan
- Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
- Conduct an audit of Point of Care behavior documentation to ensure that residents identified with aggressive behaviors have interventions and care plans in place to provide adequate supervision.
- Reeducate all staff of the facility/agency on the HVHC Safety and Supervision of Residents Policy.
- Require all staff to complete mandatory education prior to the start of their next shift.
- Do not allow any staff member to return to work until the mandatory education has been completed.
- Include this training in new hire orientation as part of the new hire process.
- Require all agency staff to complete this education prior to starting work in the facility.
Failure to Revise Care Plans After Repeated Resident-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans for multiple residents after substantiated resident-to-resident abuse incidents involving the same aggressor. Facility records, including final synopses of events and progress notes, documented that one resident repeatedly struck or otherwise physically contacted other residents on the memory care unit, typically when others entered her personal space or touched staff she was interacting with. Despite these documented abuse events and follow-up psychosocial support visits, the comprehensive care plans for the abused residents did not contain any information related to the incidents or any updated approaches following the altercations. For one resident, an event synopsis dated in February described that she was struck on the right side of her face by another resident who became combative on the memory care unit. Staff who frequently cared for both residents reported that both wandered throughout the unit and that the aggressor could become agitated and combative when residents were in her personal space. A progress note documented a support visit related to the altercation, during which the abused resident was unable to recall the event but stated she felt safe and happy. However, review of her comprehensive care plan, dated the prior month, showed no information related to this abuse incident. Another resident experienced multiple separate incidents with the same aggressor in April. Facility synopses and nursing notes documented that the aggressor allegedly struck this resident in the face and nose after the resident got into the aggressor’s personal space and food, and on another occasion punched her in the upper lip after the resident grabbed a CNA’s arm. Notes described small red marks and later separation of the residents, but the comprehensive care plan, dated in February, contained no entries related to these abuse incidents. Similarly, a third resident was documented as being hit on the right side of her face by the same aggressor after the aggressor became combative in the bathroom area; progress notes described assessment and a follow-up visit related to a negative encounter with another resident, but her care plan, dated in March, lacked any abuse-related information. A fourth resident had at least two documented abuse incidents with the same aggressor. In June, progress notes recorded that she was sitting in her wheelchair when the aggressor approached and hit her in the face with a comb; assessment at that time showed no injuries, and a support visit later that day documented that she had no recall of the encounter and stated she felt safe. In November, another incident was documented in which the aggressor hit her in the face with a padded box after she gently touched the aggressor’s arm; subsequent notes recorded bruising to the upper lip and a follow-up visit where the resident did not recall the negative encounter or provide information about her comfort level among others. Review of her comprehensive care plan, dated the previous December, revealed no information related to any of these abuse incidents. Interviews with facility staff confirmed that the care plans for these abused residents were not updated after the incidents. The director of social services stated she is responsible for following up on psychosocial needs after resident-to-resident altercations and that the abused resident’s care plan should be updated after any such event. A registered nurse explained that the care plan is used to ensure all care team members provide appropriate care and that it should be updated for any victim of abuse, noting that unit managers ordinarily update care plans. A unit manager LPN stated that care plans should be updated after an incident of abuse because such an event could trigger a trauma response, and that floor nurses do not typically update care plans. The facility’s own policy on comprehensive person-centered care planning stated that the interdisciplinary team is responsible for reviewing and updating care plans when there has been a significant change in condition or when goals, needs, and preferences change, yet the care plans for the four residents remained unrevised regarding the documented abuse events.
Failure to Ensure Timely Availability of Medications for New Admissions
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident, multiple medications including Pantoprazole, Amantadine, Diltiazem, Docusate, Levetiracetam, Oxybutynin, Vimpat, Tizanidine, and Propranolol were not available for scheduled administration times following admission. Documentation in the medication administration record (MAR) and nurse's notes indicated that these medications were on order, not available in the facility's Omnicell system, or awaiting delivery from the pharmacy. The resident was admitted in the afternoon, and the medications were expected to arrive during the night, but several doses were missed as a result of the delay. For another resident, staff did not ensure the availability of Sennoside, Budesonide, Humulin 70/30, and Glycopyrrolate for scheduled administration. The MAR and progress notes documented that these medications were on order and not available at the time they were due. The resident arrived at the facility in the evening, and several doses of the prescribed medications were not administered over multiple days due to unavailability. Interviews with an LPN revealed that the process for obtaining medications for new admissions involved entering orders into the computer system, which then sent them to an out-of-state pharmacy. If medications were not available at the time of administration, staff were expected to check the Omnicell, contact the pharmacy, and, if necessary, reach out to the provider for alternative orders or to hold the medication. The facility's policy required staff to notify the attending physician and document all actions taken. Despite these procedures, the medications were not available for timely administration, and the required notifications and documentation were inconsistently completed.
Failure to Notify Physician and Responsible Party of Missed Medication Administration
Penalty
Summary
Facility staff failed to notify physicians and responsible parties when prescribed medications were not available and subsequently not administered to multiple residents. For one resident with a G-tube and complex medical needs, including gastrostomy status, seizures, hypertension, constipation, and bladder spasms, several medications were missed over multiple days. Documentation in the medication administration record (MAR) indicated the medications were not given and referenced progress notes, which showed the medications were on order or unavailable. However, there was no documentation that the physician or responsible party was informed of these missed doses, despite facility policy requiring such notification. Another resident, who required medications for diarrhea and anemia, also experienced missed doses due to unavailability. The MAR and nurse's notes documented that the medications were not available and had been ordered from the pharmacy, but again, there was no evidence that the physician or responsible party was notified of the missed administrations. In one instance, a nurse practitioner was notified, but there was no documentation of communication with the responsible party. A third resident, with orders for medications related to bowel regimen, respiratory failure, diabetes, and secretions, also did not receive several scheduled doses due to medication unavailability. The MAR and nurse/respiratory therapist notes indicated the medications were on order or not available, but there was no documentation of notification to the physician or responsible party. Interviews with nursing staff confirmed the expectation to notify both the provider and responsible party and to document these actions, but this was not reflected in the records reviewed.
Failure to Administer Medications as Ordered Despite Availability
Penalty
Summary
Facility staff failed to administer medications and supplements as ordered by physicians for two residents. For one resident, Banatrol and Ferrous Sulfate were not given according to the prescribed schedule. The medication administration records (MAR) showed missed doses, with documentation codes indicating the medications were not available or other issues, and nurse's notes confirmed that the medications were reported as unavailable and on order from the pharmacy. However, interviews with staff revealed that both Banatrol and Ferrous Sulfate were actually available as floor stock or in storage areas, and observations confirmed the presence of these medications in the facility. For another resident, Banatrol was not administered as ordered. The MAR indicated missed doses, with codes for 'Other/See Progress Notes' and 'Hold See Progress Note.' Nurse's notes again cited the medication as being on order from the pharmacy. Staff interviews and observations confirmed that Banatrol was stocked in multiple locations within the facility and had not run out. The facility's policy requires that every effort be made to ensure medications are available to meet residents' needs. Despite this, the staff did not administer the medications as ordered, even though the medications were present in the facility. The deficiency was brought to the attention of the administrator, DON, and regional nurse consultant.
Failure to Update Care Plans for Residents in Secured Dementia Unit
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #2, the care plan was not updated when the resident was moved to a secured dementia unit. The existing care plan, dated nearly two years prior, identified the resident as an elopement risk and included interventions such as frequent rounding and the use of a wander guard. However, the care plan did not reflect the resident's new living situation in the secured unit, which was confirmed as an expectation by both the Director of Nursing and the unit manager during interviews. Similarly, for Resident #3, the care plan was outdated and did not address the resident's placement in a secured dementia unit. The care plan, last revised several months prior, noted the resident's history of wandering and resistance to care, as well as a risk for falls. Despite an incident where the resident was found outside in a vulnerable position, the care plan lacked updates to reflect the resident's current needs and environment. Interviews with facility staff confirmed that the care plan should have been updated to include the resident's placement in the secured unit. The facility's policy on care planning requires updates to care plans when there are significant changes in a resident's condition or environment, among other criteria. The failure to update the care plans for these residents was acknowledged by the facility's administrative staff, including the administrator and the regional director of clinical operations, during the survey process. No additional information was provided before the survey exit.
Failure to Clarify Physician's Order for Compression Wraps
Penalty
Summary
The facility staff failed to follow professional standards of practice for a resident by not clarifying a physician's order for the application of compression wraps. The resident, who was not cognitively impaired, had a physician's order dated July 5, 2023, for bilateral lower legs to be wrapped with compression wraps once a week for six months to address edema. However, the order did not specify the type of compression wrap to be used. Interviews with several LPNs revealed that there was confusion about the type of wrap to use, with some using kling wrap, which is not considered a compression wrap, and others suggesting the use of Kerlix or ace wraps. The facility's policy requires clarification of orders that do not specify details, but this was not done in this case. The deficiency was identified during a survey when interviews with LPNs and a review of the facility's documentation showed that the order for compression wraps was not clear and had not been clarified with the prescribing practitioner. The facility's administrative staff, including the administrator, director of nursing, and regional director of clinical operations, were made aware of the issue. Despite the facility's policy on clarifying incomplete orders, the lack of clarification led to the improper application of compression wraps for the resident, which was not in accordance with professional standards of practice.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent elopement for three residents, leading to incidents where residents left the facility unsupervised. Resident #2, who was severely impaired in making daily decisions, managed to exit the building and fell on the pavement outside. Despite having a wander guard, the resident was able to leave through a door that was opened by a visitor. The resident had a history of falls and was identified as an elopement risk, yet the interventions in place were insufficient to prevent the incident. Resident #3, also severely impaired in decision-making, was found outside in the garden area of the secured dementia unit after falling. The resident had a history of wandering and falls, and the garden doors were not consistently locked, allowing the resident to access the area unsupervised. The care plan noted the resident's tendency to wander and the need for supervision, but the lack of secured access to the garden area contributed to the incident. Resident #4, moderately cognitively impaired, left the facility and was found at a private residence across the parking lot. The resident was not previously identified as an elopement risk, and the door used for exit was not adequately secured, allowing the resident to leave unnoticed. The resident's care plan did not address elopement risk until after the incident, highlighting a gap in the facility's assessment and monitoring processes.
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 maintain a clean, comfortable, and homelike environment and appropriate grooming on two nursing units, as evidenced by pervasive urine and feces odors in common areas and resident rooms, stained bed linens, dirty privacy curtains, damaged baseboards and furnishings, and clutter and trash on floors, including discarded wound dressings and gloves. Several residents were observed with wet pants, stained clothing, oily hair, and facial hair growth, and food particles were noted on clothing and wheelchairs. A bariatric resident reported that bariatric sheets and towels were not always available when linens needed changing, while housekeeping aides described cleaning 18–20 rooms per day, focusing mainly on floors and bathrooms and wiping tables only on request. A CNA reported that towels and bariatric sheets were sometimes insufficient at the start of shifts, requiring staff to obtain supplies from other units.
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 Maintain Clean, Homelike Environment and Adequate Grooming
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and appropriate grooming for residents on Units W1 and W2. Upon entering the facility lobby, surveyors noted a strong pervasive odor resembling old dried urine. On Unit W1, observations during the initial tour included privacy curtains with dark smeared substances, baseboards buckling away from the wall, and bed linens with yellow-brown halos of stains. Foul odors of feces and urine were noted at various times of the day. Residents were observed with food particles on their clothes and in their wheelchairs, as well as wearing wet pants, stained clothing, and having oily hair. On Unit W2, multiple rooms were observed to be unclean and in disrepair. In one room, the baseboard near the HVAC unit was not attached to the wall and appeared to be crumbling, window blinds were bent, and paint on the wardrobe was scuffed; both residents in that room had hair under the chin and there was a very foul odor. Another room had a bedside table with a missing drawer, yellow-orange (rust-colored) stains and various trash on the floor under the sink, including a wound dressing, glove, and straw. A different room had bedside and overbed tables with liquid spills and dried substances and a very foul odor. One resident in a bariatric bed reported that bariatric sheets were not always available when linens needed changing and that towels sometimes ran out at the start of shifts, though she confirmed her linens had been changed that day and had extra towels and washcloths at bedside. Housekeeping aides reported they typically clean 18–20 rooms per day, focusing on floors and bathrooms and only wiping tables if residents request it. A CNA stated that sometimes there were not enough towels at the beginning of a shift and that staff would go to another unit to obtain more, and that bariatric sheets were available most of the time but occasionally not.
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