Mountain Laurel Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Rural Retreat, Virginia.
- Location
- 514 North Main Street, Rural Retreat, Virginia 24368
- CMS Provider Number
- 495417
- Inspections on file
- 20
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mountain Laurel Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral issues was subjected to physical and mental abuse by an LPN, who aggressively handled the resident during an episode of agitation. The LPN forcefully grabbed the resident, pushed him against a desk, and tilted his wheelchair back, resulting in the resident falling and sustaining a head injury. Multiple staff witnessed the incident, and facility documentation confirmed the LPN's actions violated abuse prevention policies.
Facility staff failed to provide care and treatment according to provider orders and professional standards for multiple residents, including not administering emergency diabetic medication during a hypoglycemic episode, delaying and failing to notify providers about necessary diagnostic x-rays after a fall, not ensuring completion of ordered chest x-rays, and not following medication orders or discontinuations as directed by hospice. These actions resulted in residents not receiving timely or appropriate interventions for their conditions.
Facility staff failed to provide appropriate behavioral health services and timely medication management for two residents with significant mental health needs, including one hospice patient with a history of trauma and another resident with ongoing psychosis and suicidal ideation. The facility did not involve family in assessments, delayed or omitted administration of prescribed medications, failed to incorporate resident preferences and trauma history into care plans, and did not seek psychiatric services or follow up on recommendations for inpatient psychiatric care. Immediate actions to ensure resident and staff safety were lacking after incidents of aggression and threats.
A resident with multiple comorbidities and a history of UTIs did not receive a provider-ordered urinalysis after her family raised concerns about her mental status. Despite documentation that the test was not obtained and communication in shift reports, there was no follow-through to ensure the lab order was completed. The resident's condition worsened, leading to transfer to the emergency department, where she was diagnosed and treated for a UTI, dehydration, and altered mental status.
Facility staff failed to provide timely radiology and diagnostic services for two residents. In one case, a resident with multiple comorbidities experienced a fall and had a provider order for a hip x-ray, but the x-ray was delayed for two days and the provider was not notified. In another case, a resident who experienced a choking incident had a chest x-ray ordered, but it was not performed until four days later, with no documentation explaining the delay. These actions were not in accordance with facility policy or service agreements.
Facility staff failed to provide necessary care and services for two residents. One resident with severe dementia and behavioral issues was handled aggressively by an LPN during an incident, resulting in a fall and head injury. Another resident with cerebral palsy and intellectual disabilities missed a scheduled day support program because staff did not have the resident ready for transport, despite the resident's interest and care plan requirements.
A resident with a history of cardiac issues experienced severe bradycardia and upper respiratory symptoms, prompting an EKG that revealed a critical abnormality requiring immediate follow-up. Although the urgent EKG results were faxed to the facility overnight, staff did not notify the provider until several hours later, delaying the resident's transfer to the ER. This failure to promptly communicate urgent diagnostic findings was not in accordance with facility policy.
Facility staff did not respond to repeated Resident Council concerns about the lack of proper knives with meals, resulting in residents having to use inadequate utensils or their hands to eat certain foods. Despite ongoing complaints and staff acknowledgment of the issue, the problem persisted over several months, with surveyor observations confirming the absence of knives during meal service.
Facility staff did not consistently provide or document advance directive information for several residents with complex medical conditions. Some residents reported not receiving any explanation about advance directives before signing forms, and required documentation was incomplete or missing. These deficiencies were identified through record reviews and interviews, revealing a lack of adherence to facility policy regarding advance directive discussions.
Staff failed to provide a homelike environment by not supplying adequate utensils, such as knives, with meals, leading residents to use their fingers or request family assistance. Bathing areas had missing tiles and a non-functional whirlpool tub, with maintenance issues left unresolved. Additionally, a resident's wheelchair and another's toilet remained soiled over several days, and trays under ice machines in nutrition rooms were found dirty and containing debris.
Facility staff did not complete or document required background checks, reference checks, and license verifications for multiple new hires, including nurses, CNAs, housekeepers, dietary aides, and therapy staff, as required by the facility's abuse, neglect, and exploitation prevention policy.
Facility staff did not provide required written notification of transfer or discharge reasons to four residents and their representatives, and failed to notify the ombudsman in one case. The affected residents had complex medical conditions and varying cognitive abilities. Staff interviews and record reviews confirmed the absence of documentation, and facility policy requiring timely notification was not followed.
Facility staff did not provide required written bed-hold notices to several residents or their representatives when residents were transferred to the hospital, despite facility policy mandating this action. Affected residents had complex medical conditions and included both cognitively impaired and intact individuals. Record reviews and staff interviews confirmed the absence of documentation showing that the bed-hold policy was communicated at the time of transfer.
Several residents with complex medical conditions did not receive or review their baseline care plans within 48 hours of admission, as required by facility policy. In multiple cases, baseline care plans were either not created on time or not provided to residents or their representatives, and documentation lacked signatures or evidence of review. Staff interviews revealed confusion about who was responsible for this process, leading to inconsistent communication and documentation.
Facility staff did not meet professional standards in several areas, including failing to perform and document required PICC line care for a resident, inaccurately documenting the application of compression stockings for another resident who did not have them, and not properly obtaining or documenting laboratory tests and medication orders for multiple residents. These deficiencies were identified through interviews, record reviews, and policy comparisons.
A resident who was totally dependent on staff for ADLs, including incontinence care, was observed to have remained in a wet brief and clothing for an extended period due to insufficient staff availability for two-person care. Additionally, an LPN documented being unable to complete provider orders, such as wound care and dressing changes, for five residents because of increased patient load, with each nurse responsible for 28 residents. Staffing patterns and workload were confirmed by the facility's staffing coordinator, and the issue was discussed with facility leadership.
Facility staff failed to obtain ordered laboratory tests for four residents, including missing PT/INR monitoring for a resident on anticoagulants, not obtaining a wound culture for a resident with an abscess, incomplete INR testing for a resident with a prosthetic heart valve, and not completing a basic metabolic panel for a resident with chronic kidney disease. These actions did not meet the facility's policy for timely laboratory services.
Staff failed to properly label and store refrigerated and frozen food items, with multiple opened and undated containers found in resident nutrition areas. Additionally, dietary staff served green beans and collard greens using a smaller scoop than required by the menu, resulting in residents receiving less than the intended portion size before the error was corrected.
Surveyors observed that staff did not properly dispose of or contain garbage and waste, with dumpster doors left open and various debris such as medical gloves, cups, and towels found scattered around the disposal area. These findings were discussed with facility leadership.
Facility staff did not receive required training on the QAPI program, as confirmed by leadership and a review of staff files. Only one CNA had documentation of QAPI training, and no further evidence was provided to surveyors.
Surveyors identified multiple deficiencies in the development and implementation of comprehensive care plans, including failure to update care plans with relevant mental health history, inconsistent documentation and practices regarding toileting assistance, omission of a PICC line from a care plan, failure to use bed bolsters as ordered, and incorrect identification of medication purposes and interventions. These issues were observed through staff interviews, resident and family input, and review of clinical records and care plans.
Staff failed to provide necessary ADL care for four residents, including not offering regular bathing to a resident with severe cognitive and mobility impairments, delaying incontinence care for a dependent resident resulting in saturated clothing and wheelchair pads, and neglecting nail care for two residents who were dependent on staff for personal hygiene. These deficiencies were identified through observations, interviews, and record reviews.
Surveyors identified multiple deficiencies involving inaccurate and incomplete documentation in resident medical records, including failure to accurately record diagnostic procedures, medication administration, code status, and dialysis weights. Staff also documented medication administration routes incorrectly and maintained duplicate medication orders, leading to discrepancies between actual care provided and what was recorded.
Facility staff failed to maintain an effective QAPI program, resulting in repeated deficiencies in following provider orders, ensuring medication availability, preventing expired food items, and adhering to infection control guidelines. These issues were identified through multiple surveys and affected several residents, with no evidence of sustained improvement presented to surveyors.
A resident with moderate cognitive impairment and multiple medical conditions was left exposed during incontinence care when a CNA failed to close the door and privacy curtain, resulting in a loss of dignity and respect. The resident expressed discomfort about being exposed to the hallway and others in the room, and staff confirmed that proper privacy measures were not followed.
A resident with multiple chronic conditions experienced significant weight gain over several months. While the Registered Dietician updated the care plan after each weight change, there was no documentation that the physician was notified, as required by facility policy. The DON confirmed that no evidence of physician notification could be found.
A resident with moderate cognitive impairment and incontinence was left exposed during care when a CNA provided incontinence care with the room door open and the privacy curtain only partially closed. The resident's roommate was present and able to view the care, and the resident later expressed discomfort about the lack of privacy. The DON confirmed that proper privacy measures were not followed.
A resident admitted from the hospital did not have all prescribed medications and supplements addressed in their admission orders, including a delay in ordering enoxaparin and missing orders for Epipen, Baqsimi nasal spray, and several vitamins and supplements, despite facility policy requiring immediate care orders from a provider.
Staff failed to accurately complete MDS assessments for two residents: one was not coded for the use of a right-hand splint and elbow brace despite documented orders and care plan, and another was incorrectly coded as receiving anticoagulant medication when clinical records showed none was administered. These inaccuracies were identified through staff interviews, record reviews, and direct observation.
Facility staff did not complete Level I PASARR screenings for two residents with significant mental health diagnoses, despite facility policy requiring such screenings prior to admission. Both residents' records lacked documentation of the required screening, and staff interviews revealed confusion and lack of awareness regarding responsibility for PASARR completion.
Nursing staff failed to complete a provider-ordered wound care treatment for a resident with a pressure ulcer on the left buttock. The resident, who had multiple medical conditions and moderate cognitive impairment, did not receive the prescribed wound care on one occasion due to increased patient load, as documented by an LPN. The order was discontinued after the wound was assessed as healed, and the issue was reviewed with facility leadership.
A resident with a history of mental health disorders and high fall risk was repeatedly found outside unsupervised, smoking cigarettes obtained from the ground, and attempting to leave the facility. Despite care plans and facility policies requiring supervision and secure storage of smoking materials, staff did not consistently enforce these measures, resulting in the resident experiencing a fall and ongoing exposure to accident hazards.
A resident with multiple medical conditions and moderate cognitive impairment did not have documented evidence of receiving or refusing a therapeutic diet as ordered by the provider during several evening meals. Staff interviews did not confirm missed meals, but facility records lacked required documentation for meal delivery or refusals on the specified dates, except for one instance of partial intake.
Facility staff did not provide or document required respiratory treatments for two residents. One resident did not receive incentive spirometer therapy as ordered, with staff unable to confirm the order's intent or provide supporting documentation. Another resident, under hospice care, did not receive scheduled nebulizer treatments, and the DON confirmed no evidence of administration in the clinical record.
Facility staff did not coordinate care with the dialysis center for a resident with end stage renal disease, failing to obtain and document pre- and post-dialysis weights as required by policy. The dialysis book meant to accompany the resident was left blank, and staff interviews confirmed that necessary paperwork and communication with the dialysis provider were not consistently completed.
Medical providers failed to ensure accurate and appropriate physician orders for two residents. One resident had incentive spirometer orders entered with a delayed start date and no supporting documentation, while another had duplicate allopurinol orders signed by a provider without recognizing the duplication. Both issues involved orders entered or signed without proper verification or documentation.
A resident with multiple comorbidities, including diabetes, was readmitted from the hospital with instructions to discontinue several diabetic medications. Facility staff did not ensure the attending physician reviewed the discharge summary or addressed the changes in diabetic management, resulting in no provider orders or monitoring for diabetes after readmission. This led to a lack of documented oversight and intervention for the resident's diabetes, despite ongoing hyperglycemia.
Facility staff failed to ensure timely availability and administration of ordered medications for three residents, resulting in missed or delayed doses of antibiotics and pain medication due to lack of in-house supply and delays in pharmacy delivery, despite facility policy requiring a STAT supply of commonly used medications.
Facility staff did not ensure that monthly medication regimen reviews were completed by a pharmacist and that recommendations were reported to and acted upon by providers in a timely manner for several residents with complex medical needs. Documentation of provider review and action on pharmacist recommendations was delayed or missing, and some reviews were not completed for multiple months.
Facility staff administered Lantus insulin to a resident with diabetes on multiple occasions despite blood sugar readings below the physician-ordered hold parameter. The resident, who was cognitively intact and had a care plan for diabetes management, received the medication contrary to both the physician's order and facility policy, as confirmed by the DON.
Facility staff did not monitor two residents for behaviors or side effects related to prescribed psychotropic medications, despite both residents being cognitively intact and having multiple diagnoses. Required monitoring was not present in the medication records, and facility policy mandating ongoing evaluation of psychotropic medication effects was not followed.
An LPN made two medication errors during a medication pass, resulting in a medication error rate of 7.14%. A resident with multiple cardiac conditions received an incorrect dose of famotidine and had their metoprolol withheld inappropriately, contrary to physician orders. The errors were identified during a survey and confirmed by the LPN upon review.
A resident with multiple complex medical conditions did not receive the full five-day course of Levofloxacin as ordered by the provider, due to a missed dose when the resident was out of the facility for a hospital transfer. The facility's staff did not ensure the medication was administered as prescribed, resulting in a significant medication error.
Staff failed to dispose of expired medications and biologicals in one medication room, where expired laboratory tubes, D3 medication, and influenza vaccines were found and confirmed by the ADON.
Facility staff obtained INR laboratory tests for a resident more frequently than ordered by the physician, performing the test multiple times per week instead of only on Mondays as prescribed. The resident, who was cognitively intact and on anticoagulant therapy, confirmed frequent blood draws, and the DON acknowledged the error.
A resident with multiple chronic conditions and moderate cognitive impairment did not consistently receive their documented daily preference for boiled eggs at breakfast. Despite the preference being recorded on the resident's tray ticket and acknowledged by the dietary manager, the resident reported and surveyors confirmed that boiled eggs were not provided on several occasions, with the dietary manager attributing this to supply issues.
Facility staff did not involve the Medical Director when they were unable to secure a surgical consult for a resident with a rectal prolapse, despite multiple follow-up attempts and ongoing delays. The resident had several medical conditions and was cognitively intact, but staff did not escalate the issue to the Medical Director, who later confirmed he was not contacted.
Staff did not follow infection control protocols for a resident on enhanced barrier precautions due to a PEG tube, failing to wear required PPE and placing soiled items on the floor during incontinence care. The care plan and signage indicated the need for gloves and gowns, but staff were unaware or did not comply with these requirements.
Staff did not offer pneumococcal conjugate vaccines (PCV20 or PCV21) to two residents with moderate cognitive impairment and significant medical histories, despite facility policy and CDC guidelines requiring assessment and offering of the vaccine upon admission. Clinical records showed the vaccines were not up to date and had not been offered, and staff could not provide documentation that the required steps were completed.
A resident with complex medical and psychiatric needs was transferred and subsequently discharged after behavioral incidents, despite evidence from hospice and EMTs that the resident was calm and non-combative. The facility failed to document specific unmet needs or adequate attempts to address the resident's behaviors before issuing a 30-day discharge notice, and medication management was inconsistent. The required documentation supporting the discharge was not present in the medical record.
Failure to Protect Resident from Physical and Mental Abuse by LPN
Penalty
Summary
Facility staff failed to protect a resident's right to be free from physical and mental abuse during an incident involving an LPN and a resident with multiple complex medical and psychiatric diagnoses, including severe vascular dementia, traumatic brain injury, and a history of agitation and behavioral disturbances. The resident, who was moderately cognitively impaired, became physically aggressive with staff and other residents, leading to an intervention by an LPN. According to multiple staff and witness statements, the LPN responded by grabbing the resident's arms aggressively, pushing the resident up against a desk, and then tilting the resident's wheelchair back onto two wheels in an attempt to move the resident down the hall. During this process, the resident continued to resist, and the LPN ultimately let go of the wheelchair, causing the resident to fall backward and strike his head on the floor, resulting in a contusion and a scalp hematoma. Documentation in the clinical record and facility incident reports indicated that the LPN's actions were physically forceful and included aggressive handling of the resident. Witnesses described the LPN as slamming the resident against the desk and making statements such as, "We aren't doing this," and, "If anyone wants to report me for abuse then so be it." The incident was corroborated by multiple staff statements and was reported to have caused both physical harm and mental distress to the resident. The resident was subsequently sent to the emergency room for evaluation of the head injury sustained during the fall. The facility's own investigation and staff interviews confirmed that the LPN's intervention escalated the situation and resulted in the resident's injury. The facility's abuse policy prohibits the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and the actions taken by the LPN were found to be in violation of this policy. The incident was substantiated as abuse, and the LPN involved was not permitted to return to the facility following the investigation.
Failure to Provide Care and Treatment According to Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care services in accordance with professional standards of practice for multiple residents, as evidenced by several documented incidents. For one resident with diabetes, staff did not follow standing orders for hypoglycemic management during a critical episode. Despite a blood glucose reading of 30, staff did not administer glucagon as required by protocol, and there was confusion and lack of documentation regarding the availability and administration of emergency medications. The resident was transferred to a higher level of care due to the unresolved hypoglycemic event. Another resident who experienced a fall and complained of hip pain did not receive a timely x-ray as ordered by the medical provider. The x-ray, which was supposed to be performed promptly, was delayed over the weekend, and staff failed to notify the provider about the delay. The resident continued to report pain, and only after several days was sent to the hospital, where a hip fracture was diagnosed, requiring surgical intervention. Documentation errors were also noted, with staff incorrectly recording that the x-ray had been completed when it had not. Additional deficiencies included failure to ensure a resident received a chest x-ray as ordered, with no evidence the procedure was completed or documented. In another case, staff did not administer Seroquel as ordered and failed to discontinue multiple medications per hospice instructions, resulting in discrepancies between the medication administration record and provider orders. There were also failures to follow medication orders related to a change in condition for another resident, with prescribed treatments not administered and incomplete documentation of assessments and interventions.
Failure to Provide Appropriate Behavioral Health Services and Medication Management
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to residents with mental disorders, psychosocial adjustment difficulties, and histories of trauma. For one resident, who was a hospice patient with a history of trauma, the facility did not involve the family in the comprehensive admission assessment and failed to administer medications ordered for paranoia and agitation in a timely manner. The resident exhibited escalating behaviors, including physical aggression towards staff and other residents, but the facility did not incorporate the resident's preferences or trauma history into the care plan. Additionally, there was no evidence that psychiatric services were sought, despite the facility's stated ability to care for residents with complex psychiatric needs. The clinical record showed that the resident's behaviors were not effectively managed, and staff responses included physical interventions that resulted in injury to the resident. Medication orders for antipsychotic and anxiolytic medications were delayed in being added to the medication administration record (MAR) and were not administered as prescribed, even when the resident was exhibiting ongoing behaviors. The facility also failed to communicate and collaborate effectively with hospice staff, who reported that their offers to assist in managing the resident's behaviors were declined, and that the facility proceeded with a 30-day discharge notice based on the resident's psychiatric history rather than current behaviors. For another resident, the facility did not follow up on a Pre-admission Screening and Resident Review (PASARR) that recommended inpatient psychiatric hospitalization due to psychiatric instability. The resident remained in the facility without a psychiatric evaluation for inpatient treatment, despite ongoing symptoms such as hallucinations, delusions, threats towards others, and suicidal ideation. The facility did not take immediate action to ensure the safety of other residents after threats were made, and there was a lack of documentation and communication regarding these incidents. Both cases demonstrate failures in assessment, care planning, medication management, and coordination of behavioral health services for residents with significant mental health needs.
Failure to Obtain Provider-Ordered Urinalysis Resulting in Hospital Transfer
Penalty
Summary
Facility staff failed to obtain a provider-ordered urinalysis for a resident with a history of chronic kidney disease, bladder cancer, diabetes, and recurrent urinary tract infections. The urinalysis was ordered after the resident's husband expressed concerns about changes in her mental status, but the test was not completed. Documentation by an LPN indicated the urinalysis was not obtained during the shift, and although it was noted in shift and 24-hour reports, it was not communicated in the MD/Nursing communications report. No requisition for the urinalysis was found in the lab book, and the laboratory company confirmed that no urinalysis was performed for the resident on the ordered date. Following the missed urinalysis, the resident's condition deteriorated, with staff documenting decreased oral intake, altered mental status, and increased resistiveness to care. The resident's husband repeatedly contacted the facility due to ongoing concerns about her health and ultimately requested that she be sent to the emergency department. Upon transfer, the resident was found to have abnormal urinalysis results, dehydration, and altered mental status, and was treated with IV fluids and antibiotics for a urinary tract infection. The facility's policy required timely provision or procurement of laboratory services when ordered by a provider. Despite this, the ordered urinalysis was not obtained, and there was a lack of effective communication and follow-through among staff to ensure the test was completed. The failure to obtain the urinalysis contributed to the resident's transfer to a higher level of care and subsequent treatment for a UTI and related complications.
Delayed Radiology and Diagnostic Services for Two Residents
Penalty
Summary
Facility staff failed to provide or obtain timely radiology and diagnostic services for two residents, resulting in deficiencies related to delayed x-ray procedures. In the first case, a resident with multiple diagnoses, including dementia, hypertension, and chronic kidney disease, experienced a fall and complained of left hip pain. Although a provider ordered a left hip x-ray the day after the fall, the x-ray was not performed as scheduled due to a delay by the mobile x-ray company, which did not arrive until two days later. Facility staff did not notify the medical provider of the delay, and documentation inaccurately reflected that the x-ray had been completed. The resident continued to experience pain and was eventually sent to a higher level of care, where a left hip fracture requiring surgical repair was diagnosed. Interviews with staff and family members confirmed that the x-ray was not performed as ordered and that communication with the provider regarding the delay was lacking. The facility's agreement with the mobile x-ray company stipulated availability of radiology services seven days a week, and facility policy required prompt physician notification in the event of changes in condition, such as accidents with potential for physician intervention. Despite these policies, the delay in obtaining the x-ray and the lack of provider notification were not addressed in a timely manner. In the second case, another resident with a history of cerebral infarction, metabolic encephalopathy, and other conditions experienced a choking incident, prompting a provider order for a chest x-ray to rule out aspiration pneumonia. The chest x-ray was not obtained until four days after the order was placed, and there was no documentation explaining the delay. The Director of Nursing confirmed the delay and was unable to provide a reason for it. Facility policy required that radiology and other diagnostic services be provided to meet residents' needs, but this was not followed in this instance.
Failure to Provide Necessary Care and Services for Two Residents
Penalty
Summary
Facility staff failed to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being for two residents. For one resident with multiple complex diagnoses, including severe dementia, traumatic brain injury, and a history of behavioral issues, staff did not recognize the resident as an individual or provide a safe and supportive environment during a behavioral incident. The resident became physically aggressive, and an LPN intervened in a manner described by multiple witnesses as aggressive, including grabbing the resident's arms, pushing the resident in a wheelchair, and tilting the wheelchair onto two wheels. This resulted in the resident falling backward and sustaining a head injury. Documentation and witness statements indicated that the LPN's actions escalated the situation, and the resident was subsequently sent to the emergency room for evaluation of a scalp hematoma. The incident was further complicated by inconsistent accounts from staff and a lack of immediate provision of medications by the facility nurse, despite the hospice nurse's request. The resident's daughter was notified, and the resident was described as calm during transport and at the hospital. Upon return from the hospital, the resident was found in soiled clothing and bedding, indicating a lack of attention to personal care needs. The facility's own investigation and staff statements confirmed the aggressive handling of the resident by the LPN, and the facility's policy on abuse, neglect, and exploitation was reviewed as part of the survey. For another resident with spastic quadriplegic cerebral palsy and intellectual disabilities, the facility failed to ensure attendance at a scheduled day support program. Despite a care plan specifying participation in day support three times a week, the resident was not ready for transport when the day support staff arrived, due to incomplete morning care and medication administration. The day support staff were unable to wait, and the resident remained at the facility, missing the program. Interviews with the resident, family, and staff confirmed the resident's enjoyment of and desire to attend the program, and that the failure to send the resident was due to the facility's inability to prepare the resident in time.
Delay in Provider Notification of Urgent EKG Results
Penalty
Summary
Facility staff failed to promptly notify the provider of urgent diagnostic results for a resident with a history of complete AV block, cardiac pacemaker, hypertension, and asthma. The resident experienced bradycardia and upper respiratory symptoms, and an EKG was ordered after persistent low heart rates were observed. The EKG report, which indicated severe bradycardia and possible third-degree heart block requiring immediate follow-up, was faxed to the facility at 12:47 AM. However, the provider was not notified of these urgent results until approximately 7:30 AM, resulting in a delay of several hours before action was taken. During this period, the resident continued to feel unwell and expressed significant fatigue. The delay in provider notification was confirmed through clinical record review and staff interviews, with staff stating that the results were not received or acted upon until the morning. Facility policy required prompt notification of abnormal diagnostic results to the ordering provider, but this was not followed in this instance, leading to a delay in the resident's transfer to the emergency room for further evaluation and treatment.
Failure to Address Resident Council Grievances Regarding Meal Utensils
Penalty
Summary
Facility staff failed to consider and act upon the grievances and recommendations of the Resident Council regarding the consistent lack of appropriate utensils, specifically knives, with resident meals. Over several months, Resident Council meeting minutes repeatedly documented concerns about not receiving knives or only receiving plastic knives, which were inadequate for cutting meat and spreading condiments. Residents reported having to use their fingers or forks to eat items like pork chops due to the absence of proper knives. The issue persisted despite multiple documented complaints, with residents also noting the frequent use of plastic plates and utensils, especially on weekends. During interviews, residents confirmed the ongoing problem, and staff acknowledged a shortage of knives in the kitchen, with an order for additional knives placed months prior. Surveyor observations during meal service corroborated the absence of knives on meal trays. Documentation provided by the administrator regarding staff education and room rounds did not address the specific concern about knives. No further information or evidence of resolution was provided to the survey team before the exit meeting.
Failure to Provide and Document Advance Directive Information for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that multiple residents were provided with the opportunity to formulate, review, or discuss advance directives upon admission or during their stay. Several residents with significant medical histories, including conditions such as peripheral vascular disease, respiratory failure, congestive heart failure, diabetes, atrial fibrillation, and dementia, were not given clear information or the chance to express their wishes regarding advance directives. In some cases, documentation of advance directive discussions was missing, incomplete, or not witnessed, and residents reported that no one had reviewed the information with them prior to their signatures being obtained. For example, one resident with chronic illnesses was listed as their own responsible party and had a form marked as declined, but when interviewed, indicated that no one had explained advance directive information before the form was signed. Another resident, who was alert and oriented, had a DNR order and a signed advance directive form, but also stated that the facility staff had not reviewed advance directive information with them upon admission. In both cases, the forms lacked witness signatures, and there was no evidence in the clinical record that the required discussions had taken place. Additionally, a resident with a DDNR order had an incomplete form, with required sections left unchecked, and other residents with cognitive capacity were not provided with or did not recall receiving information about advance directives. Facility policy required that advance directive information be provided and discussed upon admission, but documentation and resident interviews revealed that this process was not consistently followed. These deficiencies were identified through clinical record reviews, resident and staff interviews, and examination of facility policies.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to provide a safe, clean, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies observed during the survey. Residents consistently did not receive knives with their meals, and when knives were provided, they were plastic and inadequate for cutting certain foods such as pork chops. Resident Council minutes over several months documented repeated complaints about the lack of proper utensils, with residents expressing frustration and reporting that they had to ask families to bring in knives or resort to eating with their fingers. Staff interviews confirmed a shortage of knives in the kitchen, and although a purchase order for new silverware was provided, the issue persisted at the time of the survey. The facility also failed to maintain clean and functional bathing areas. Residents reported missing tiles and an inoperative whirlpool tub in two of the four bathing areas. Observations confirmed missing and chipped tiles, as well as a whirlpool tub with non-functional jets and a leaking door. Staff acknowledged the ongoing issues, with maintenance efforts hampered by difficulties in sourcing replacement parts and uncertainty about whether the whirlpool would be replaced. The administrator was aware of the problems but could not confirm plans for a replacement tub for residents who preferred baths. Additional deficiencies included unclean resident equipment and nutrition areas. One resident's wheelchair was repeatedly observed to be soiled with a dry, tan-colored substance over several days, despite staff being responsible for cleaning and a cleaning schedule being in place. Another resident's toilet and bedside commode were found with brown matter smeared on them over multiple days, contrary to the facility's policy of daily cleaning. Furthermore, white trays placed beneath ice machines in nutrition rooms were found to contain debris such as food waste, wrappers, and other contaminants, with staff confirming these trays were not part of the manufacturer's setup and should be monitored daily for cleanliness.
Failure to Complete Required Employee Screening for Abuse, Neglect, and Exploitation
Penalty
Summary
Facility staff failed to implement their policy regarding the screening of new hires for abuse, neglect, and exploitation. Specifically, for 13 out of 25 new hires, required background checks, reference checks, and license verifications were either not completed or not documented. The policy in place required that all potential employees, including contracted and temporary staff, be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that documentation of these screenings be maintained. However, upon review, the facility was unable to provide evidence that these screenings had been conducted for the identified new hires, including licensed nurses, certified nursing assistants, housekeepers, dietary aides, and therapy staff. During the survey, the team requested and reviewed the facility's Abuse, Neglect, and Exploitation policy, which outlined the required screening procedures. The surveyors found that for several new hires, there were missing background checks, reference checks, and license verifications. The facility was only able to provide some of the missing documentation after the survey began, and for the majority of the identified staff, no further information was provided prior to the exit conference. No information about residents or their conditions was included in the report.
Failure to Provide Written Transfer/Discharge Notification to Residents, Representatives, and Ombudsman
Penalty
Summary
Facility staff failed to provide written notification of the reasons for transfer and/or discharge to residents and their representatives in four cases out of fifty-five sampled. In each instance, the clinical record review and staff interviews revealed that no evidence could be found that written notice was given to either the resident or their representative at the time of transfer to the hospital. The residents involved had significant medical histories, including conditions such as cerebral infarction, diabetes, chronic kidney disease, dementia, mood disorders, hemiplegia, hypertension, seizures, and respiratory failure. Cognitive assessments indicated that some residents were severely impaired, while others were cognitively intact. For one resident, the facility also failed to provide evidence that the local long-term care ombudsman was notified of the transfer or discharge, as required. Staff interviews confirmed that no documentation or notification was sent to the ombudsman, the resident, or the family in this case, due to a lack of awareness that the resident had been transferred. Facility policy required that transfer notices be provided as soon as practicable to both the resident and their representative, but this was not followed in the cited cases. The surveyors requested documentation and reviewed facility policies, but no further information or evidence of compliance was provided prior to the survey exit. The deficiency was discussed with facility leadership during end-of-day meetings, and the lack of written notification was confirmed by staff, including the DON, ADON, and social worker, who stated that discharge notifications were not completed.
Failure to Provide Bed-Hold Notices Upon Resident Transfer
Penalty
Summary
Facility staff failed to provide written bed-hold notices to residents and/or their representatives upon transfer to a hospital or for therapeutic leave, as required by facility policy. In multiple instances, surveyors found no evidence in the clinical records that the bed-hold policy was given at the time of transfer, despite requests for documentation. The facility's own policy, reviewed and revised on 12/1/22, states that written notice specifying the duration of the bed-hold policy must be provided at the time of transfer for hospitalization. Specific cases included residents with significant medical histories and varying cognitive abilities. One resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and acute respiratory failure, was transferred to the hospital without documentation of a bed-hold notice being provided. Another resident, cognitively intact and diagnosed with hemiplegia, diabetes, and other conditions, was also transferred without evidence of receiving the required notice. Additional residents with complex medical backgrounds, including dementia, chronic kidney disease, and depression, were similarly affected. Staff interviews and record reviews confirmed that in each case, no documentation could be found to show that the bed-hold policy was communicated to the resident or their representative at the time of transfer. The issue was discussed with facility leadership during survey meetings, and the only documentation provided was the facility's policy itself, not evidence of compliance for the affected residents.
Failure to Provide and Document Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement baseline care plans and/or provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission for seven out of fifty-five sampled residents. In several cases, baseline care plans were either not created within the required timeframe or, when created, were not reviewed with the resident or their representative, nor was a written summary provided as required by facility policy. Documentation often lacked signatures or other evidence that the care plan had been reviewed or received by the resident or their representative. Multiple residents with complex medical histories, including conditions such as bipolar disorder, seizures, chronic kidney disease, atrial fibrillation, diabetes, and Parkinson's disease, were affected by these deficiencies. For example, one resident with cognitive impairment and another who was cognitively intact both reported not receiving or reviewing their baseline care plans. In some cases, family members expressed concerns about care practices, such as toileting, and reported not being involved in care planning discussions or provided with care plan documentation. Interviews with staff revealed confusion and inconsistency regarding who was responsible for providing and reviewing baseline care plans with residents and their representatives. Some staff believed it was the responsibility of the nurse on the hall, while others assumed the social worker handled it. Facility policy clearly stated that a supervising nurse or MDS nurse/designee was responsible for providing the written summary and obtaining signatures, but this process was not consistently followed, resulting in a lack of documentation and communication with residents and their representatives.
Failure to Meet Professional Standards in Care, Documentation, and Medication Management
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of quality for multiple residents. For one resident with a PICC line, staff did not perform required dressing changes or flushes after the completion of IV antibiotics, and there was no documentation of these actions or provider orders for them. The dressing was observed to be compromised and the date illegible, with the resident unable to recall when it was last changed. The facility's own policy required dressing changes every seven days and immediate changes if the dressing integrity was compromised, but these standards were not met. Another resident with an order for TED hose/compression stockings did not have the stockings available for approximately two weeks, yet staff continued to document their application and removal as if the care was provided. The resident confirmed not having the stockings during this period, and the facility's documentation policy required factual and accurate records, which was not followed in this case. Additional deficiencies included failure to obtain and document laboratory tests as ordered for a resident on anticoagulant therapy, improper documentation and clarification of medication orders for a resident who was NPO but had oral medications documented as given, and failure to clarify and address duplicate medication orders for another resident, resulting in inaccurate medication administration records. These actions and inactions were identified through resident and staff interviews, clinical record reviews, and facility policy reviews.
Failure to Provide Adequate Nursing Staff Resulting in Missed Care and Incomplete Treatments
Penalty
Summary
Facility staff failed to provide adequate nursing staff each day to meet the needs of all residents, resulting in deficiencies in care for six residents. One resident with spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia was observed to be totally dependent on staff for activities of daily living, including incontinence care. The resident was documented as always incontinent and required two staff members for transfers and care. Despite care plan interventions specifying incontinence checks every two hours and as needed, the resident was observed seated in the same location throughout the day, and when incontinence care was finally provided, the resident's brief, clothing, and wheelchair pad were found to be saturated and wet. Staff interviews revealed that CNAs were responsible for high numbers of residents, with one CNA stating she had 16 residents that day, which was fewer than usual, and that she could not complete her work without stopping due to lack of available assistance for two-person care tasks. Additionally, for five other residents, an LPN documented being unable to complete provider orders due to increased patient load. The clinical records for these residents included notes stating that certain treatments, such as wound care and dressing changes, were not completed because of the nurse's workload. The LPN did not specify which tasks were left incomplete in some cases, and the documentation was entered as a medication administration note. The LPN was responsible for 28 residents during the shift, and a review of the staffing schedule confirmed that this was typical staffing for the unit, with two nurses and five CNAs assigned to 56 residents. The facility's staffing coordinator confirmed the usual staffing patterns and acknowledged the workload assigned to staff. The issue of incomplete care and documentation due to staffing levels was discussed with facility leadership, including the administrator, director of nursing, and regional clinical staff. No additional information or clarification regarding the incidents was provided to the survey team prior to the exit conference.
Failure to Obtain Provider-Ordered Laboratory Tests for Multiple Residents
Penalty
Summary
Facility staff failed to obtain provider-ordered laboratory tests for four residents, resulting in missing or incomplete lab results as required by medical orders. For one resident with chronic atrial fibrillation and on anticoagulant therapy, PT/INR tests were not obtained on three separate occasions despite clear orders for weekly monitoring. The resident's care plan included interventions for labs as ordered, but the clinical record lacked the required PT/INR results, and the facility was unable to provide them upon surveyor request. Another resident with a left lower buttock abscess and multiple comorbidities had a wound culture ordered by the wound provider, but the initial culture was not obtained as required. The lab later rejected two wound cultures for unclear reasons, and a repeat culture was only obtained during a subsequent provider visit, which revealed significant bacterial growth. The facility could not provide results or documentation for the initial culture order during the survey period. Additional deficiencies included failure to obtain daily INR tests for a resident with a prosthetic heart valve and altered cardiovascular status, as only three out of five ordered tests were completed. Nursing notes confirmed that the tests were not obtained on two of the required days. Another resident with chronic kidney disease and other conditions had a basic metabolic panel ordered, but the results were not found in the clinical record. The order was later discontinued after consultation with a nurse practitioner, but the initial test was not completed as ordered. In all cases, the facility's policy required timely provision or procurement of laboratory services as ordered by providers, which was not met.
Deficiencies in Food Storage, Labeling, and Serving Sizes
Penalty
Summary
Facility staff failed to store and label resident food items in accordance with professional standards for food service safety. During observations in two resident unit pantry/nutrition areas, multiple food items in both refrigerators and freezers were found to be unlabeled, undated, or improperly stored. Examples included opened containers of ice cream, handheld pastries, and other food items that lacked use-by or expiration dates, as well as items not labeled with residents' names. Some items, such as a jar of strawberry jam, were found with the lid ajar, and a container of milk was past its date. These findings were inconsistent with the facility's own policies, which require labeling, dating, and proper storage of refrigerated and frozen foods. Additionally, the facility staff did not serve food according to the menu's specified serving sizes. During a midday meal observation, dietary staff used three-ounce scoops to serve green beans and collard greens, despite the menu indicating a four-ounce serving size for these items. The Dietary Manager confirmed the incorrect scoop was used and that some resident trays had already been sent out with the smaller portion before the error was corrected. These actions resulted in residents receiving less than the intended portion sizes for their meals.
Improper Disposal and Containment of Facility Garbage and Waste
Penalty
Summary
Facility staff failed to ensure proper disposal and containment of garbage and waste, as observed by surveyors and the Dietary Manager. During an inspection of the facility's outdoor garbage disposal area, it was noted that one dumpster had both doors open and the other had one door open. Additionally, various debris, including blue medical gloves, plastic drinking cups, a piece of foil, a disposable towel, small medication cups, and an empty plastic cup previously containing jello or pudding, were found scattered on the ground around the dumpsters. These observations were discussed with facility leadership during a meeting following the inspection. No information regarding specific residents or their medical conditions was provided in the report.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
Facility staff failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members. During the survey, the team leader requested documentation of staff training and competencies, which, according to the facility assessment, should include QAPI for all staff. Upon review, the Administrator was unable to produce any records of QAPI training or education for facility staff, except for one Certified Nursing Assistant who had completed QAPI training previously. No additional evidence of QAPI training for other staff was provided to the survey team prior to the exit conference. The deficiency was identified through staff interviews and document reviews, with the lack of QAPI training being confirmed by facility leadership and the absence of supporting documentation in staff files.
Deficiencies in Comprehensive Care Planning and Implementation
Penalty
Summary
Facility staff failed to develop and/or revise comprehensive, person-centered care plans to meet the needs of several residents, as identified through observation, staff interviews, clinical record reviews, and facility document reviews. For one resident with a complex mental health history, the care plan did not reflect pertinent diagnoses such as a history of suicide attempt and abuse, nor did it include individualized interventions. Additionally, staff did not consistently follow the care plan regarding the administration of ordered medications for behavioral symptoms, with documentation showing missed or delayed administration of antipsychotic and anxiolytic medications. Another resident's care plan did not accurately reflect the level of assistance required for safe toileting. There was inconsistency between the care plan, staff practices, and family expectations regarding toileting methods, with conflicting documentation about the use of bedpans versus transferring to the toilet. The care conference notes lacked specific documentation of discussions with the family about these concerns, and the care plan did not clearly address the resident's physical limitations and preferences. Additional deficiencies included the failure to address the presence of a peripherally inserted central catheter (PICC) in a resident's care plan, and the failure to implement care plan interventions such as the use of bed bolsters for fall prevention. In another case, a resident's care plan did not correctly identify the purpose of an anticonvulsant medication and included incorrect interventions referencing anti-Parkinson's medications without supporting diagnoses. These deficiencies were identified during surveyor observations, interviews, and record reviews, and were discussed with facility leadership during exit conferences.
Failure to Provide Required ADL Care Including Bathing, Incontinence, and Nail Care
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) care for four residents, resulting in deficiencies related to bathing, incontinence care, and nail care. One resident with multiple complex diagnoses, including severe cognitive impairment and mobility deficits, was not offered a full bed bath or shower at least twice a week as required. Bathing records showed that over a five-day period, the resident received only one partial bath, with no documentation of refusals, despite care plan interventions specifying extensive assistance with bathing. Staff interviews revealed inconsistencies in the understanding and delivery of bathing routines, and observations noted delays in changing soiled clothing after incidents such as vomiting. Another resident, who was totally dependent on staff for ADLs due to spastic quadriplegic cerebral palsy and was always incontinent, was not provided timely incontinence care. Observations throughout the day showed the resident remained in the same location, and when incontinence care was finally provided, the resident's brief, clothing, and wheelchair pad were found to be fully saturated. Staff interviews indicated that care was delayed due to the need for two-person assistance and lack of available staff, despite care plan interventions and facility policy requiring checks and care every two hours. Two additional residents, both dependent on staff for personal hygiene, were not provided adequate nail care. One resident's toenails were observed to be long, and the resident reported being unable to care for them independently. The other resident had long, thick toenails and fingernails that were jagged with debris present. Staff interviews and observations confirmed that nail care was not being performed as required by care plans, with some staff deferring responsibility to a podiatrist. These deficiencies were confirmed through direct observation, staff and resident interviews, and review of facility records and policies.
Multiple Documentation and Medication Record Deficiencies Identified
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for multiple residents, resulting in several documentation deficiencies. For one resident, staff inaccurately documented that a left hip x-ray was completed, despite evidence that the x-ray was not performed as scheduled. Another resident's clinical record contained inconsistent documentation regarding the date of death, with a nurse practitioner entering an incorrect date in the medical record. Additionally, staff failed to document the administration of Tylenol for a resident experiencing pain, with the responsible LPN admitting to administering the medication but not recording it in the medication administration record (MAR). Further deficiencies included the failure to ensure medication orders were correct for a resident who was to receive nothing by mouth (NPO) but had multiple oral medication orders and documentation of administration. Another resident's provider notes incorrectly stated the resident's code status as full code when a do not resuscitate (DNR) order was in place, and staff documented the administration of an antibiotic via the wrong route. The facility also failed to document pre- and post-dialysis weights for a resident with end stage renal disease, despite facility policy requiring this information to be recorded in the clinical record. Additional issues were identified with the administration and documentation of allopurinol for a resident with gout, where duplicate orders led to the MAR reflecting two doses administered on several days, though only one dose was actually given. These deficiencies were identified through staff interviews, clinical record reviews, and facility policy reviews, and were discussed with facility leadership during the survey process.
Repeated QAPI Failures in Quality of Care, Pharmacy, Nutrition, and Infection Control
Penalty
Summary
Facility staff failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by repeated deficiencies in multiple areas including Quality of Care, Pharmacy Services, Food and Nutrition Services, and Infection Control. These deficiencies were identified through staff interviews, clinical record reviews, and facility document reviews, and were noted to have recurred across several standard and abbreviated surveys over a period of several years. Specifically, staff did not consistently follow medical provider orders for a significant number of sampled residents, did not ensure that provider-ordered medications were available and administered as ordered, and allowed expired food items to remain in use. Additionally, staff failed to adhere to established infection control guidelines. The report details that the same areas of deficiency were cited in previous surveys, indicating a lack of effective monitoring and revision of plans of correction. For example, failures to follow medical provider orders and ensure medication availability were cited in both past and current surveys, as was the presence of expired food and lapses in infection control practices. Despite the facility having a policy outlining a systemic approach to performance improvement, there was no evidence provided to the survey team that demonstrated effective tracking or sustained improvement in these areas prior to the exit conference.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
Facility staff failed to maintain the dignity and respect of a resident during incontinence care. The incident involved a certified nurse's aide (CNA) providing care to a resident with multiple diagnoses, including cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety. The resident was assessed as moderately cognitively impaired. During the care, the CNA left the resident's door open and did not fully close the privacy curtain between the resident and her roommate, resulting in the resident's bare bottom being exposed while the roommate was present and the door was open to the hallway. The resident expressed discomfort about the situation, specifically noting concern about men walking in the hallway and potentially entering the room while she was exposed. The CNA acknowledged that the door was not properly closed, and the director of nursing confirmed that both the door and privacy curtain should have been closed during care. The deficiency was identified through observation, staff interview, and resident interview.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
Facility staff failed to notify the physician of a significant change in condition for one resident who experienced notable weight gain. The resident had multiple diagnoses, including diabetes, atherosclerosis, peripheral vascular disease with a left below-knee amputation, gastroesophageal reflux disease, essential hypertension, and major depressive disorder. Clinical records showed that the resident's weight increased from 127.5 lbs to 146 lbs within a little over a month, and from 126.8 lbs to 153 lbs over six months, representing a 14.51% and 20.66% gain, respectively. The Minimum Data Set (MDS) assessment identified these as significant weight gains. Although the Registered Dietician reviewed each significant weight gain and updated the care plan accordingly, there was no evidence found in the clinical record that the primary care provider was notified of these changes. The facility's own policy required physician notification in the event of significant weight changes. During interviews and document reviews, the Director of Nursing confirmed that no documentation existed to show the provider had been informed, and no further information was provided to the survey team before the exit conference.
Failure to Ensure Resident Privacy During Incontinence Care
Penalty
Summary
Facility staff failed to ensure personal privacy for a resident during incontinence care. During an observation, a certified nurse's aide (CNA) was providing care to a resident with the room door open and the privacy curtain only partially pulled, leaving the resident's buttocks exposed. The resident's roommate was present in the room and facing toward the resident receiving care. The CNA acknowledged that the door did not latch properly and believed it was closed, but it was not. The surveyor entered the room after knocking and was able to see the resident exposed, prompting an immediate exit and closure of the door. The resident involved had diagnoses including cerebral infarction, chronic kidney disease, and chronic pain syndrome, and was assessed as moderately cognitively impaired with frequent urinary incontinence and occasional bowel incontinence. The resident later expressed discomfort about the lack of privacy, specifically noting concern about people in the hallway and the need for the door to be closed during personal care. The director of nursing confirmed that both the door and privacy curtain should have been closed during such care.
Failure to Address Resident's Medication Needs Upon Admission
Penalty
Summary
Facility staff failed to ensure that a resident's medication needs were addressed as part of the admission orders. Upon admission from the hospital, the resident's discharge summary included instructions to continue several medications and supplements, including enoxaparin, Epipen, Baqsimi nasal spray, ergocalciferol, olopatadine eye drops, and various vitamins and supplements. However, the facility's medical provider did not order enoxaparin until two days after admission, and there was no documentation explaining the omission for the intervening day. Additionally, orders for Epipen and Baqsimi nasal spray were not obtained until prompted by a surveyor, and several other medications and supplements listed in the hospital discharge summary were not addressed in the admission orders at all. The resident was documented as alert, oriented, with adequate vision and grossly intact hearing at the time of admission. The facility's own policy required that a physician or other qualified provider give orders for the resident's immediate care and needs upon admission, including medication orders if indicated. Despite this, the admission provider failed to address all medications and supplements specified in the hospital discharge summary, and the facility's standing orders did not cover all of the resident's needs, such as the Baqsimi nasal spray for low blood sugar.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
Facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident with multiple diagnoses including mild cognitive impairment, cerebral infarction, and right-side hemiparesis, staff did not code the use of a right-hand splint and right elbow extension brace on the MDS assessment, despite provider orders, care plan documentation, and treatment administration records confirming the use of these devices for contracture management. The resident was observed by the surveyor wearing the splint, and the care plan and orders clearly indicated the need for these interventions, but the MDS did not reflect this information. For another resident with diagnoses such as cerebral infarction, metabolic encephalopathy, and moderate cognitive impairment, staff incorrectly coded the MDS to indicate the use of anticoagulant medication during the assessment period. A review of the clinical record did not show evidence that the resident received any anticoagulant medication in the relevant seven-day period. The MDS Coordinator confirmed the error after reviewing the record. No additional information regarding these concerns was provided to the survey team prior to the exit conference.
Failure to Complete Required PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
Facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was completed for two residents with significant mental health diagnoses. One resident had diagnoses including cerebral infarction, metabolic encephalopathy, convulsions, unspecified psychosis, major depressive disorder, and generalized anxiety disorder, and was assessed as moderately cognitively impaired with delusions and wandering behavior. Despite residing in the facility for approximately five months, no Level I PASARR was found in the clinical record, and staff interviews confirmed that the screening had not been completed. The facility policy required all applicants to be screened for serious mental disorders or intellectual disabilities prior to admission, and for records of the pre-screening to be maintained in the resident's medical record. However, staff were unclear about their responsibilities regarding PASARR completion, with the social worker and admissions coordinator both stating they had not been instructed to complete the screenings. A second resident with diagnoses including suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features also did not have a Level I PASARR in their clinical record. The resident was cognitively intact according to the most recent assessment. Staff interviews revealed a lack of awareness and training regarding the facility's policy on PASARR responsibilities, with both the social worker and admissions director stating they had never completed or been told to complete Level I PASARRs. The facility's policy designated the social services director as responsible for tracking PASARR status, but the social worker was unaware of this policy. No further information or documentation regarding PASARR completion was provided to the survey team prior to the exit conference.
Failure to Complete Provider-Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility nursing staff failed to complete a provider-ordered treatment for a pressure ulcer on a resident's left buttock. The resident had diagnoses including paranoid schizophrenia, diabetes, and chronic pain syndrome, and was assessed as moderately impaired in cognitive skills. The resident was identified as being at risk for pressure ulcers and had a provider order to cleanse the open area, apply barrier cream, and cover with a bordered gauze dressing daily and as needed. On one occasion, the treatment was not completed as ordered, with documentation indicating that the LPN was unable to perform the wound care due to increased patient load. The provider order for the wound care was discontinued the following day after the wound was assessed as healed. The deficiency was identified through staff interview, clinical record review, and facility document review, and was discussed with facility leadership during an end-of-day meeting. No additional information regarding the missed treatment was provided to the survey team prior to the exit conference.
Failure to Prevent Accident Hazards and Provide Supervision for High-Risk Resident
Penalty
Summary
Facility staff failed to ensure an environment free from accident hazards and did not provide adequate supervision for a resident with a history of suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features. The resident was assessed as cognitively intact, at high risk for falls, and at risk for wandering. Despite these risks, the resident was repeatedly found outside the facility unsupervised, smoking cigarettes obtained from the ground, and attempting to leave the premises. The resident's care plan included interventions for self-care deficits, fall risk, and behavioral issues, but these were not effectively implemented to prevent the resident from accessing hazardous areas or engaging in unsafe behaviors. Multiple nursing notes documented incidents where the resident was found outside, sometimes in the driveway or attempting to leave, and on one occasion, the resident fell while outside, hitting his head and abdomen. Staff were aware of the resident's revoked smoking privileges due to policy violations, yet the resident continued to access cigarettes and lighters. Observations by the surveyor confirmed the resident was outside unsupervised, and staff acknowledged this was a recurring issue. Facility policy required supervision and secure storage of smoking materials, but these measures were not consistently enforced for this resident.
Failure to Document and Provide Evidence of Therapeutic Diet Delivery
Penalty
Summary
Facility staff failed to provide evidence that a resident with multiple complex medical diagnoses, including atrial fibrillation, dementia, heart failure, and a history of falls, received or refused a therapeutic diet as ordered by the medical provider during several evening meals. The resident was assessed as moderately cognitively impaired and had a care plan in place to provide and monitor a regular diet, with intake to be recorded at each meal. However, meal intake records for specific dates showed no documentation of meal percentages consumed or refusals for the evening meals in question. Interviews with staff and the local ombudsman did not yield direct observations of the resident missing meals, and staff recalled the resident typically ate independently after tray setup, preferring finger foods. Despite this, the facility was unable to provide documentation for meal delivery or refusals on the specified dates, except for one instance where partial intake was recorded. The facility's policy required encouragement of resident participation in meals, but no further information was provided to demonstrate compliance with ordered dietary interventions during the identified periods.
Failure to Provide and Document Ordered Respiratory Care
Penalty
Summary
Facility staff failed to provide ordered respiratory care and treatments for two residents. For one resident, there were medical provider orders for the use of an incentive spirometer, including specific instructions for use and monitoring of vital signs and breath sounds before and after each treatment. However, the start date for the treatment was incorrectly entered, and staff could not find documentation that the incentive spirometer was provided or that the orders were carried out. Further investigation revealed uncertainty among staff and the medical provider regarding whether the order was intended for this resident, and no supporting documentation was found in the clinical record. For another resident, who was under hospice care, the hospice plan of care included scheduled nebulizer treatments with albuterol and ipratropium every eight hours. The resident's hospice certification and plan of care confirmed these treatments were to be continued. However, there was no evidence in the clinical record that the nebulizer treatments were administered between the hospice visit and the resident's death. The DON confirmed the absence of documentation for these treatments after reviewing the records. Interviews with facility staff, including the RN who entered the orders, the Medical Director, and the DON, confirmed the lack of documentation and uncertainty regarding the administration of the ordered respiratory treatments. The survey team discussed these findings with facility leadership, highlighting the failure to provide and document required respiratory care as ordered for both residents.
Failure to Coordinate Dialysis Care and Document Required Weights
Penalty
Summary
Facility staff failed to coordinate care with the dialysis center for a resident diagnosed with end stage renal disease who required dialysis three times a week. The resident's care plan included interventions to coordinate care with the dialysis provider as needed, and facility policy required obtaining pre- and post-dialysis weights and ensuring communication with the dialysis center. However, during clinical record review, there was no documentation of pre- or post-dialysis weights for the resident, and the dialysis book intended to accompany the resident to dialysis contained only blank pages. Interviews with staff revealed that required paperwork was not consistently sent with the resident to dialysis, and staff did not obtain or document the necessary weights as outlined in facility policy. The absence of completed documentation and lack of coordination with the dialysis center were confirmed by both the Assistant Director of Nursing and the Unit Manager. No further information or documentation regarding the coordination of care was provided to the survey team prior to the exit conference.
Failure to Ensure Accurate and Appropriate Physician Orders for Residents
Penalty
Summary
Medical providers at the facility failed to ensure that physician orders addressed the needs of two residents. For one resident, incentive spirometer orders were entered with a delayed start date and without supporting documentation in the clinical record. The orders were signed by a medical provider without adjustment, and both the nurse who entered the orders and the medical director could not confirm for whom the orders were intended. The nurse suggested the orders may have been entered for the wrong resident and could not locate documentation to support their necessity. For another resident, duplicate orders for allopurinol were entered by non-prescribing staff and subsequently signed by a medical provider without identifying the duplication. The duplicate orders remained active until a different medical provider later discontinued one of them after recognizing the duplication. Both residents were assessed as alert and oriented, with adequate cognitive and sensory function documented at the time of the deficiencies.
Failure to Review and Address Diabetic Medication Changes Post-Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident's attending physician reviewed the hospital discharge summary following a hospital stay, specifically neglecting to address changes in the resident's diabetic medications. The discharge summary indicated that several diabetic medications, including insulin and metformin, were to be discontinued. However, upon the resident's readmission, there was no documentation of a medical provider reviewing or addressing these medication changes, nor were there new provider orders or progress notes explaining the discontinuation or providing alternative diabetic management. The resident had a complex medical history, including Type 2 Diabetes Mellitus with chronic kidney disease, atrial fibrillation, morbid obesity, and other significant comorbidities. Despite a care plan goal to prevent complications related to diabetes, the clinical record showed no evidence of diabetic medication orders or blood glucose monitoring after the resident's return from the hospital. The last recorded blood sugar check was prior to the hospital transfer, and subsequent lab results revealed persistently high glucose levels and an elevated A1C, indicating poor glycemic control. Interviews with administrative staff confirmed the absence of provider documentation or orders regarding the resident's diabetes management after readmission. The facility's policy required verification of transfer orders and provider review, but this process was not followed. The resident was unaware of his current diabetic medication regimen, and staff could not provide an explanation for the lack of diabetic care orders until the issue was identified during the survey.
Failure to Provide Timely Access to Ordered Medications
Penalty
Summary
Facility staff failed to ensure that ordered medications were available and administered as prescribed for three residents. For one resident with multiple diagnoses including neuropathy, diabetes, Alzheimer's disease, and atrial fibrillation, an order for Rocephin (Ceftriaxone Sodium) to treat a suspected urinary tract infection was not fulfilled because the medication was not available in the in-house supply. Staff used the last available dose, and subsequent attempts to obtain the medication from the Cubex system were unsuccessful. The pharmacy was not restocked in a timely manner, and the medication was placed on hold until it arrived, resulting in a missed dose. Another resident with diagnoses such as diabetes, obstructive and reflux uropathy, hypertension, and atrial fibrillation did not receive a one-time ordered dose of Ceftriaxone Sodium (Rocephin) as scheduled. The medication was not available in the Cubex system at the time of administration, and the dose was delayed until it could be obtained from the pharmacy. Facility policy indicated that a STAT supply of commonly used medications should be maintained in-house, but this was not followed in these instances. A third resident, with a history of femur fracture, chronic atrial fibrillation, restless leg syndrome, and osteoarthritis, did not receive two scheduled doses of Lyrica for pain management because the medication was not available. Nursing notes documented calls to the pharmacy and provider to obtain a new prescription and indicated that the medication was on order and awaiting delivery. The care plan for this resident included medicating as ordered for comfort, but the medication was not administered as prescribed due to unavailability.
Failure to Complete and Act Upon Medication Regimen Reviews
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews (MRRs) were completed by a licensed pharmacist and that recommendations from these reviews were reported to and acted upon by medical providers in a timely manner for multiple residents. For one resident with multiple complex diagnoses, including progressive multifocal leukoencephalopathy and chronic kidney disease, the MRR completed by the pharmacist was not acknowledged or signed by a medical provider until well after the recommendation was made. The recommendation involved evaluating the use of multiple antidepressants and considering a dose reduction, but documentation of timely provider review and action was lacking. Another resident with severe cognitive impairment and multiple chronic conditions did not have evidence of MRRs being completed for several consecutive months. When MRRs were completed, the reports and recommendations were not promptly available in the clinical record, and provider responses were delayed. Recommendations included monitoring thyroid therapy and clarifying medication stop dates, but provider acknowledgment and action were not documented until weeks after the pharmacist's recommendations. A third resident with severe cognitive impairment had a pharmacist's recommendation for a dose reduction of Depakote that was not addressed by the medical provider for several months. The facility's policy required that MRR irregularities be reported and acted upon, but documentation showed significant delays in provider response and action. These deficiencies were confirmed through staff interviews, clinical record reviews, and facility policy review, with no additional information provided to the survey team prior to exit.
Failure to Hold Insulin per Physician Parameters
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of Lantus insulin. The resident, who had diagnoses including cerebral infarction, type 2 diabetes mellitus, and hypertension, was cognitively intact according to the most recent MDS assessment. The resident's care plan included diabetes management with medication as ordered by the physician. The physician's order for Lantus insulin specified that it should be held if the resident's blood sugar (BS) was less than 150. Review of the electronic medication administration records (eMAR) for February and March showed that the resident received Lantus insulin multiple times when their BS was below the ordered hold parameter of 150. Specific instances included administration with BS readings of 147, 129, 104, 128, 142, 131, and 117. The DON confirmed that the insulin should have been held according to the physician's parameters. Facility policy also required medications to be held when vital signs were outside prescribed parameters. No additional information was provided prior to the survey exit.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
Facility staff failed to ensure that two residents were free from unnecessary psychotropic medications by not monitoring for behaviors or side effects associated with these medications. For one resident with diagnoses including Bipolar Disorder, Seizures, Insomnia, Chronic Kidney Disease, Borderline Personality Disorder, and Atrial Fibrillation, there were no orders or documentation for behavior or side effect monitoring related to prescribed psychotropic medications such as Effexor, Trazadone, Depakote, and Ziprasidone during the month of March. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15, and was a new admission to the facility. The lack of monitoring was confirmed by facility leadership during the survey process. Another resident, with diagnoses including Progressive Multifocal Leukoencephalopathy, Anorexia, Chronic Kidney Disease, Acute Kidney Failure, Anxiety Disorder, Repeated Falls, Ataxia, Acute Respiratory Failure with Hypoxia, and Wasting Disease Syndrome, was also not monitored for behaviors or side effects related to psychotropic medications in April. This resident was prescribed multiple psychotropic medications, including Citalopram, Doxepin, Trazadone, and Lorazepam. The resident was cognitively intact, with a BIMS score of 15 out of 15. The April medication administration and treatment records did not include any psychotropic drug monitoring, despite the care plan indicating the need to observe and document adverse reactions. Facility policy required ongoing evaluation of the effects of psychotropic medications on residents' physical, mental, and psychosocial well-being, consistent with clinical standards and the residents' comprehensive care plans. However, in both cases, the required monitoring was not implemented or documented as required, leading to the identified deficiencies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 28 opportunities, resulting in a 7.14% error rate. During a medication pass, an LPN administered the incorrect dose of famotidine to a resident with diagnoses including atrial fibrillation, heart failure, bradycardia, and GERD. The LPN gave 10 mg of famotidine instead of the ordered 20 mg. Additionally, the LPN withheld the resident's metoprolol based on a pulse of 60, despite the physician's order specifying to hold the medication only if the pulse was less than 60 or systolic blood pressure was less than 100. Upon review, the LPN acknowledged the errors when prompted by the surveyor, confirming that the correct famotidine dose should have been two 10 mg tablets and that metoprolol should not have been withheld. These errors were discussed with facility leadership, including the Administrator and Director of Nursing, during the survey process. No further information was provided to the survey team prior to the exit conference.
Failure to Administer Prescribed Antibiotic as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not administering Levofloxacin as ordered by the provider. The provider's order specified that the resident was to receive Levofloxacin 750 mg orally once daily for five days, starting on 3/11/25. However, review of the medication administration record (MAR) and clinical documentation showed that the resident only received four doses of the medication, rather than the prescribed five. On the first scheduled day, the resident was marked as being on a leave of absence due to a hospital transfer and did not receive the medication. The resident involved had multiple complex diagnoses, including Progressive Multifocal Leukoencephalopathy, Chronic Kidney Disease, Acute Kidney Failure, and Acute Respiratory Failure with Hypoxia, among others. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Despite the facility's policy requiring medications to be administered as ordered, the missed dose was not addressed, resulting in the resident not receiving the full prescribed course of antibiotic therapy.
Expired Medications and Biologicals Not Disposed in Medication Room
Penalty
Summary
Facility staff failed to dispose of expired medications and biologicals in one of two medication rooms, specifically the [NAME] side medication room. During an observation conducted by the surveyor and the Assistant Director of Nursing (ADON), multiple expired items were found, including 16 red top laboratory tubes with expiration dates of 12/31/24 and 11/30/24, a box of opened green top tubes with an expiration date of 03/31/25, four bottles of D3 medication expired as of 03/2025, and four boxes of Influenza vaccine labeled 2023-2024 formula with an expiration date of 06/30/24, each containing 10 syringes. The ADON confirmed these items were expired upon review. The issue was subsequently discussed with the Administrator, Director of Nursing, and Regional Director of Clinical Services. No additional information regarding this issue was provided to the survey team prior to the exit conference.
Laboratory Tests Performed Without Proper Physician Order
Penalty
Summary
Facility staff obtained laboratory tests for a resident without a proper physician's order. Specifically, the resident had a physician's order for an international normalized ratio (INR) test to be performed every Monday. However, clinical record review and laboratory reports showed that the INR was obtained on multiple days throughout the week, not just on Mondays as ordered. The electronic medication administration record indicated that the INR was documented as being obtained daily, except for one day, which was inconsistent with the physician's order. The resident involved had diagnoses including cerebral infarction, type 2 diabetes mellitus, and a prosthetic heart valve, and was on anticoagulant therapy. The resident was cognitively intact and confirmed during an interview that blood was drawn for INR testing about three times a week. The DON acknowledged that the INR should only have been obtained on Mondays, as per the physician's order. Facility policy requires laboratory services to be provided only when ordered by an appropriate practitioner.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's documented food preference for boiled eggs each day. The resident, who has diagnoses including cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety, was assessed as moderately cognitively impaired with a Brief Interview for Mental Status score of 8 out of 15. The resident's face sheet and tray ticket both indicated a preference and instruction for boiled eggs daily. However, during multiple observations and interviews, the resident reported not receiving boiled eggs for breakfast, and surveyors confirmed that the breakfast trays did not contain boiled eggs on those occasions. The dietary manager acknowledged awareness of the resident's preference, stating that the information was obtained through direct communication with residents and recorded on meal tickets. Despite this, the dietary manager admitted that boiled eggs were not consistently provided, citing supply issues and a lack of regular ordering. The deficiency was discussed with facility leadership, but no additional information was provided prior to the survey exit.
Failure to Involve Medical Director in Securing Surgical Consult
Penalty
Summary
Facility staff failed to involve the Medical Director when they encountered ongoing difficulties in scheduling a surgical consult for a resident with a rectal prolapse. The resident, who had diagnoses including rectal prolapse, Barrett's Esophagus, GERD, and dementia, was assessed as having intact or borderline cognition. After a physician assistant identified a rectal prolapse and attempted but was unable to reduce it, a referral to colorectal surgery was ordered. Despite the referral being sent and multiple documented follow-up attempts by the facility scheduler over several months, no appointment was secured for the resident. Throughout this period, staff continued to document the resident's condition and made repeated calls to the surgical clinic, but were consistently informed that no appointment had been scheduled. The scheduler also attempted to contact another clinic, which did not perform the required surgery. At no point during these delays did staff seek the Medical Director's assistance, and the Medical Director later confirmed he had not been contacted regarding the issue. The deficiency centers on the staff's failure to utilize the Medical Director's role in coordinating medical care when standard processes were unsuccessful.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to follow established infection control guidelines for a resident with spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia, who was dependent for toileting hygiene and always incontinent of bowel and bladder. The resident was on enhanced barrier precautions due to a PEG tube, as indicated in the care plan and by a sign on the resident's door. During incontinence care, two CNAs did not wear proper PPE, specifically gowns, and placed soiled incontinence briefs and wet shorts on the floor beside the resident's bed. One CNA later confirmed only wearing gloves and was unaware that a gown was required, despite the presence of a sign indicating enhanced barrier precautions. The DON acknowledged that staff should have worn proper PPE and not placed soiled items on the floor. The facility's enhanced barrier precautions signage clearly outlined the requirement for gloves and gowns during high-contact care activities, including changing briefs and providing hygiene for residents with devices such as feeding tubes.
Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
Facility staff failed to offer pneumococcal conjugate vaccines (PCV20 or PCV21) to two residents following their admission, despite both having previously received PCV13 and being assessed as not up to date with pneumococcal vaccination. For both residents, clinical records and the Minimum Data Set (MDS) indicated moderate cognitive impairment and documented that the pneumococcal vaccine was not up to date, with the stated reason being that it was not offered. Both residents had significant medical histories, including Alzheimer's disease and other chronic conditions. The facility's policy required assessment and offering of pneumococcal immunization upon admission in accordance with CDC guidelines, with documentation of efforts to obtain immunization history. However, staff interviews and record reviews revealed that these steps were not completed for the two residents in question. The assistant director of nursing, who also served as the infection preventionist, was unable to provide documentation that the vaccine had been offered or administered, and no further information was provided prior to the survey exit.
Failure to Permit Resident to Remain and Inadequate Discharge Documentation
Penalty
Summary
Facility staff failed to permit a resident with multiple complex diagnoses, including seizures, COPD, hypertension, anxiety, heart failure, a history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance, to remain in the facility. The resident had moderate cognitive impairment and required maximum assistance for most activities of daily living. Despite the resident's preferences for certain activities and his non-ambulatory status, the facility initiated a transfer to the emergency room following an incident where the resident reportedly exhibited behavioral issues, including hitting staff and making threats. However, documentation from hospice and EMTs indicated that the resident was calm and non-combative during their assessments, and the resident expressed a desire not to be transferred to the hospital. The facility administrator cited a policy requiring ER evaluation for aggressive behaviors, but the current administrator later clarified that this was not a formal policy but rather a section in the admission agreement. The facility issued a 30-day discharge notice after learning more about the resident's psychiatric history, despite a care plan being developed in collaboration with hospice to address his needs. Interviews with hospice staff revealed that the facility did not attempt to implement the agreed-upon interventions before issuing the discharge notice. The discharge notice cited the facility's inability to meet the resident's needs and concerns for the health, safety, and well-being of others, but there was no documentation of specific needs that could not be met or of attempts to address those needs as required by facility policy. Medication management for the resident was also inconsistent, with delays in starting prescribed medications and some orders not being administered as intended. Staff interviews indicated that while the resident had some behavioral incidents, there was no evidence that he attempted to harm other residents. The facility's own assessment stated that it could care for residents with psychiatric and behavioral needs, yet the documentation and actions taken did not reflect adequate attempts to meet this resident's needs prior to discharge. The required documentation supporting the discharge, including specific unmet needs and efforts to address them, was not found in the medical record.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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