Maimonides Health Center Of Virginia Beach
Inspection history, citations, penalties and survey trends for this long-term care facility in Virginia Beach, Virginia.
- Location
- 6401 Auburn Dr, Virginia Beach, Virginia 23464
- CMS Provider Number
- 495186
- Inspections on file
- 13
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Maimonides Health Center Of Virginia Beach during CMS and state inspections, most recent first.
Facility staff did not promptly notify responsible parties and medical providers of significant changes in condition for two residents, including rapid weight gain, worsening edema, and severe abdominal pain. These failures led to delayed interventions, with one resident experiencing a fatal outcome after delayed hospital transfer and another developing sepsis from a perforated ulcer. Family members reported difficulty reaching staff and were not informed of their loved ones' deteriorating conditions until late.
Two residents experienced neglect due to staff failing to provide timely care, including delayed notification of physicians and responsible parties, inadequate monitoring and response to worsening symptoms, insufficient provision of fluids and hygiene, and delayed transfer to the hospital. One resident with severe cardiac issues was not properly monitored for weight gain and edema, while another with multiple comorbidities suffered prolonged abdominal pain and was not assessed or transferred promptly, resulting in a diagnosis of septic shock and a perforated ulcer.
A resident with complex medical needs, including nephrostomy tubes and severe heart failure, did not receive adequate bathing or ADL care during a 43-day stay. Despite staff indicating that showers or tub baths are typically provided twice weekly and daily bed baths as needed, the resident received only three bed baths and had two documented refusals, with no other hygiene care documented. Other residents were found to have received appropriate hygiene care.
A resident with significant physical and cognitive impairments, dependent for toileting hygiene and requiring supervision for transfers, was left unattended in the bathroom after requesting privacy. The resident was later found unresponsive on the floor with a head injury and was pronounced deceased. Staff interviews and records confirmed that the required supervision was not provided, and the resident was moved before a full nursing assessment was completed, contrary to facility policy.
A resident with a fluid restriction experienced significant weight gain, edema, and shortness of breath due to staff failing to provide adequate hydration and not notifying the cardiologist as required. Despite daily weight monitoring and clear care plan instructions, the resident rarely received the prescribed fluid amount, and staff and family reported frequent complaints of thirst. The facility physician adjusted medications to manage symptoms, but the underlying deficiency in hydration and monitoring persisted.
A resident with severe cognitive impairment and a history of CHF and DVT experienced persistent cough, new bilateral leg edema, and was not weighed as scheduled. Staff did not promptly recognize or act on these symptoms of heart failure exacerbation, resulting in delayed assessment and intervention.
A resident with severe cognitive impairment and multiple medical conditions developed a sacral pressure ulcer that was not properly addressed in the care plan or consistently documented by staff. Required weekly skin assessments were missed, and the ulcer's progression was not adequately tracked, resulting in a deficiency related to pressure ulcer prevention and management.
Facility staff did not promptly notify the physician and a resident's representative about multiple significant changes in the resident's skin condition, including injuries and new wounds. Despite documentation of these changes and a care plan requiring notification, there was no evidence that the required notifications were made, as confirmed by facility leadership and record review.
Facility staff did not follow abuse and neglect policies when a resident with severe cognitive impairment and total dependence was found with a black and blue area on the chest. Required notifications to the physician and resident representative were not documented, and no investigation into the injury was conducted, despite staff acknowledging that such injuries should be reported and investigated according to facility policy.
A resident with severe cognitive impairment and total dependence was found with a black and blue area on the chest, but staff did not report the injury of unknown origin to the physician, resident representative, or state agencies within required timeframes. Interviews and record reviews confirmed that facility policies for immediate reporting and investigation were not followed, and no documentation of timely notification or investigation was found.
A resident with severe cognitive impairment and total dependence was found with a black and blue bruise on the chest, but staff did not conduct a thorough investigation or document a Facility Reported Incident as required by facility policy. Interviews with staff confirmed that the expected procedures for reporting and investigating such injuries were not followed.
A resident admitted with multiple chronic conditions who primarily spoke Spanish did not have her communication needs addressed in her baseline care plan. Staff relied on her son for translation or used ad hoc methods like phone apps, and the resident was unable to communicate dietary preferences until a Spanish-speaking surveyor intervened. The deficiency was due to the absence of a person-centered, effective communication plan for the resident.
Facility staff did not update person-centered care plans when residents experienced changes in condition, such as new pressure ulcers and skin injuries. For example, a resident with severe cognitive impairment developed a stage two sacral pressure ulcer that was not addressed in the care plan, and another resident with multiple diagnoses had several skin issues that were not reflected in care plan updates. Required interdisciplinary team input was also missing from at least one care plan meeting.
A resident with severe cognitive impairment and multiple health conditions experienced significant weight loss due to staff failing to recognize and address signs of malnutrition, inconsistently consulting the RD as ordered, and not implementing care plan interventions such as regular weight monitoring and timely dietary changes.
A resident with multiple chronic conditions and intact cognition was found with a cup containing about ten pills left at the bedside after refusing to take them when offered by an LPN. The LPN left the medications at the resident's request instead of returning them to the medication cart, contrary to professional standards.
A resident with severe cognitive impairment and multiple diagnoses was started on hospice services without a written contract in place between the facility and the hospice provider. Hospice care documentation, including care plans and orders, was not maintained in the electronic health record, and staff communication with hospice was informal and lacked a structured process.
An LPN failed to perform proper hand hygiene during wound care for a resident with multiple chronic conditions, neglecting to remove gloves and sanitize hands before handling clean supplies. This breach of infection control protocol was observed and acknowledged by the staff member.
A resident's code status was changed to DNR/DNI without authorization, despite their expressed wish to remain a full code. The resident's family discovered the change and requested it be reverted. Interviews revealed inconsistencies in the facility's process for discussing code status, with staff unclear on who is responsible for these discussions.
Two residents in a facility experienced significant medication errors. A post-kidney transplant resident was given Cyclophosphamide instead of Cyclosporine for eight days due to a provider error and miscommunication. Another resident missed three doses of Phenobarbital due to unavailability and delayed pharmacy communication. These errors highlight lapses in medication administration and verification processes.
Failure to Notify Responsible Parties and Providers of Changes in Condition
Penalty
Summary
Facility staff failed to notify residents' representatives and medical providers of significant changes in condition for two residents, resulting in harm. One resident with complex cardiac and renal conditions experienced a rapid and sustained weight gain, worsening edema, and shortness of breath over several days. Despite care plan instructions and hospital discharge orders requiring immediate physician notification for specific weight increases, there was no evidence that the cardiology physician was contacted. The resident's family was not informed of these concerning symptoms until the family member initiated contact, and the resident was ultimately sent to the hospital only after the family insisted, where she later expired. Another resident with multiple chronic conditions, including diabetes, chronic kidney disease, and heart failure, reported severe abdominal pain and vomiting over an extended period. Documentation and interviews revealed that the resident's pain and deteriorating condition were not promptly communicated to the Nurse Practitioner or the resident's Power of Attorney/daughter. The resident continued to experience pain and was not transferred to the hospital until many hours after the initial complaints, with the family only being notified shortly before the transfer. The delay in notification and treatment contributed to the resident's decline, and the hospital later determined the resident became septic due to a perforated ulcer. Interviews with staff and family members confirmed that communication failures occurred, with family members having difficulty reaching staff and not being informed of significant changes in the residents' conditions. Clinical records and care plans indicated that staff did not follow established protocols for timely notification of changes in condition to both medical providers and responsible parties, resulting in delayed interventions and harm to the residents.
Failure to Provide Timely Care and Services Resulting in Resident Neglect
Penalty
Summary
Facility staff failed to protect two residents from neglect by not providing timely care and necessary services. One resident with severe cardiac disease and nephrostomy tubes experienced a significant weight gain, worsening edema, and shortness of breath over a 43-day stay. Despite clear care plan instructions and hospital discharge orders to notify cardiology for specific weight gains, there was no evidence that the cardiology physician was ever contacted. The resident's fluid intake was consistently below the ordered restriction, and documentation showed inadequate provision of fluids and bathing, with only three bed baths recorded and no showers provided. The resident's family was not notified of her worsening condition, and she was not sent to the emergency room until three hours after the order was received, ultimately expiring in the hospital two days later. Another resident with multiple comorbidities, including diabetes, chronic kidney disease, and heart failure, reported severe abdominal pain and vomiting. The resident's complaints began late at night and persisted for over 11 hours before a nurse practitioner was notified. During this period, the resident continued to experience pain, was unable to eat, and required repeated pain assessments and interventions. The facility staff did not notify the resident's responsible party of the change in condition until more than 17 hours after the initial complaint. The resident was eventually transferred to the hospital, where she was diagnosed with septic shock and a perforated ulcer. Staff interviews and clinical record reviews confirmed delays in notification, assessment, and treatment for both residents. The facility failed to provide required goods and services, including timely medical intervention, adequate hydration, hygiene, and communication with family members. These failures resulted in neglect as defined by federal regulations, with harm identified for one resident and significant delays in care for the other.
Failure to Provide Adequate Bathing and ADL Care to Dependent Resident
Penalty
Summary
Facility staff failed to provide adequate bathing and activities of daily living (ADL) care to a dependent resident with significant medical needs, including nephrostomy tubes, chronic heart failure, and an artificial heart valve. The resident was admitted with an order for oxygen and had a severely weakened heart muscle. Review of ADL records showed that the resident received only three bed baths during a 43-day stay, with only two documented refusals for bathing. No other baths or showers were provided during this period, despite the resident's condition requiring frequent hygiene care due to the presence of nephrostomy tubes, which are known to leak and necessitate regular cleaning. Interviews with staff indicated that the standard practice was to provide showers or tub baths twice weekly and daily bed baths as needed. However, this standard was not met for the resident in question. Other residents reviewed during the survey were found to have received adequate hygiene care, and no issues were reported by other residents or family members. The deficiency was communicated to the Director of Nursing and Assistant Director of Nursing, who did not provide additional information.
Failure to Provide Adequate Supervision During Toileting Results in Resident Fall and Death
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent an accident for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, unsteadiness on feet, and chronic congestive heart failure, was assessed as dependent for toileting hygiene and required supervision or touching assistance for transfers. Despite these needs, the resident was left unattended in the bathroom during toileting after requesting privacy, with the CNA stepping out and closing the bathroom door but remaining in the room. Shortly after, a noise was heard, and the resident was found on the bathroom floor, unresponsive, with a head injury and blood present. The resident was taking Apixaban for atrial fibrillation, which increases the risk of bleeding. The care plan and therapy evaluations indicated the resident required at least supervision or hands-on assistance for toileting and transfers, and the facility's fall policy required that residents not be moved until a nurse completed an assessment. However, after the fall, the resident was moved from the bathroom floor to the bed using a Hoyer lift by two staff members before a full assessment was completed. The charge nurse did not direct this action and did not perform or document an assessment due to being emotionally affected by the incident. Interviews with facility staff, including the nurse practitioner, LPN, and rehab manager, confirmed that the resident's functional abilities required supervision during toileting and transfers. Documentation and staff statements revealed that the required level of supervision was not provided, and the resident was left alone despite being dependent for toileting hygiene. The lack of adequate supervision and failure to follow established protocols directly contributed to the resident's unwitnessed fall and subsequent death.
Failure to Maintain Adequate Hydration and Monitoring for a Dependent Resident
Penalty
Summary
Facility staff failed to maintain adequate hydration for a resident who was dependent on staff for care. Upon admission, the resident had hospital orders for labs to be drawn in three days, but the facility delayed the first lab draw to eight days after admission and then scheduled subsequent labs at irregular intervals. The resident was placed on a 1500 ml fluid restriction, with daily weights ordered and documented. Despite clear instructions in the hospital discharge summary and care plan to notify the cardiology physician if the resident experienced a significant weight gain or worsening edema, there is no evidence that the cardiologist was ever contacted, even as the resident's weight increased by over 8 pounds, and symptoms of edema and shortness of breath developed. Instead, the facility physician made four medication changes to manage fluid overload symptoms. Review of intake and output records revealed that the resident rarely received the full amount of fluids allowed by the restriction, with only one day where the 1500 ml limit was met. Most days, the resident received significantly less, and there were days with no fluids recorded at all. Staff and family interviews indicated that the resident frequently complained of thirst and sought fluids from others, contradicting staff notes of noncompliance with the fluid restriction. The pattern of inadequate fluid provision, lack of timely physician notification, and insufficient monitoring contributed to the resident's worsening condition during the stay.
Failure to Recognize and Respond to Heart Failure Exacerbation
Penalty
Summary
Facility staff failed to recognize and respond to symptoms indicating an exacerbation of heart failure in a resident with a history of chronic non-occlusive DVT and congestive heart failure with a reduced ejection fraction of 30 percent. The resident, who had severely impaired cognitive abilities, reported a persistent dry cough that had not improved with her usual home remedy, as well as new swelling in her right leg in addition to known left leg edema. Observations confirmed significant pitting edema in both legs, and the resident was found to be wearing non-skid socks that left indentations, with no compression hose available due to improper fit. The resident also reported not being weighed for several days and was unaware of her current weight. Staff interviews and clinical record review revealed that the resident had not been weighed as scheduled, and her symptoms of worsening heart failure, including increased edema and a cough persisting for weeks, were not promptly recognized or addressed. When the resident was finally weighed, a significant weight gain of over three pounds in one day was noted, prompting a change in her treatment plan. The delay in assessment and intervention contributed to the failure to provide appropriate care according to the resident's orders, preferences, and goals.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
Facility staff failed to prevent the development of a pressure ulcer and did not provide appropriate management for an avoidable pressure ulcer in one resident. The resident, who had significant cognitive impairment and multiple medical conditions including chronic non-occlusive DVT and congestive heart failure, was admitted after a hospital stay. Initial assessments indicated intact skin, but a sacral pressure ulcer was identified within eleven days of admission. The care plan noted the resident was at risk for impaired skin integrity but did not address the newly developed sacral ulcer after it was identified. Documentation of the pressure ulcer's progression was incomplete, with missing weekly skin observation tools and lack of detailed information such as measurements, stage, and characteristics for several weeks. Staff interviews confirmed that required weekly skin assessments were not consistently performed or documented. The resident reported ongoing discomfort from the ulcer, and direct observation confirmed the presence of a stage two sacral pressure ulcer. The deficiency was due to the facility's failure to consistently assess, document, and update the care plan to address the resident's pressure ulcer after its development.
Failure to Notify Physician and Resident Representative of Significant Change
Penalty
Summary
Facility staff failed to immediately notify the physician and the resident's representative of significant changes in a resident's condition on multiple occasions. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, experienced several changes in skin condition, including an area on the chest that was black and blue, skin tears on both wrists, blisters on both feet, and an open area on the left posterior shoulder. Documentation in the clinical record indicated that while some changes were noted and referred to medical staff, there was no evidence that the resident's representative was promptly notified as required by facility policy. Interviews with facility leadership confirmed the lack of documentation regarding immediate notification to the physician and resident's representative for the identified changes in condition. The resident's care plan included interventions to monitor and report changes in skin condition, and the facility's policy required prompt notification of significant changes. However, reviews of the clinical record and care plan revealed that these procedures were not consistently followed, resulting in a failure to communicate important health status changes to the appropriate parties.
Failure to Implement Abuse and Neglect Policy for Injury of Unknown Origin
Penalty
Summary
Facility staff failed to implement the abuse and neglect policy for a resident with severe cognitive impairment and total dependence for activities of daily living, who was found with an injury of unknown origin. The resident, who had multiple diagnoses including dementia, malnutrition, and osteoporosis, was discovered by an RN to have a black and blue area on the chest. Despite this finding, there was no evidence that the required notifications to the physician or resident representative were made, nor was there documentation of an investigation into the injury as required by facility policy. Interviews with facility staff, including the administrator, CNA, LPN, and ADON, revealed a lack of follow-through on the established procedures for reporting and investigating unexplained injuries. Staff confirmed that any new injuries or changes in condition should be immediately reported to the nurse, and that injuries of unknown origin, especially in nonverbal residents, should be reported to the physician and family and investigated for possible abuse or neglect. However, the administrator was unable to provide any investigation records related to the injury, and the ADON could not find documentation of immediate notifications or an incident report in the resident's record. A review of facility policies confirmed that all unexplained injuries, including bruises and injuries of unknown source, must be investigated, documented, and reported to the appropriate parties. The policy also requires modification of the care plan to prevent recurrence. In this case, the facility did not follow its own procedures for reporting, investigating, and documenting the injury of unknown origin, resulting in a failure to protect the resident as required by policy.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to ensure the timely reporting of an injury of unknown origin for one resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who had multiple complex diagnoses including dementia, malnutrition, and physical debility, was found by an RN to have a black and blue area on the chest. The nurse documented the finding and intended to notify the nurse practitioner, but there was no evidence that the injury was reported to the physician, resident representative, or appropriate state agencies within the required timeframes. Interviews with facility staff, including the Administrator, CNA, LPN, and ADON, revealed that the facility's policy requires immediate reporting and investigation of unexplained injuries, as well as notification of the physician and resident representative. However, the Administrator confirmed that no Facility Reported Incident (FRI) was submitted for this injury, and the ADON was unable to find documentation of timely notifications or an investigation related to the incident. Staff interviews further confirmed that such injuries, especially in nonverbal residents, should be treated as potential abuse or neglect and reported accordingly. A review of facility policies on unexplained injuries and abuse indicated clear procedures for reporting, investigating, and notifying appropriate parties within specified timeframes. Despite these policies, the required steps were not followed in this case, as there was no documentation of immediate notification or investigation of the injury of unknown origin. The deficiency was confirmed during the survey, and no additional information was provided by the facility at the end of the review.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who had multiple diagnoses including dementia, malnutrition, and osteoporosis, was found to have a black and blue bruise on the chest by an RN, who documented the finding and noted intent to notify the nurse practitioner. However, there was no evidence that a comprehensive investigation was initiated or completed regarding the injury. Interviews with facility staff, including the administrator, CNA, LPN, and ADON, confirmed that the facility's policy requires immediate investigation and notification of the physician and resident representative for injuries of unknown origin. Despite these policies, the administrator was unable to provide any documentation of a Facility Reported Incident or investigation related to the injury. The facility's own policy outlines specific steps for investigating alleged abuse or neglect, but these procedures were not followed in this case.
Failure to Address Communication Needs for Spanish-Speaking Resident
Penalty
Summary
Facility staff failed to ensure that the baseline care plan for a newly admitted Spanish-speaking resident addressed her communication needs. The resident, who was admitted with multiple diagnoses including sepsis, type 2 diabetes mellitus, chronic kidney disease, hypertension, peripheral vascular disease, and anemia, had no mention of her language preference or communication requirements in her baseline care plan. Staff interviews and observations revealed that the resident primarily spoke Spanish, and staff members attempted to communicate with her using gestures, limited English, or by relying on her son to translate. The son was not always present, and staff sometimes attempted to use personal translation apps on their phones. During meal service, the resident was unable to understand what was on her tray until a Spanish-speaking surveyor intervened, indicating that her dietary preferences and needs were not being effectively communicated. Staff acknowledged the importance of communication but did not have a consistent or facility-approved method in place at the time of the survey. The lack of a person-centered, effective communication plan was evident in the care provided, as the resident's ability to participate in her care and express her needs was compromised.
Failure to Revise Care Plans After Changes in Resident Condition
Penalty
Summary
Facility staff failed to review and revise person-centered care plans as residents' conditions changed, resulting in deficiencies for two residents. One resident, admitted after an acute hospital stay with diagnoses including chronic non-occlusive DVT and congestive heart failure, was assessed as having severely impaired cognitive abilities. Despite the development of a care plan addressing risk for impaired skin integrity, the plan was not updated to address a newly identified open area on the sacrum, which was later observed and assessed as a stage two sacral pressure ulcer. Another resident with multiple complex diagnoses, including dementia, severe protein calorie malnutrition, and total dependence for activities of daily living, experienced several skin issues such as skin tears, blisters, and open areas. Progress notes documented these changes, but the care plan was not revised to reflect the new injuries or pressure areas. Additionally, there was a lack of documentation showing immediate physician or responsible party notification of these changes in condition. The facility's policy requires that comprehensive care plans be prepared, reviewed, and revised by an interdisciplinary team after each comprehensive and quarterly MDS assessment, and that care plans include measurable objectives and time frames. However, the care plans for both residents were not updated in response to significant changes in their conditions, and required interdisciplinary team input was missing from at least one care plan meeting.
Failure to Ensure Adequate Nutrition and Timely Dietary Intervention
Penalty
Summary
Facility staff failed to ensure adequate nutrition for a resident with severe cognitive impairment and multiple comorbidities, including dementia, severe protein calorie malnutrition, and dysphagia. The resident experienced a significant weight loss of 29 pounds over a period of approximately six weeks. Despite documented evidence of underweight status and ongoing weight loss, staff did not consistently recognize or respond to signs of malnutrition, nor did they consult with the registered dietician for recommendations as ordered by the physician on several occasions. Medical records and provider notes indicated repeated concerns about the resident's low BMI, declining oral intake, and the need for close monitoring and dietary consultation. The registered dietician's evaluation lacked current weight data and did not recommend changes, stating that intake met or exceeded estimated needs, despite evidence to the contrary. The resident's care plan included goals for gradual weight gain and interventions for monitoring and reporting signs of malnutrition, but these were not effectively implemented, as weights were not regularly checked and dietary consults were not consistently obtained. Documentation also revealed confusion regarding the resident's hospice status, which impacted the monitoring of weights and implementation of care plan interventions. The resident was not on hospice for a period when the care plan indicated otherwise, and routine weights were not obtained during this time. Supplements and dietary changes were not initiated in a timely manner, with house shakes only ordered on the day of the resident's death, despite ongoing weight loss and nutritional risk.
Medications Left Unattended at Bedside
Penalty
Summary
Facility staff failed to ensure that medications were administered in accordance with accepted professional standards for one resident. The resident, who had diagnoses including atrial fibrillation, diabetes, and hypertension, was cognitively intact as indicated by a high BIMS score. During an observation, a medication cup containing approximately ten pills of various sizes and colors was found on the resident's bedside table. The resident explained that he could not take the medications when they were brought to him because he had a piece of candy in his mouth and intended to take them after finishing the candy. An interview with the LPN responsible for administering the medications revealed that the nurse left the medications at the bedside at the resident's request, as the resident was described as non-compliant with care and refused to take the medications at the time they were offered. The LPN later retrieved the empty medication cup, indicating the resident had taken the medications. The facility's administration confirmed that the nurse should not have left the medications at the bedside and should have returned them to the medication cart.
Failure to Secure Hospice Contract and Maintain Hospice Records
Penalty
Summary
Facility staff failed to secure a written agreement with a hospice provider prior to the initiation of hospice services for a resident with multiple complex medical conditions, including dementia, severe protein calorie malnutrition, major depressive disorder, and total dependence for activities of daily living. The resident was started on hospice services, but the required contract with the hospice provider was not in place until the first day of the survey. Additionally, hospice care documentation, including care plans, visit notes, and medication and treatment orders, was not maintained in the resident's electronic health record during the period hospice services were provided. The deficiency was identified through interviews, clinical record review, and facility documentation. The administrator and staff were unable to locate the original hospice contract and had to request a new one from the hospice provider. Communication between facility staff and hospice was described as occurring verbally and by telephone, but there was no established process for ensuring hospice records were integrated into the facility's electronic health record.
Failure to Follow Hand Hygiene During Wound Care
Penalty
Summary
Facility staff failed to adhere to proper hand hygiene practices during wound care for one resident. During an observation of sacral pressure ulcer care, an LPN, assisted by a CNA, performed wound cleansing and dressing changes. After cleaning the wound and before handling clean wound care supplies, the LPN did not remove her gloves or wash or sanitize her hands, as required by infection prevention protocols. This lapse was acknowledged by the LPN during an immediate post-procedure interview. The resident involved had a history of atrial fibrillation, diabetes, and hypertension, and was cognitively intact at the time of the incident. The wound care procedure required the use of clean gloves and hand hygiene between handling soiled and clean supplies, but these steps were not followed, as directly observed by surveyors.
Unauthorized Change of Code Status for Resident
Penalty
Summary
The facility staff failed to respect and honor a resident's right to remain a full code, as evidenced by the unauthorized change of code status for a resident who was admitted from the hospital as a full code and expressed wishes to remain so. Despite the resident's clear communication and cognitive ability to make decisions, an order was entered to change the resident to a DNR/DNI without a signed document to support this change. The resident's family member discovered the unauthorized change and requested the order be reverted to the resident's original wishes. Interviews with facility staff revealed inconsistencies in the process of discussing code status with residents. The Licensed Practical Nurse indicated that the social worker typically discusses code status, while the Assistant Director of Nursing stated that the doctor would have this conversation. The Social Service Director mentioned not seeing residents until 72 hours after admission, which may have contributed to the oversight. The facility's policy on resident rights emphasizes participation in care decisions, yet this was not upheld in the case of the resident in question.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #7, who was a post-kidney transplant patient, was mistakenly administered Cyclophosphamide, a chemotherapy drug, instead of the prescribed Cyclosporine, an immunosuppressant necessary to prevent organ rejection. This error occurred over an eight-day period during which the resident received multiple incorrect doses. The error was identified when the transplant clinic contacted the facility to verify the medication, leading to the resident being sent to the hospital for evaluation. The error for Resident #7 was traced back to a provider mistake where Cyclophosphamide was ordered instead of Cyclosporine. The error was compounded by the fact that the correct medication was not listed on the hospital discharge summary, and the facility did not accept medications brought in by the family. Despite the family providing accurate medication information, the facility continued to administer the wrong medication until the transplant center intervened. Resident #6 experienced a significant medication error when the facility failed to administer the ordered anti-seizure medication, Phenobarbital, for three days. This lapse was due to the medication not being available and a delay in communication with the pharmacy. The facility's emergency medication supply did not include Phenobarbital, and the staff did not follow up promptly to ensure the medication was obtained. This oversight left the resident without necessary medication for seizure control, posing a risk of seizures.
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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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