Parham Health Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 2400 E Parham Road, Richmond, Virginia 23228
- CMS Provider Number
- 495097
- Inspections on file
- 29
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 60 (3 serious)
Citation history
Health deficiencies cited at Parham Health Care & Rehab Center during CMS and state inspections, most recent first.
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.
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.
A resident with dysphagia, severe cognitive impairment, and an order for a pureed/mechanically altered diet was repeatedly served food and beverages that did not match the prescribed texture, including improperly textured chicken and a cookies-and-cream milkshake. The resident’s care plan and MDS documented the need for a pureed diet, yet observations and interviews showed multiple instances of incorrect meal trays and non-pureed items being provided and consumed. A provider later documented radiographic evidence of recurrent aspiration pneumonia and noted a report that the resident had recently received a milkshake containing candy pieces, which was identified as likely contributing to the aspiration episode.
Staff on two nursing units failed to protect the confidentiality of clinical records by using personal laptop computers to access resident information. Multiple nurses reported they brought their own computers because there were not enough facility devices, some unit computers lacked chargers, and uncharged equipment delayed medication passes. Leadership confirmed that staff were not authorized to use personal computers, that the EHR was only accessible on the facility network, and that there was no system to prevent staff from saving residents’ personal or medical information on personal devices, despite a policy stating employees should use company computers primarily for company business.
An LPN with long artificial nails repeatedly failed to follow hand hygiene and infection control practices during a med pass involving multiple residents. The LPN handled oral meds directly in the bare hand, including scooping pills from multi‑dose bottles with a fingernail and transferring pills from blister packs into the palm before placing them in cups, and picked up a pill from the top of the med cart with a bare hand. After performing a fingerstick blood glucose check with a glucometer and administering meds, the LPN removed gloves, placed the glucometer on and then into the med cart without disinfecting it, and documented on the computer without performing hand hygiene. The LPN continued to administer meds, prepare MiraLAX, access the treatment cart, and handle wound care supplies while moving between resident rooms, the med cart, and the nurses’ station, all without hand hygiene, contrary to facility policies on handwashing, ABHR use, and fingernail standards.
Facility staff failed to maintain adequate linen supplies and a sanitary, comfortable environment across all units. An oriented resident reported waiting hours for incontinence care due to insufficient linens, and observations showed linen carts on all units with only minimal towels, wash cloths, sheets, and blankets, forcing CNAs to search other units for supplies. Hallways and common areas on one wing had dirty floors, debris in corners, and soiled or empty hand sanitizer dispensers, while a water fountain near a nurses’ station had a brown stain around the drain and gnats emerging when water was run, which a unit manager said resembled a nutritional supplement used during med pass. One cognitively impaired resident with multiple neurologic diagnoses had a room with clothes piled on the floor, debris, dirty dishes, and a brown substance on the floor and in the bathroom, and two residents sharing another room reported infrequent cleaning as their room remained in disarray with trash and soiled floors. Throughout the survey, cobwebs and a spider web remained in a window near the therapy gym, and housekeeping and regional housekeeping leadership acknowledged reduced housekeeping staffing and described daily cleaning expectations that were not met in the observed areas.
Facility staff failed to notify a resident’s responsible party after the resident, who had severe cognitive impairment and multiple neurologic and respiratory diagnoses, was found on the floor with a bruised orbital area and later sent to the ER. The resident’s face sheet listed a family member as the responsible party and primary emergency contact, and facility policy required responsible party notification for significant changes of condition. Review of clinical records and interviews with leadership, including the DON, showed no documentation or evidence that the responsible party was informed of either the fall or the hospital transfer.
A resident’s right to voice grievances was not honored when the facility failed to fully resolve a complaint about missing clothing sent by the resident’s family. The grievance documented that clothing delivered to the front desk was never received by the resident, and the facility’s investigation noted the items could not be located and that the resident’s sister would be reimbursed for the loss. Despite documentation of the planned reimbursement and supporting receipts, the family later reported they had not received any payment, and the administrator confirmed the reimbursement was still pending, indicating the grievance remained unresolved.
Facility staff failed to protect a resident’s right to be free from misappropriation of property when clothing delivered by the resident’s family was left at the front desk, never reached the resident, and could not be located. The resident’s record contained no documentation of a request for clothing or receipt of the items. A grievance from the family stated the clothes were missing, and the facility’s investigation noted the items could not be found and that reimbursement would be provided. However, the family later reported they had not received reimbursement, and the administrator confirmed that payment had not been sent despite documentation indicating otherwise.
Facility staff failed to consistently implement a comprehensive care plan for a resident with dysphagia and severe cognitive impairment, including not obtaining weekly weights as care-planned and not reliably providing the ordered puree diet. Record review showed only two documented weights over about a month despite a weekly weight intervention. Observation of a lunch meal revealed chicken that was a mixture of mechanically altered and pureed textures, which the SLP deemed unsafe for this resident. A family member reported the resident had been given an inappropriate milkshake with solid mix-ins and had received incorrect meal trays on multiple occasions, demonstrating inconsistent adherence to the resident’s diet and nutritional care plan.
Multiple residents were physically assaulted by peers, including being punched and sustaining injuries that required medical attention, due to staff failing to provide required supervision and timely intervention. Some residents with known behavioral risks were not adequately monitored, and staff did not consistently follow care plans or document incidents, resulting in harm and immediate jeopardy.
Multiple residents with cognitive impairment and behavioral issues physically assaulted others due to inadequate supervision, despite some having orders for 1:1 monitoring. In several cases, residents were left unsupervised in high-risk areas, such as the smoking courtyard, leading to injuries that required medical attention. Staff failed to update care plans or consistently document incidents, and residents assessed as needing supervised smoking were allowed to possess smoking materials independently, violating safety protocols.
Facility staff did not provide a full-time, qualified social services director, as the current director worked remotely and part-time after accepting another full-time job. The social services assistant lacked the necessary qualifications, resulting in the facility not meeting residents' social service needs as required.
Facility staff failed to maintain an effective QA program, resulting in multiple residents being abused by staff and other residents. There were repeated failures to report, investigate, and prevent abuse, as well as inadequate supervision and lack of adherence to abuse policies. Despite previous corrective actions, additional residents were harmed, and immediate jeopardy was identified due to ongoing non-compliance.
Facility staff did not conduct complete investigations into multiple allegations of abuse and misappropriation involving several residents. In one case, a resident with a TBI physically assaulted another resident, but the investigation lacked staff witness statements and failed to identify all individuals present. In another incident, a resident was assaulted in the hallway, yet there was no evidence that residents or staff were interviewed or that all witnesses were identified. Additionally, when a resident reported missing money after a room change, the investigation was limited to a brief summary and did not include staff interviews or efforts to locate the missing funds.
Facility staff failed to follow professional standards by not documenting or transcribing a physician's order for Benadryl after a resident's allergic reaction, administering medications outside the scheduled window for another resident, and not documenting resident-to-resident altercations in the clinical records for three residents. Nursing and administrative staff confirmed these actions did not meet basic nursing practice requirements.
Dietary staff failed to follow sanitary practices during meal preparation and service, including not wearing beard guards, not taking holding temperatures before serving, using the same gloves to handle multiple items and surfaces, directly handling food without utensils, and serving food on wet plates. These actions did not comply with facility policies for food safety and staff hygiene.
Facility staff did not ensure a clean environment in four resident rooms, as evidenced by trash and dirty floors, strong urine odors, and stained or discolored tiles. A resident reported unaddressed housekeeping requests, and the environmental services manager confirmed that daily cleaning was insufficient for the level of soiling observed. Some rooms required deep cleaning or tile replacement, but these actions had not been completed.
A resident was found with an over-the-counter medication at the bedside and reported self-administering it daily without a documented assessment or physician order. Despite facility policy requiring an interdisciplinary team assessment for self-administration, staff confirmed that no such assessment or order was in place for any residents on the unit.
Facility staff did not follow required procedures for timely reporting and thorough investigation of multiple abuse, neglect, and theft allegations. In several cases, incidents were not reported within the mandated timeframe, and investigations lacked interviews with all involved parties and witnesses, resulting in incomplete documentation and failure to meet policy standards.
Facility staff did not report allegations of misappropriation and physical abuse involving three residents to the required agencies within the mandated timeframes. In one case, a resident's missing money was not reported for several days, and in another, two residents involved in an altercation were not reported within the two-hour window required for abuse allegations. Staff interviews and documentation confirmed that reporting procedures were not followed as outlined in facility policy.
Facility staff did not create a comprehensive care plan for a resident with multiple food and drug allergies, resulting in an allergic reaction after being served fish. Although allergies were noted in various records, there was no care plan addressing them, and no documentation of physician orders, medication administration, or nursing assessment following the incident.
Staff did not review or update care plans for two residents after each was involved in a physical altercation with another resident. Both residents had documented histories of behavioral issues, including aggression, but following the incidents, there was no evidence that their care plans were evaluated for effectiveness or revised. Interviews with LPNs and a unit manager confirmed that care plans should be updated after such events, but this was not done in these cases.
Staff failed to provide timely incontinence care and repositioning for a dependent resident with multiple medical conditions, resulting in the resident remaining in bed for over five hours without necessary ADL assistance. Upon eventual care, the resident was found with a wet brief, a small bowel movement, and a new pink area on the sacrum. Facility leadership confirmed this lapse exceeded expected care intervals.
A resident who sustained a hematoma to the forehead after an unwitnessed fall was not properly monitored for latent injuries, as required neurological checks were incomplete or missing. Despite staff knowledge of the protocol and facility policy mandating neuro checks at specific intervals, documentation showed that these assessments were not performed as required after the incident.
Facility staff did not complete annual performance evaluations for two certified nursing assistants, as confirmed by the DON during interviews and document review. The facility was also unable to provide a policy on staff training and performance evaluations when requested.
The facility failed to maintain complete and accurate medical records for two residents: one with multiple allergies who experienced an undocumented allergic reaction and did not have a physician's order for Benadryl transcribed or assessment documented, and another involved in a physical assault incident where details were missing from the clinical record and the aggressor was misidentified in facility documentation.
The QAPI committee did not consistently include the Infection Preventionist as required, and documentation for one quarterly meeting was missing. The DON confirmed that the Infection Preventionist was not always present at meetings, and facility policy mandates their attendance.
Staff failed to maintain a working call bell system, leaving multiple residents without a reliable way to call for help from their rooms or bathrooms during repeated outages. Interviews and documentation revealed that staff were unaware of the location of hand bells, there was no clear policy for alternative assistance, and residents experienced prolonged periods without functioning call bells, leading to fear and frustration.
A dietary aide was found to have not received the required Resident's Rights training, as confirmed by a review of employee records and interviews with the DON and Regional Director of Clinical Services. Documentation provided was either dated prior to the aide's hire or did not show evidence of the necessary training, and no facility policy or additional proof was presented.
A dietary aide was found to have no credible evidence of completing required abuse and neglect training, as revealed during a review of employee records and interviews with the DON and RDCS. Documentation provided was either dated prior to the aide's hire or did not show completion of the necessary training, and no facility policy on staff training was produced when requested.
Facility staff did not provide required Quality Assurance and Performance Improvement (QAPI) training for a dietary aide, as shown by a lack of credible documentation in the employee's record. The DON confirmed that all staff, including dietary, should receive QAPI and related training, but could not provide evidence that this occurred. No staff training policy was presented when requested.
A dietary aide was found to have no credible evidence of completing mandatory infection control training, as required by facility policy. The DON and Regional Director of Clinical Services confirmed that all employees should have this training, but documentation was lacking and no policy was provided when requested.
A dietary aide was found to have no credible evidence of having completed required compliance and ethics training after being hired. Documentation provided was either dated before employment or did not include the necessary training, and facility leadership could not produce a staff training policy or additional proof of compliance.
Surveyors observed persistent urine odors, flies, missing or loose hand sanitizer units, damaged breakfast trays, missing tiles, stained mattresses, and unresolved maintenance issues such as a leaking sink and a detached footboard. Residents with complex medical histories were directly affected, and staff interviews confirmed awareness of some issues but lack of resolution or reporting to management.
A resident with a history of stroke, left-sided weakness, and chronic heart disease was injured when a poorly maintained closet door, lacking proper screws and showing signs of water damage, fell onto her while she was seated in her wheelchair. The closet was also infested with cockroaches, and the facility had not implemented an effective pest control or timely maintenance program, despite being aware of ongoing issues with closet safety and building climate control.
Staff did not maintain an effective pest control program, with flies observed throughout the facility and a strong urine odor present. Environmental issues included missing or loose hand sanitizer units, missing tiles, damaged mattresses, and a breakfast tray with sharp corners served to a resident. Plastic utensils were used for meals due to staff shortages, and a leaking sink in a resident's room remained unfixed for several days. Residents affected had complex medical conditions, and interviews confirmed ongoing unresolved issues.
A resident who was totally dependent on staff for ADL care and had multiple medical conditions was found soiled in urine and feces for several hours, with her bed and clothing saturated and stained. The resident's room and unit had a strong odor, and she reported that this lack of timely hygiene care happened often due to insufficient staffing. Documentation indicated that required bathing and hygiene were not provided as needed, and the resident was not seen out of bed during daytime hours.
A resident with multiple chronic conditions, who was cognitively intact and fully dependent on staff, experienced repeated delays in medication administration, with some doses given hours late or even the next day. The resident was also observed to be soiled in bed for extended periods, despite documentation indicating regular care. These deficiencies were confirmed through interviews, record reviews, and direct observation.
A resident with multiple medical conditions was repeatedly observed accessing unsecured hazardous areas, including a biohazard bin, open generator, and debris-filled walkways, due to staff failure to secure these locations and restrict access. Staff were aware of the resident's behavior and the lack of proper security measures, such as missing locks and unsecured doors, but did not effectively prevent access. Additionally, a generator exhaust pipe with a large rusted hole was found, posing a risk of carbon monoxide exposure, and was only temporarily addressed after being identified.
A resident with no cognitive impairment was repeatedly able to access unsecured, dirty biohazard containers outside the facility, despite staff interventions and education. The resident was observed opening and reaching into a large biohazard bin containing medical waste, and clinical records documented ongoing behaviors of entering hazardous areas. The facility failed to secure these containers and restrict resident access, resulting in an infection control deficiency.
Two residents developed Stage 3 pressure ulcers after staff failed to identify early skin breakdown, provide timely wound assessments, and implement necessary interventions such as nutritional support and pressure-relieving devices. Lapses in documentation, communication, and adherence to care protocols led to harm, with staff sometimes unaware of the severity of wounds and recommended interventions not consistently applied.
Facility staff did not consistently provide meals and snacks at regular times or in accordance with resident needs and preferences. Residents reported rarely receiving bedtime snacks, with some diabetic residents not getting snacks regularly, and non-ambulatory residents unable to access snacks left at the nursing station. Observations confirmed delayed meal delivery, long intervals between dinner and breakfast, and limited food variety. The Dietary Manager stated that only diabetic residents received bedtime snacks, and staffing shortages were cited as a factor affecting meal service.
Staff did not maintain comfortable temperatures throughout the facility, with residents observed wrapped in blankets and room temperatures below the facility's minimum standard. The heating and cooling system was not functioning properly due to unresolved mechanical issues, and water leakage from a malfunctioning air conditioning unit was also observed. Despite a policy for timely repairs, these deficiencies remained unresolved by the end of the survey.
Staff failed to maintain an effective pest control program, resulting in ongoing infestations of roaches, ants, and mice throughout the facility. Surveyors observed live pests in resident and common areas, and residents unanimously reported persistent pest problems. Documentation showed that pest control services were not effective, and a significant roach infestation was found in the dishwasher, impacting meal service.
Residents experienced discomfort due to inadequate temperature control, with some rooms being too cold and residents not always receiving extra blankets. Multiple sanitation issues were observed, including roaches in resident areas and on medication carts, foul odors, dirty shower rooms, and persistent pest infestations affecting kitchen equipment. Environmental maintenance was insufficient, with damaged walls, missing floor tiles, and unresolved repairs to heating, cooling, and kitchen appliances, resulting in an environment that was not clean, safe, or comfortable for residents.
Facility staff did not act on repeated grievances and recommendations from the Resident Council regarding food quality, temperature, staffing, pests, and the lack of regular bedtime snacks. Residents, including those with diabetes, reported inconsistent snack distribution and observed staff consuming snacks meant for residents. Documentation showed no written responses from the facility to the council's concerns, and not all meeting minutes were provided as requested.
Facility staff did not consistently notify medical providers when two residents repeatedly refused medications and care. One resident with dementia and depression refused psychiatric medications without the PMHNP being informed, while another resident with multiple diagnoses often refused ADL and incontinent care, with inconsistent notification to the physician. These failures were confirmed through staff interviews and record reviews.
A resident with multiple chronic conditions and a history of refusing medications did not receive pain medication after a dental procedure, as staff did not prepare or offer medications according to professional standards. An LPN reported that medications were not removed from the cart unless the resident agreed to take them, leading to a delay in pain management. Facility leadership did not comment on these findings.
Two residents who were unable to perform self-care did not receive the required showers or hair washing, with one resident reporting a 12-hour wait for incontinence care and the other observed with soiled clothing and bedding. Staff interviews and clinical records confirmed that only bed baths were provided, despite facility policy requiring two showers per week and prompt response to hygiene needs.
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 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 Provide Ordered Pureed Diet Resulting in Aspiration Pneumonia
Penalty
Summary
Facility staff failed to provide a provider-ordered pureed/mechanically altered diet to a resident with dysphagia and severe cognitive impairment, resulting in pneumonia requiring antibiotic treatment. The resident’s diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction, and the hospital discharge summary specified a pureed diet. The admission MDS documented severe cognitive impairment (BIMS score 2/15) and a mechanically altered diet, and the comprehensive care plan identified dysphagia requiring a puree diet. Although an initial order on 12/19/25 was for a regular diet with dysphagia advanced texture and thin liquids, this was changed on 12/22/25 to a pureed diet per hospital recommendations. Despite these orders, the resident was observed on 02/11/26 with a lunch tray containing chicken that the dietician and SLP determined was a mixture of mechanically altered and pureed textures; the SLP stated it would not be safe for this resident to consume. The tray ticket listed the entrée as puree crispy chicken thigh, indicating a discrepancy between the ordered/printed diet and the actual food consistency served. In addition, the resident’s family reported multiple occasions when the resident did not receive the correct diet, including being provided a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving wrong meal trays on three occasions. Facility emails related to this incident showed a CNA first acknowledging giving an Oreo milkshake to a resident on a puree diet, then later stating the milkshake given was safe and that the Oreo milkshake was not provided. Another resident reported ordering a cookies and cream milkshake for the resident via a delivery service and instructing that the pieces be ground up because the resident was on a puree diet, and confirmed the resident consumed it. The provider documented that a chest radiograph on 02/11/26 showed infiltrate consistent with recurrent aspiration pneumonia and noted it was reported the resident recently received a milkshake containing candy pieces, which likely contributed to this aspiration episode. Documentation from the DON also indicated the resident had previously been served the wrong diet over the weekend of 12/20/25–12/21/25, which the resident ate, followed by chest X-ray findings of bilateral perihilar atelectasis/infiltrate and initiation of antibiotic therapy for pneumonia on 12/24/15.
Failure to Protect Confidentiality of Clinical Records Due to Staff Use of Personal Computers
Penalty
Summary
Facility staff failed to maintain resident clinical records in a manner that ensured privacy and confidentiality on two of three nursing units (Central and West/[NAME] wings). During observations on the units, six nurses were seen using their own personal laptop computers to access resident clinical records and documents. Staff interviews revealed that they resorted to using personal computers because there were not enough facility computers available, only one computer per unit, and some facility computers were missing chargers or were not charged, which staff stated caused delays in passing medications. Staff also reported that they could not access resident clinical records when offsite using their personal computers. In a meeting with the administrator, DON, and regional director of clinical services (RDCS), it was confirmed that staff were not supposed to use personal computers and that access to the electronic health record was limited to the facility’s network. During this discussion, it was acknowledged that there was no system in place to ensure that staff did not save residents’ personal medical or identifying information on their personal computers for later use. Facility documentation titled “Technology & Information Systems Acknowledgement,” updated 09/2023, stated that employees should use company computers and information systems primarily for company business only, but no additional information was provided to address the observed practice of using personal devices for resident record access.
Failure to Follow Hand Hygiene and Glucometer Disinfection Practices During Med Pass
Penalty
Summary
The deficiency involves failure to follow infection prevention and control standards during medication administration on the west wing, involving four residents over a 42‑minute observation period. An LPN with long artificial nails was observed repeatedly handling oral medications with bare hands, including inserting a finger into multi‑dose bottles and using a fingernail to scoop pills out, then placing the pills into a medication cup. On multiple occasions, pills were removed from pharmacy blister cards into the palm of the LPN’s bare hand before being transferred to a medication cup, and a pill that fell onto the top of the medication cart was picked up with a bare hand and placed into the cup. These practices occurred despite facility policies requiring good hand hygiene prior to handling medications and maintaining fingernails short, neat, and trimmed. During blood glucose monitoring and medication administration for one resident, the LPN donned gloves to perform a fingerstick and used a glucometer, but after completing the procedure, disposed of the lancet, medication cup, and gloves, placed the glucometer on top of the medication cart, and began documenting on the computer without performing any hand hygiene. The glucometer was later placed into the medication cart drawer without any cleaning or disinfection. The LPN then proceeded to administer medications to additional residents, again handling medications in the bare hand and entering and exiting resident rooms without performing hand hygiene between residents or before returning to the medication cart and computer. Throughout the observation period, the LPN moved between multiple residents, the medication cart, the nurses’ station, and the treatment cart without performing hand hygiene, despite direct contact with resident environments and equipment. After administering medications and preparing a dose of MiraLAX for another resident, the LPN again failed to perform hand hygiene before accessing the treatment cart drawers and manipulating wound care supplies, which were then taken into a resident’s room. When questioned, the LPN acknowledged the importance of hand hygiene to prevent spreading germs between residents and stated that sanitizer was normally kept in a pocket but was in a bag at that time. Facility policies reviewed by surveyors specified that staff must perform hand hygiene before beginning a medication pass, prior to handling any medication, after direct resident contact, and before and after invasive procedures such as fingerstick blood sampling, as well as maintain appropriate fingernail hygiene.
Widespread Environmental and Linen Deficiencies Affecting Resident Care and Cleanliness
Penalty
Summary
The facility failed to provide a functional, sanitary, and comfortable environment on all three units, beginning with inadequate linen supplies necessary for resident care. An alert and oriented resident with a BIMS score of 15/15 reported having to wait long periods, sometimes hours, for incontinence care because staff did not have enough linen. Observations on multiple days showed linen carts on all units with only a scarce amount of linen, including limited blankets, gowns, wash cloths, towels, fitted sheets, incontinence pads, and pillowcases. CNAs reported they frequently did not have enough linen and often had to go to other units to find supplies, with one CNA stating the facility did not have adequate linens to meet resident care needs. The facility also failed to maintain clean and sanitary common areas and resident rooms. On the East Wing, hallway floors were dirty with debris and dirt buildup in the corners, and several hand sanitizer dispensers outside resident rooms were dirty with white debris caked on the bottom dish, with some dispensers empty and their casings dirty. In one resident’s room, wet towels with dark orangish-brown stains were observed under bins by the window and remained in place with the stains appearing larger over two days. A water fountain near the East Wing nurses’ station had a brownish stain around the drain, and when the button was pressed, gnats emerged from the drain while gnats were also flying over the fountain and landing on the walls. The Unit Manager stated the stain looked like a nutritional supplement used during medication pass and acknowledged that nurses were expected to ensure residents consumed medications and supplements. Individual resident rooms were observed to be unclean and cluttered. One resident with diagnoses including metabolic encephalopathy, aphasia, hemiplegia, and hemiparesis, and a BIMS score of 6 indicating severely impaired cognitive skills, had a room with clothes piled on the floor, debris scattered on the floor, dirty dishes on the overbed table, and a brown substance on the floor at the doorway and in the bathroom. This resident required assistance with ADLs and had behaviors with an intervention of 1:1 until seen by a provider, and did not have a roommate at the time. Another shared room on the west wing occupied by two residents was in disarray with refuse throughout the floor, a pile of paper trash in front of bedside tables, soiled floors, and debris in the bathroom; one resident reported it had been four days since someone cleaned, and the other stated cleaning did not occur every day and depended on who was working. Additional environmental concerns included cobwebs and a spider web in a window across from the therapy gym that remained present throughout the survey. Housekeeping staff reported that the number of housekeepers had been reduced from 5–6 per day to about 3–4 per day, and one housekeeper stated she sometimes worked until late in the evening to get to every room and that after weekends the facility looked very unkempt. The regional housekeeping director stated there were only three housekeepers per day recently, described that each room was supposed to be cleaned daily according to a defined task list, and acknowledged that the observed conditions were not sanitary or comfortable. Facility policy for daily resident room cleaning outlined tasks such as straightening rooms, dusting, cleaning vents and surfaces, sweeping and mopping floors, emptying and cleaning trashcans, and wet mopping with disinfectant, which contrasted with the observed state of multiple areas and rooms.
Failure to Notify Responsible Party of Resident Fall and ER Transfer
Penalty
Summary
Facility staff failed to notify the responsible party of a resident’s change in condition following a fall and subsequent transfer to the emergency room. The resident had diagnoses including vascular dementia, stridor, cerebral infarction, and dysphagia, and an admission MDS with a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making. The resident’s face sheet identified a family member as the responsible party and primary emergency contact. Nursing documentation showed that in the early morning hours the resident was found on the floor in his room with a small bruise to the orbital area, and later that same day the resident was sent to the ER. During clinical record review, the surveyor was unable to locate any documentation that the responsible party had been notified of either the fall or the ER transfer. When requested during an end-of-day meeting, facility leadership could not provide evidence of such notification, despite a facility policy titled “Significant Change of Condition” stating that the responsible party will be notified of a change of condition. The DON later confirmed they were unable to find any notification to the responsible party regarding the fall and acknowledged that the responsible party should have been notified when the resident fell and was stabilized.
Failure to Resolve Grievance Regarding Missing Personal Clothing
Penalty
Summary
Facility staff failed to honor a resident’s right to voice grievances without discrimination or reprisal by not appropriately responding to and resolving a grievance related to missing clothing. A resident’s clinical record, including progress notes and care plan, contained no documentation of a request for the resident’s family to provide clothing. The resident reported receiving some new clothes a few months prior but could not recall details and stated his memory was not perfect. Attempts to reach the resident’s family, who was the designated representative, were initially unsuccessful. Subsequently, the facility produced a grievance filed by the resident’s family member, dated 9/26/25, stating that clothes sent to the facility and left at the front desk were never received by the resident. The grievance investigation summary documented that the facility searched but was unable to locate the clothing and that the resident’s sister would be reimbursed $119.34 for the missing items. Attached documentation included a delivery receipt to the facility and a purchase receipt for the clothes. However, during a later phone call, the family member reported never receiving the reimbursement, and the administrator confirmed that the reimbursement was still pending approval with the business office, demonstrating that the grievance had not been fully resolved.
Failure to Protect Resident From Misappropriation of Personal Property
Penalty
Summary
Facility staff failed to protect a resident’s right to be free from misappropriation of property when clothing items delivered for the resident were not provided to him and were subsequently unable to be located. A review of the resident’s clinical record, including progress notes and care plan, showed no documentation that the family had been asked to provide clothing or that any clothing had been received. During an interview, the resident recalled receiving some new clothes a few months prior but could not remember what items were received, who provided them, and stated that his memory was not perfect. A grievance filed by the resident’s family member documented that clothing had been sent to the facility, left at the front desk, and never received by the resident. The grievance form indicated that the facility searched but was unable to locate the clothing and that the resident’s sister would be reimbursed for the missing items, with attached receipts for both delivery and purchase. In a subsequent phone call, the family member reported that reimbursement had never been received despite multiple conversations with facility leadership. The administrator later confirmed that the reimbursement had not been sent, contrary to what was documented on the grievance form, and stated it was still pending approval with the business office.
Failure to Implement Care-Planned Puree Diet and Weekly Weights
Penalty
Summary
Facility staff failed to consistently implement a person-centered comprehensive care plan for one resident with dysphagia, vascular dementia, stridor, and cerebral infarction. The resident’s admission MDS showed a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making, and Section K documented a mechanically altered diet. The resident’s care plan identified risk for weight loss or malnutrition related to chronic disease, cognitive impairment, need for assistance with eating, and dysphagia requiring a puree diet, with an intervention for weekly weights initiated on 12/22/25. However, clinical record review revealed only two documented weights over approximately a one-month period, despite the weekly weight intervention, with weights recorded on 12/31/25 and 01/30/26. The facility also failed to consistently provide the correct diet texture as ordered and care planned. A provider order dated 12/19/25 specified a regular diet with dysphagia advanced texture and thin liquids, which was changed on 12/22/25 to a puree diet per hospital recommendations. On observation during a lunch meal, a CNA questioned the consistency of the resident’s chicken; the dietician stated the chicken needed more liquid, and the SLP determined the chicken was a mixture of mechanically altered and pureed and stated it would not be safe for this resident to eat. In a family interview, a family member reported concerns that the resident had not been receiving the correct diet, including being given a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving the wrong meal trays on three occasions. Facility administrative staff later terminated a CNA for providing the wrong texture milkshake. These findings demonstrated that the resident’s care-planned puree diet and weekly weights were not consistently implemented.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
Facility staff failed to protect multiple residents from physical abuse by other residents, resulting in several incidents of harm and injury. In several documented cases, residents were physically assaulted by peers, including being punched in the face, head, or chest, and in some cases, these assaults resulted in hospital transfers, visible injuries such as bruising, lacerations, abrasions, and the need for medical treatment. The incidents involved residents with known behavioral issues or histories of aggression, some of whom had orders for 1:1 supervision or required supervision during specific activities such as smoking. Despite these known risks, staff did not consistently provide the required supervision or intervene in time to prevent altercations. Specific events included one resident being repeatedly assaulted by a roommate, another being attacked in a smoking area where supervision was required but not provided, and others being struck in common areas or hallways. In several cases, staff documentation was incomplete or failed to describe the altercations, and there were lapses in following care plans or behavioral interventions. Witness statements and staff interviews confirmed that staff were not always present or able to intervene promptly, and that some residents were fearful of aggressive peers due to repeated incidents. The facility's own policies defined physical abuse as intentional harm by another person, and staff interviews confirmed their understanding of the responsibility to protect residents from abuse by anyone, including other residents. However, the documented events show that staff did not consistently implement or maintain necessary supervision, failed to reassess and update care plans in response to behavioral changes, and did not always document or communicate incidents effectively. These failures resulted in immediate jeopardy to resident safety and placed all residents at risk of abuse.
Removal Plan
- Resident #32, #7, #26 are under 1:1 supervision with staff in close proximity to deescalate or intervene with any possible altercations.
- Resident #40 and #26 will not be allowed to smoke unsupervised.
- A dedicated staff member has been assigned to monitor residents #40 and #26 during smoking breaks.
- A dedicated staff member has been established in the designated smoking area within a secure part of the facility grounds.
- Resident #37, #41, and #39 will have trauma screens performed on all residents that were abused by other residents.
- Resident #12 and #43 no longer reside in the facility.
- All staff will be educated on the abuse policy.
- The DON or designee will educate on abuse and 1:1, ensuring staff doing 1:1 are in close proximity to intervene and provide privacy during bodily functions.
- The DON or designee will conduct an audit of residents currently on 1:1 to ensure the person assigned is monitoring the patient.
- Nursing staff on all shifts will document any unusual, increased, or change in behaviors in the medical records.
- Clinical review will determine residents at risk for aggressive behaviors and appropriate interventions will be put in place.
- All residents that require supervised smoking will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed.
- Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
- The facility will schedule a staff member to be in the courtyard while smoking occurs.
- The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
- IDT will be educated on what a 1:1 entails, including maintaining arm's length inside and outside of the room.
- Anyone providing 1:1 care will be scheduled by staffing with their relief person for break noted on the schedule.
- Resident on 1:1 will be documented on daily by assigned staff, collected by charge nurse.
- Staff will be educated that they may not leave the resident until they have a relief person and must remain in close proximity to intervene.
- The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking.
- The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
- This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
- A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
- The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to intervene.
- Facility will monitor all residents who have been identified as supervised smokers.
- All supervised smokers will smoke in the designated smoking area within a secure part of the facility grounds.
- If supervision is deemed necessary, the resident will be supervised by a designated staff.
- The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.
Failure to Prevent Resident-to-Resident Altercations and Inadequate Supervision
Penalty
Summary
Facility staff failed to provide adequate supervision and care to prevent resident-to-resident altercations and ensure a safe environment for multiple residents. Several residents with known histories of aggressive behaviors, cognitive impairment, traumatic brain injury, or dementia physically assaulted other residents on multiple occasions. In several cases, residents had active provider orders for 1:1 supervision, yet were still able to engage in physical altercations resulting in injuries to others. Documentation revealed that after each incident, care plans and interventions were not reviewed or revised to address the ongoing risks, and there was a lack of consistent documentation regarding the incidents and supervision provided. In one instance, a resident with a traumatic brain injury and intellectual disability, who had a history of aggression and was under orders for 1:1 supervision, physically assaulted other residents on three separate occasions, causing injuries that required hospital evaluation and treatment. Another resident with severe cognitive impairment and behavioral issues also physically assaulted other residents multiple times, with no evidence of care plan updates or intervention changes following these events. Additionally, two residents in a designated smoking area, both assessed as requiring supervision while smoking, were left unsupervised, resulting in one resident being pulled from his wheelchair and assaulted, sustaining injuries that required medical treatment. Staff and resident interviews confirmed that supervision was not present at the time of the incident, and documentation errors further complicated the facility's response. Other deficiencies included a resident on 1:1 supervision who was able to strike another resident, and a resident assessed as needing supervised smoking who was observed carrying smoking materials independently through the facility, contrary to safety protocols. Multiple staff interviews confirmed that residents requiring supervision were not being adequately monitored, and that facility policies did not clearly address the requirements for 1:1 supervision or the handling of smoking materials for residents assessed as needing supervision. These failures resulted in harm to residents and placed all residents at risk of abuse and unsafe conditions.
Removal Plan
- Resident #32, #7, #26 is now under 1:1 supervision being in close proximity to ensure staff can deescalate or intervene with any possible altercations.
- Resident #40 will not be allowed to smoke unsupervised.
- Resident #26 will not be allowed to smoke unsupervised.
- A dedicated staff member has been assigned to always monitor residents #40 and #26 during smoking breaks.
- The dedicated staff member has been established to the designated smoking area within a secure part of the facility grounds.
- The facility will educate all staff on the abuse policy.
- The DON or designee will educate on abuse and 1:1, ensuring that staff doing 1:1 are in close proximity to the resident to de-escalate or intervene with any possible altercations and will provide privacy while performing bodily functions outside of the door.
- The DON or designee will conduct an audit of those residents currently on 1:1 to ensure the person assigned is monitoring the patient.
- Nursing staff on all shifts will document any unusual, increased, or change in behaviors, which will be reported and documented in the medical records.
- During clinical review, residents at risk for aggressive behaviors will be determined and appropriate interventions will be put in place.
- Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine a need for supervision.
- Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
- The facility will schedule a staff member to be in the courtyard while smoking occurs.
- The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
- IDT will be educated on what a 1:1 entails, which includes maintaining arm's length while inside and outside of the room.
- Anyone providing 1:1 care will be scheduled by staffing, with their relief person for break noted on the schedule.
- Resident on 1:1 will be documented on daily by assigned staff, and this will be collected by the charge nurse.
- Staff will be educated that you may not leave the resident until you have a relief person; you have to remain in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations while on one-to-one inside and outside of room.
- The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking, ensuring all residents requiring supervision are supervised while smoking.
- The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
- This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
- A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
- The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations.
- Facility will monitor all residents who have been identified as supervised smokers.
- All supervised smokers will smoke in the designated smoking area that has been established within a secure part of the facility grounds.
- If supervision is deemed necessary, the resident will be supervised by a designated staff.
- The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.
Failure to Employ Full-Time Qualified Social Services Director
Penalty
Summary
Facility staff failed to employ a full-time, qualified social services worker to meet residents' individual needs. Interviews and document reviews revealed that the facility did not have a full-time social services director on-site. The social services assistant confirmed she did not have the qualifications to serve as the director, and the current social services director was reported to be working remotely, primarily during evenings and weekends, rather than being present in the facility. Further interviews established that the social services director had accepted full-time employment elsewhere and was only working part-time at the facility as needed, focusing on audits and compliance checks rather than providing direct, full-time services. Prior to this change, the director was responsible for trauma screenings, psychosocial assessments, MDS reviews, and direct support to residents and families. The absence of a full-time, qualified social services director resulted in the facility not meeting the requirement to provide adequate social services staffing for its residents.
Systemic Failure to Prevent and Address Resident Abuse Due to Ineffective QA Program
Penalty
Summary
Facility staff failed to maintain an effective quality assurance program focused on outcomes of care and quality of life, resulting in multiple residents across all units being victims of abuse. Survey findings revealed that seven residents were abused by staff and/or other residents, with failures in reporting allegations, investigating incidents, and preventing further abuse. The facility's quality assurance program was involved in developing a plan of correction and ongoing monitoring, but these actions did not sustain compliance. During a subsequent survey, nine residents were identified as victims of abuse, with continued failures in reporting, investigation, and supervision, leading to deficiencies in abuse prevention and quality of care. Further review showed that the facility was previously cited for failing to protect residents from abuse, failing to report and investigate abuse, and not correcting repeated willful abuse. Despite audits and staff education on abuse policies, additional residents were found to have been abused, and immediate jeopardy was identified due to the facility's failure to protect residents' rights. The facility did not implement interventions such as 1:1 supervision, psychiatric services, timely reporting, thorough investigations, and staff education as outlined in their plan of correction. The DON acknowledged the lack of evidence for an effective QA program, and the administrator was not available for interview.
Failure to Conduct Thorough Investigations into Abuse and Misappropriation Allegations
Penalty
Summary
Facility staff failed to conduct thorough investigations into multiple allegations of abuse and misappropriation involving four residents. In one incident, a resident with a traumatic brain injury physically assaulted another resident in the smoking area, resulting in injury. Documentation of the incident was incomplete, lacking details such as staff witness statements and identification of all individuals present. Interviews revealed that no staff were present during the incident, and the assigned staff member for supervision was not interviewed as part of the investigation. The investigation file contained only a single resident witness statement and did not include comprehensive evidence collection or interviews with all potential witnesses. In another case, the same resident assaulted a different resident in the hallway, and there was a lack of evidence that a thorough investigation was conducted. The investigation file did not indicate that either resident or any staff were interviewed, nor were attempts made to identify additional witnesses. Documentation showed that the resident was on one-to-one supervision at the time, but there was no evidence that the assigned staff member was interviewed. The clinical records and incident summaries provided were insufficient to demonstrate a complete investigation into the events. Additionally, a resident reported missing money after being moved to a different room, but the facility failed to provide credible evidence of an investigation. The investigation file contained only an incident summary, a facility synopsis, and a handwritten, undated, and unsigned statement. There was no indication that staff interviews were conducted or that efforts were made to determine if anyone had seen the money prior to the report. The facility's own policies require immediate and thorough internal investigations, including evidence collection and interviews, but these procedures were not followed in the cases reviewed.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for five residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, failed to document an assessment of an allergic reaction after the resident was served fish, and did not update the care plan to address allergies. Interviews and record reviews confirmed that the allergic reaction was not properly documented, and there was no evidence of the medication being administered or the event being recorded in the clinical record. Another resident received medications outside of the scheduled administration window on multiple occasions, as shown by medication administration records. The medications involved included midodrine, sennosides-docusate sodium, carbamazepine, and pregabalin. Nursing staff confirmed that medications should be administered within a two-hour window for resident safety, but records showed doses given significantly outside this timeframe. Additionally, for three separate residents involved in resident-to-resident altercations, staff failed to document the incidents in the clinical records as required by professional nursing standards. Facility synopses described the altercations and subsequent assessments, but there were no corresponding progress notes in the residents' clinical records. Interviews with nursing staff and administration confirmed that documentation of such events is a basic nursing practice and should include a description of the incident, steps taken to ensure safety, and assessment results.
Failure to Maintain Sanitary Food Preparation and Serving Practices
Penalty
Summary
Facility dietary staff failed to maintain sanitary food preparation and serving practices in the kitchen. During dinner preparation, multiple staff members with facial hair did not wear beard guards, despite being aware of the requirement. Staff also failed to take holding temperatures of food items prior to serving them from the steam table. Throughout the meal service, staff wore the same gloves while serving multiple plates, touched the steam table surface with gloved hands, and then used those same gloves to handle serving utensils and directly pick up baked fish and rolls without using utensils. This resulted in the contamination of serving utensils and glove surfaces. Additionally, one staff member used gloved hands to shape rice after touching the steam table and serving utensils, and food was served on plates that had visible water droplets. Interviews with staff confirmed awareness of the need for beard guards and the risks associated with improper glove use, cross-contamination, and serving food on wet plates. Facility policies reviewed indicated requirements for proper staff attire, hand washing, glove use, temperature monitoring, and appropriate use of serving utensils to prevent cross-contamination. These policies were not followed during the observed meal service.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
Facility staff failed to maintain a clean environment in four of 88 resident rooms, as evidenced by direct observations and resident and staff interviews. One resident reported requesting housekeeping services multiple times in a single day without response, and surveyors observed trash and unclean floors in the resident's room on consecutive days. Additional observations in several rooms revealed dark stains along the walls and floors, strong urine odors in bathrooms, and significant discoloration of bathroom tiles. The environmental services manager confirmed that daily cleaning was supposed to occur, including mopping floors and cleaning all horizontal surfaces, but acknowledged that the current cleaning methods were insufficient to address the level of staining and odor present in the rooms. The environmental services manager further explained that some rooms required more intensive cleaning, such as stripping and waxing of floors, or even tile replacement, to achieve an acceptable level of cleanliness. However, the rooms identified as deficient had not been included in the recent schedule for stripping and waxing, and some tiles were described as beyond repair. Facility records confirmed that the affected rooms had not received the necessary deep cleaning. The director of nursing and regional director of clinical services were informed of these findings, but no additional information was provided prior to the survey exit.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed for self-administration of medication, as required by facility policy. During the survey, an over-the-counter bottle of Thera-Flu Max was observed at the bedside of a resident who reported self-administering the medication daily for congestion. The resident had a history of cerebral infarct, hemiplegia, cognitive communication deficit, and asthma, but demonstrated no cognitive impairment with a BIMS score of 15 out of 15 and required assistance with activities of daily living. Upon review, there was no documented assessment or physician order authorizing self-administration of the medication or allowing the medication to be kept at the bedside. Staff interviews confirmed that no residents on the unit had completed assessments or orders for self-administration of medications. Facility policy requires an interdisciplinary team determination for clinical appropriateness and safety before permitting self-administration, which was not completed in this case.
Failure to Timely Report and Thoroughly Investigate Abuse, Neglect, and Theft Allegations
Penalty
Summary
Facility staff failed to implement their abuse policy for reporting and conducting thorough investigations in multiple incidents involving five residents. In two cases, staff did not report incidents of abuse within the required two-hour timeframe. Specifically, after a physical altercation between two residents, the incident was not reported to the state survey agency, adult protective services, or the ombudsman until several hours after the event, exceeding the facility's policy and regulatory requirements for timely reporting. The DON confirmed that the facility's process was to report within 24 hours, which contradicted the policy's two-hour requirement for abuse or bodily injury cases. Additionally, the facility did not conduct comprehensive investigations into allegations of abuse and misappropriation of property. In one instance, a resident was assaulted by another resident in the smoking area, but the investigation file lacked statements from staff or all potential witnesses, and only included a single resident's account. Another incident involved a resident being struck in the face by a peer, but the investigation did not include interviews with the victim, the alleged perpetrator, or the staff assigned to supervise. In the case of a resident reporting missing money, the investigation was limited to a brief summary and did not include interviews with staff or attempts to identify witnesses, despite the resident's claim of seeing a staff member near his belongings. The facility's documentation and interviews revealed that required investigative steps, such as collecting evidence and interviewing all involved parties, were not consistently followed. The investigation files provided to surveyors were incomplete, often missing critical witness statements and lacking evidence of a thorough review as outlined in the facility's own policies. These deficiencies were confirmed through interviews with the DON and review of facility records, which showed a pattern of incomplete and delayed responses to allegations of abuse, neglect, and theft.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to report allegations of misappropriation and abuse to the required agencies within the mandated timeframes for three residents. In one case, a resident reported missing money from his bedside drawer after being moved to a different room. The incident was documented in the clinical record, and an internal investigation was initiated, but the allegation was not reported to the state survey agency, adult protective services, or the ombudsman until four days after the initial report, exceeding the required reporting period. In another instance, two residents were involved in an altercation resulting in physical abuse. The clinical record indicated that one resident, who had a diagnosis of traumatic brain injury, hit another resident and exhibited threatening behavior toward staff. Emergency services were called, and the resident was sent to the hospital for evaluation. Despite the seriousness of the incident, the facility did not report the event to the appropriate agencies until more than eight hours after it occurred, which was outside the two-hour reporting requirement for abuse allegations. Interviews with facility staff, including the DON, confirmed that the facility's process for reporting such incidents did not align with the policy requirements, which mandate immediate reporting—no later than two hours for abuse or bodily injury and no later than 24 hours for other incidents. Facility policies reviewed by surveyors clearly outlined these requirements, but the staff failed to adhere to them in the cases identified.
Failure to Develop Comprehensive Care Plan for Resident Allergies
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan to address a resident's multiple food and drug allergies. The resident, who was cognitively intact and independent in activities of daily living, reported having numerous allergies, including to fish and seafood. Despite this, he experienced an allergic reaction after being served fish in the dining room. Although the kitchen staff removed the fish from his plate upon his reminder, they did not provide a clean plate, and he subsequently had a reaction requiring emergency intervention with an EpiPen and Benadryl. Interviews with staff revealed that while allergies were documented on meal tickets, the MAR, and in CNA tasks, there was no care plan in place specifically addressing the resident's allergies. The Unit Manager and MDS nurse both confirmed that allergies were not included in the care plan, and the Director of Nursing stated that the facility did not care plan for allergies. Review of the resident's clinical record showed no evidence of a care plan for allergies, no physician orders, and no documentation of the administration of Benadryl or EpiPen, nor any nursing assessment or follow-up after the allergic reaction. Facility policy required a comprehensive care plan to be completed and updated as changes occurred, with input from relevant staff and the resident. However, in this case, the care plan did not address the resident's significant allergy history, and there was a lack of documentation and follow-up regarding the allergic event. The deficiency was identified through interviews, record review, and facility documentation, confirming the absence of a comprehensive care plan for the resident's allergies.
Failure to Review and Revise Care Plans After Resident Altercations
Penalty
Summary
Facility staff failed to review and/or revise care plans for two residents following resident-to-resident altercations. In the first instance, a resident with a history of traumatic brain injury, cognitive impairment, restlessness, agitation, mood disorder, and physical aggression was involved in an altercation where he punched another resident in the face. The incident resulted in the aggressor being placed on 1:1 supervision and the victim sustaining abrasions and undergoing neurochecks. Despite these events, there was no evidence that the care plan interventions for the aggressor were reviewed for effectiveness or revised after the incident. In the second case, another resident with dementia and a history of hoarding and physical aggression struck a peer in the chest as the peer attempted to pass by in a common area. Staff immediately separated the residents and placed the aggressor on 1:1 supervision. However, the care plan for this resident, which already noted aggressive behaviors, was not reviewed or updated following the altercation. Interviews with LPNs and a unit manager confirmed that care plans are intended to guide staff in meeting residents' needs and should be reviewed and updated after incidents such as physical altercations. Facility policy also requires care plans to be updated as changes occur and reviewed quarterly. Despite these requirements, there was no documentation of care plan review or revision for either resident following their respective incidents.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically incontinence care and repositioning, to a resident who was completely dependent on staff for these needs. The resident, who had significant medical conditions including intracerebral hemorrhage, hemiplegia, aphasia, chronic respiratory failure, and was always incontinent, was observed in bed for at least five continuous hours without staff checking for incontinence or repositioning. During this period, only brief interactions occurred for medication administration and tube feeding, with no ADL care provided. When staff eventually entered the room to provide care, the resident was found with a wet brief containing a small bowel movement and a newly observed pink area on the sacral region, which had not been present two days prior. Interviews with staff and the DON confirmed that the facility's expectation was to check dependent residents for incontinence and repositioning at least every two to four hours, and the observed lapse exceeded this standard. The documentation reviewed did not specify required frequency for incontinence care, and no additional information was provided by facility leadership regarding the incident.
Failure to Complete Neurological Assessments After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to appropriately assess and monitor a resident following a fall with injury. After an unwitnessed fall, the resident was found alert and responsive with a hematoma on her forehead. Initial interventions included checking the resident, helping her onto a chair, applying ice, and notifying the on-call physician and family. Although the facility's policy and staff interviews confirmed that neurological checks (neuro checks) should be performed at specific intervals following a fall with a head injury, the clinical record review revealed that the neurological assessment for this resident was grossly incomplete. Vital signs and other required neuro check components were either missing or dated incorrectly, indicating that the assessments were not performed as required. Staff interviews confirmed knowledge of the protocol for neuro checks after a fall with possible head injury, including the frequency and components of the assessment. The facility's policy also outlined the need for thorough and timely neurological assessments to detect early signs of brain injury. Despite this, documentation showed that the required neuro checks were not completed, and the resident was not adequately monitored for latent injuries following the fall.
Failure to Complete Annual Performance Evaluations for C.N.A.s
Penalty
Summary
Facility staff failed to complete annual performance evaluations for two out of five reviewed certified nursing assistants (C.N.A.s). Specifically, there was no evidence of annual performance reviews for C.N.A.s hired on 7/22/1986 and 11/29/2022. During staff interviews, the Director of Nursing acknowledged responsibility for ensuring annual evaluations and confirmed that evaluations for these two C.N.A.s had not been completed, although evaluations for the other three reviewed C.N.A.s were provided. Additionally, when requested, the facility was unable to present a policy on staff training and performance evaluations. No further information or documentation was provided by facility leadership regarding this concern.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, nor did they document the assessment or follow-up after the resident experienced an allergic reaction to fish served at lunch. The resident reported symptoms such as swelling and redness of the lips and a funny feeling in the mouth after being served fish, despite having informed staff of his allergy. Interviews with staff and review of the clinical record revealed that no documentation existed for the physician's order, administration of Benadryl, or nursing assessment related to the event. Additionally, there was no care plan addressing the resident's multiple allergies. Another resident's clinical record was incomplete regarding an incident where the resident physically assaulted another resident. Progress notes indicated the resident was placed on 1:1 supervision for physical assault, but there were no details documented about the incident itself. Facility incident summaries and witness statements described the resident punching another resident in the face in the smoking area, resulting in an abrasion to the victim's head. However, the clinical record lacked documentation of the incident's specifics, and there was confusion in the facility's incident summary regarding the identity of the aggressor. Interviews with staff and residents confirmed the occurrence of the assault and the lack of staff presence in the smoking area at the time. The facility's director of nursing acknowledged the documentation errors and the absence of detailed records regarding the incident. The facility's own policy requires thorough documentation of adverse events, including objective findings, measures taken, and patient interpretation, but these standards were not met in either case.
QAPI Committee Lacked Required Members and Documentation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Performance Improvement Committee (QAPI) was composed of the minimum required members for three out of five meetings during the year. Specifically, review of the QAPI meeting attendance/sign-in sheets for the dates provided showed that the Infection Preventionist did not attend the meetings on three occasions. Additionally, there was no sign-in sheet available for one of the required quarterly meetings, indicating a lack of documentation for that meeting. During interviews, the Director of Nursing confirmed the typical attendees of the QAPI meetings and acknowledged that the Infection Preventionist was not always present, sometimes due to other duties. The facility's own policy requires the Infection Preventionist, along with other specified staff, to be part of the QAPI committee. No further information or documentation was provided by facility staff to address the absence of the Infection Preventionist or the missing meeting documentation.
Failure to Maintain Operational Call Bell System and Provide Alternative Means for Resident Assistance
Penalty
Summary
Facility staff failed to maintain an operational call bell system in resident rooms, bathrooms, and bathing areas, resulting in multiple instances where residents had no reliable means to call for assistance. During the survey, it was observed that at least one resident did not have a functioning call bell and no alternative method to summon help. Staff interviews revealed a lack of knowledge regarding the location and distribution of hand bells, with only five hand bells initially found for the entire facility, which houses up to 180 residents. Additional hand bells were later located in a locked maintenance room, but staff were unaware of their availability or how to access them during emergencies. There was no established policy or procedure for staff to follow when the call bell system was inoperable, and staff did not know how to mitigate the risk to residents during outages. Resident interviews confirmed repeated and prolonged outages of the call bell system, with some residents reporting that their call bells were nonfunctional for several days at a time. Residents described situations where they were unable to call for help from their beds or bathrooms, and in some cases, hand bells provided as alternatives could not be heard outside the room. Residents expressed feelings of fear and frustration during these outages, particularly those with limited mobility. Documentation review, including resident council minutes and maintenance logs, showed ongoing and unresolved issues with the call bell system, including entire wings being affected and repeated system failures requiring maintenance intervention. The facility's own policy required monthly inspection and testing of all call systems, including in bathrooms and shower rooms, and documentation of any malfunctions and repairs. Despite this, the facility was aware of ongoing problems with the call bell system but did not provide staff with procedures to ensure residents had a means to call for help during outages. Staff interviews and documentation confirmed that there was no contingency plan in place, and residents were left without reliable access to assistance during repeated system failures.
Failure to Provide Required Resident's Rights Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required Resident's Rights training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but no credible evidence was found in the employee records to confirm completion of Resident's Rights training. The Director of Nursing (DON) stated that training on resident rights, abuse, and similar topics was expected for all staff, including dietary staff, prior to beginning their duties. However, the only documentation provided was a Skills Competency Validation Record dated before the employee's hire date, and a transcript from the employee's phone app that did not show completion of Resident's Rights training. During interviews, the DON and Regional Director of Clinical Services confirmed that all employees were expected to complete Resident's Rights training, but were unable to provide a facility policy on staff training or any additional documentation to support that the dietary aide had received the required training. No further information was provided by facility staff when given the opportunity to do so.
Failure to Provide Required Abuse and Neglect Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required abuse and neglect training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence in the employee records to show that this individual had completed the mandated abuse and neglect training. The Director of Nursing (DON) confirmed that all staff, including dietary staff, were expected to receive training on abuse, neglect, infection control, kitchen safety, quality assurance, compliance, ethics, and resident rights prior to beginning their duties. However, documentation provided by the DON and Regional Director of Clinical Services (RDCS) included a Skills Competency Validation Record dated before the employee's hire date and a transcript from a phone app that did not show completion of abuse and neglect training. During interviews, the DON stated that training on resident rights and abuse was part of the basics covered during orientation, and affirmed that all staff should receive this training. Despite this, no policy on staff training was provided when requested, and no additional information or documentation was submitted by facility leadership to demonstrate that the required training had been completed for the dietary aide. The RDCS confirmed the expectation that all employees complete abuse and neglect training, but the facility was unable to produce evidence that this requirement was met for the identified staff member.
Failure to Provide Required QAPI Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required Quality Assurance and Performance Improvement (QAPI) training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence in the employee's record to show completion of the mandatory QAPI training. The Director of Nursing (DON) acknowledged that her focus was primarily on clinical staff training and that new employees received basic orientation, but could not confirm that QAPI training was included for dietary staff. When asked, the DON agreed that dietary staff should receive training on infection control, abuse, kitchen safety, quality assurance, compliance and ethics, and resident rights before starting their duties. Further review of documentation provided by the DON and Regional Director of Clinical Services revealed a Skills Competency Validation Record for the dietary aide, but it was dated prior to the employee's hire date and was not considered credible evidence of QAPI training. The dietary aide's own training transcript also did not show completion of QAPI training. Additionally, the facility was unable to provide a policy on staff training when requested. No further information or documentation was provided by facility leadership to address the concern.
Failure to Provide Required Infection Control Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required infection control training for a dietary aide, as evidenced by a review of six employee records during an extended survey. The dietary aide in question was hired on 8/26/25, but there was no credible evidence that this employee had completed the mandatory infection control training. The Director of Nursing (DON) acknowledged that her focus was primarily on clinical staff training and could not provide documentation that the dietary aide had received infection control training. A document presented as evidence of training was dated prior to the employee's hire date and was therefore not considered credible. Further review of the dietary aide's training transcript did not reveal any infection control training since employment at the facility. The Regional Director of Clinical Services confirmed that all employees were expected to complete infection control training. Additionally, when asked, the DON was unable to provide a copy of the facility's policy on staff training. No further information or documentation was provided by facility leadership to address the concern regarding the lack of infection control training for the dietary aide.
Failure to Provide Compliance and Ethics Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide the required compliance and ethics training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence that this individual had completed the necessary compliance and ethics training. The only documentation produced was a Skills Competency Validation Record dated prior to the employee's hire date, and a transcript from the employee's phone app showed no record of the required training since employment. The Regional Director of Clinical Services confirmed that all employees were expected to complete compliance and ethics training. During interviews, the DON stated that her focus was primarily on clinical staff training and that all new employees should receive training on resident rights, abuse, and other basics during orientation. When specifically asked about dietary staff, the DON agreed that they should receive training on infection control, abuse, kitchen safety, quality assurance, compliance, ethics, and resident rights before starting their duties. However, no staff training policy was provided upon request, and no additional information was presented by facility leadership to demonstrate compliance with training requirements.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to ensure a safe, clean, comfortable, and homelike environment for all residents, as evidenced by multiple observations and interviews. Surveyors noted a strong urine odor in the hallway past the lobby on two separate occasions, and flies were observed throughout the facility, including resident rooms and hallways over several days. Breakfast trays were served with plastic utensils due to staff callouts, and a damaged breakfast tray with sharp corners was delivered to a resident before being removed. Wall-mounted hand sanitizer units were found to be missing or loose, and there were missing tiles in hallways and resident rooms, as well as a baseboard pulled away from the wall with a blackish gray residue. Mattresses in one room were heavily stained and had a crackled appearance. A resident with multiple chronic conditions, including hypertension, heart failure, and chronic kidney disease, was observed eating breakfast after his tray with sharp corners was removed due to safety concerns. Staff interviews confirmed that damaged trays should be reported and replaced, but the Dietary Manager was not aware of any damaged trays prior to the surveyor's inquiry. Another resident, also with significant medical history, experienced a persistent leaking sink in her room, with a bath basin repeatedly observed full of water under the sink over several days. The resident reported that the issue had not been resolved despite staff emptying the basin. Additionally, a footboard was observed leaning against the wall in a resident room, with the corresponding bed missing its footboard. The resident, who has moderate cognitive impairment and multiple diagnoses, stated the footboard belonged to his roommate, but could not recall how long it had been there. These findings were reviewed with facility leadership during the survey, and no further information was provided at that time.
Unsafe Closet and Pest Infestation Result in Resident Injury
Penalty
Summary
Facility staff failed to provide safe and secure clothing and storage closets in a resident's room, resulting in a closet door falling onto a resident who was seated in her wheelchair. The door, which was not properly fastened with the required screws, struck the resident on the right side of her face, causing three abrasions. The closet structure was found to be deteriorating, with separated, chipped, and peeling particle board, and water damage was observed on the ceiling above the closet. The air conditioning and heating system in the building was known to be inoperable, contributing to condensation and further damage to the closet structure. The facility was aware of the need for closet repairs and replacements in other rooms, but did not act quickly enough to prevent the incident. Additionally, the closet in the resident's room was infested with cockroaches, which were observed darting into the closet and cracks in the wall during inspection. The closet's poor condition, including sawdust-like disintegration and water damage, created an environment conducive to pest infestation. The resident involved had a history of stroke with left side weakness, hypertension, chronic heart disease, and was unable to stand alone. At the time of the incident, the resident was cognitively intact, as indicated by a recent assessment. The facility failed to implement an effective pest prevention and control program, as well as timely maintenance to ensure resident safety.
Failure to Maintain Effective Pest Control and Environmental Safety
Penalty
Summary
Facility staff failed to maintain an effective pest control program across all units, as evidenced by multiple observations of flies throughout resident rooms and hallways over several days. There was also a persistent strong urine odor in a hallway past the lobby, and several environmental deficiencies were noted, including missing or loose wall-mounted hand sanitizer units, missing tiles in hallways and resident rooms, and baseboards pulled away from the wall with blackish-gray residue present. Mattresses in one room were heavily stained and had a crackled appearance, and a damaged breakfast tray with sharp corners was served to a resident before being removed by staff after it was reported. Additional deficiencies included the use of plastic utensils for meal service due to staff callouts, as explained by the Dietary Manager, and repeated observations of water accumulating in a bath basin under a resident's sink over several days, indicating an unresolved leak. The resident confirmed ongoing issues with the leaking sink and reported that the problem had not been fixed despite staff emptying the pan. Another room was observed to have a footboard leaning against the wall, with a resident's bed missing its footboard, and the resident could not recall how long it had been in that state. The residents involved had complex medical histories, including conditions such as hypertension, chronic kidney disease, major depressive disorder, obstructive sleep apnea, and HIV. Cognitive assessments indicated that some residents were cognitively intact, while others had moderate cognitive impairment. Interviews with residents and staff confirmed the persistence of these deficiencies and the lack of timely resolution, as discussed during the end-of-day debriefing with facility leadership.
Failure to Provide Timely ADL Care to Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary Activities of Daily Living (ADL) care to a dependent resident who was admitted with multiple diagnoses, including Parkinson's disease, muscle atrophy, diabetes type 2, hypertension, and anemia. The resident was cognitively intact and able to communicate her needs. Despite being totally dependent on staff for ADL care, the resident was found to be soiled in urine and feces from 10:00 A.M. until 1:40 P.M., with her bed and clothing saturated and stained. The room and unit had a pervasive odor of urine and feces, and the resident reported that this situation occurred frequently due to insufficient staffing. Review of facility documentation indicated that the resident was supposed to receive a bath every morning and was dependent on staff for all ADL care. However, during the survey, the resident was observed to remain in a soiled bed with soiled linens for several hours and was not seen out of bed during daytime hours. Interviews with the resident and review of care records confirmed that hygiene and bathing were not provided in a timely manner or as often as needed. Facility leadership was made aware of these concerns during the survey.
Failure to Provide Timely Medication Administration and Personal Care
Penalty
Summary
Facility staff failed to provide timely medication administration to a resident who was admitted with multiple diagnoses, including Parkinson's disease, muscle atrophy, diabetes type 2, hypertension, and anemia. The resident was cognitively intact, able to make her own decisions, and was totally dependent on staff for activities of daily living. Despite care records indicating that a bath was given every morning, the resident was observed to be soiled in bed with soiled linens for several hours during the survey, and her room had a pervasive odor of urine, feces, and body odor. The resident reported that medications were often administered late, sometimes hours after the scheduled time, and attributed this to insufficient staffing. Review of the medication administration records for March, April, and May revealed multiple instances where medications were given significantly later than ordered, including one occasion where a set of medications scheduled for the evening was not administered until the following morning, resulting in an 11-hour delay. Facility policy and the resident's care plan both required medications to be administered according to physician orders, but these were not followed. The deficiency was confirmed through resident and staff interviews, clinical record review, and facility documentation.
Failure to Prevent Resident Access to Hazardous Areas and Unsafe Generator Maintenance
Penalty
Summary
Facility staff failed to maintain a safe environment free from accident hazards, resulting in a finding of Immediate Jeopardy for one resident and potentially others. A resident with multiple medical diagnoses, including heart failure, diabetes, and a history of major depressive disorder, was observed independently accessing hazardous areas outside the rear of the building. These areas included a large, unsecured biohazard bin containing dirty containers, an open generator with exposed mechanical parts and tools, and a collection of paint cans and wooden pallets with exposed nails. The resident was able to open and reach into the biohazard bin and was aware of its contents, as indicated by his statements to staff. Staff interviews confirmed that the resident had been accessing these hazardous areas for approximately three weeks, and staff had made multiple unsuccessful attempts to prevent this behavior through education and verbal redirection. Additional observations revealed that the walkway leading to the rear entrance was cluttered with sharp machinery panels, cardboard, and other debris, and that the mechanical room was unsecured, lacking a doorknob or lock, allowing residents unrestricted access. The mechanical room itself was cluttered with tools, sharp objects, electrical cords, and lawn equipment. Staff interviews indicated that maintenance personnel were aware of the need for a new doorknob and lock for the maintenance room door but had not yet addressed the issue. Clinical record reviews documented repeated staff interventions to educate the resident about the dangers of accessing hazardous areas, but the resident continued to do so despite these efforts. Unrelated to the Immediate Jeopardy, an additional deficiency was identified regarding the facility's generator. The exhaust pipe leading from the generator had a large rusted-out hole at the level of a window vent, which could potentially allow carbon monoxide fumes to enter the building. The Maintenance Director acknowledged the issue upon observation and recognized the potential for hazardous fumes to leak into the facility. The state Life-Safety department was notified, and a temporary fix was put in place until the exhaust pipe could be properly replaced.
Resident Access to Unsecured Biohazard Containers
Penalty
Summary
Facility staff failed to provide a safe and sanitary environment by allowing a resident with no cognitive impairment to access unsecured, dirty biohazard containers located outside in the rear of the building. The resident was observed ambulating in a wheelchair, opening, and reaching into a large lidded 55-gallon red biohazard bin, which was clearly labeled for hazardous materials such as needles and blood. There were twenty unsecured, dirty biohazard containers in the area at the time of observation. Clinical record review revealed that the resident had a history of rummaging in trash and hazardous waste areas outside the building, despite multiple staff interventions and education about the dangers of sharp objects and medical debris. Progress notes documented repeated attempts by staff to redirect and educate the resident, but the behavior persisted. The resident had previously worked as a maintenance man and demonstrated understanding of the risks when spoken to by staff, but continued to access restricted areas. The facility's failure to secure biohazard containers and restrict resident access to hazardous areas resulted in a situation where a resident was able to repeatedly enter and interact with dangerous materials. This deficiency was identified through observation, interview, and review of clinical records and facility documentation, leading to a finding of Immediate Jeopardy in the area of infection control.
Failure to Prevent and Manage Stage 3 Pressure Ulcers
Penalty
Summary
Facility staff failed to identify and appropriately manage pressure ulcers for two residents, resulting in the development and progression of Stage 3 pressure ulcers. One resident, with a history of a right above-the-knee amputation, atherosclerosis, diabetes, and chronic kidney disease, was admitted and later readmitted to the facility. Initial skin assessments identified only a Stage 1 pressure ulcer and a surgical site, but a subsequent assessment revealed a new Stage 3 pressure ulcer on the right buttock. There was no evidence of a timely nutrition assessment or additional nutritional support after the Stage 3 ulcer was identified, and weekly wound measurements and skin observations were not consistently documented as required. Another resident, diagnosed with quadriplegia, was assessed as being at risk for pressure ulcers according to the Braden Scale. Despite care plans and physician orders for pressure-relieving interventions, the resident developed a Stage 3 pressure ulcer on the right ischium, which was not present on admission. Skin assessments prior to the identification of the ulcer did not document any issues in that area. Interviews revealed that the resident was not consistently turned or repositioned, and staff were not always aware of the presence or severity of the pressure ulcer, leading to delays in implementing appropriate interventions such as specialized support surfaces and nutritional support. Observations and interviews with staff and residents indicated that there were lapses in communication, documentation, and implementation of pressure ulcer prevention and management protocols. Staff were sometimes unaware of the severity of wounds, and recommended interventions were not always put in place in a timely manner. These failures resulted in harm to the residents, as evidenced by the progression of pressure ulcers to advanced stages.
Failure to Provide Timely Meals and Snacks According to Resident Needs and Preferences
Penalty
Summary
Facility staff failed to provide meals and snacks at regular times and in accordance with resident needs, preferences, and requests across all three units. During a resident council meeting, ten alert and oriented residents from all units reported that bedtime snacks were rarely offered, and snacks were not provided on a regular basis. Residents with diabetes stated they did not consistently receive snacks, and snacks left at the nursing station were only accessible to ambulatory residents, leaving non-ambulatory residents without. Residents also observed nursing staff consuming snacks intended for residents. Additionally, complaints were made about the quality and variety of food, with residents noting that meals were often salty and starchy, and fresh fruit options were limited to bananas, with canned fruit tasting old. Observations confirmed that snacks were not offered or provided to residents prior to surveyor intervention. Meal delivery was delayed, with one resident observed waiting for breakfast and unable to obtain coffee before trays arrived. Breakfast trays were delivered late to certain units, and there were inconsistencies in meal delivery times, resulting in some residents having only two to two and a half hours between breakfast and lunch, and more than 14 hours between dinner and breakfast. Facility documentation corroborated these extended intervals between meals. Residents attributed these issues to chronic short staffing, which they stated affected the timeliness of meal service and led some to order food from outside due to hunger and dissatisfaction with the facility's food. Interviews with the Dietary Manager revealed that only residents with diabetes were provided with bedtime snacks, as per the dietary contract, and that snacks for other residents were not supplied. The Dietary Manager acknowledged complaints about meal delivery times and stated that efforts were made to deliver meals as quickly as possible, with dietary staff delivering carts and nursing staff distributing trays. Despite these efforts, the survey team found that most residents did not receive a bedtime snack, and meal delivery was not consistently timely, resulting in long intervals between meals and unmet resident preferences.
Failure to Maintain Safe and Comfortable Ambient Temperatures
Penalty
Summary
Facility staff failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not ensuring comfortable ambient temperatures throughout the building. On the morning of 4/17/25, residents on all three units complained about the facility being cold, and were observed wrapped in blankets in the hallway. Room temperatures measured by surveyors, accompanied by the maintenance director, ranged from 65 to 68 degrees in resident rooms, below the facility's stated minimum of 71 degrees. The maintenance director explained that the building's old heating and cooling system could not keep up with fluctuating temperatures and that the chiller in use was not functioning properly due to prior vandalism and ongoing mechanical issues. Internal emails revealed that the chiller project had been delayed for months, with unresolved repairs and concerns about potential state action if not addressed. Additionally, water was observed dripping from the ceiling into a trash can in one unit, attributed to condensation from a malfunctioning rooftop air conditioning unit. The maintenance director reported that a technician found significant ice buildup on the coils, requiring the unit to be shut down for repairs. A review of past surveys showed the facility had previously been cited for lack of a functioning air conditioning system. Despite the facility's policy requiring timely repairs, by the end of the survey, the heating and air conditioning issues remained unresolved, and the administrator was made aware of the ongoing deficiencies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program, resulting in persistent infestations of roaches, ants, and mice throughout the building. During an initial tour, surveyors observed a live roach in the East Unit shower room. Multiple observations over several days confirmed the presence of pests, including ants seen in the conference room by surveyors. The Resident Council meeting documented unanimous agreement among residents present that there was an ongoing problem with roaches and ants in the facility. A review of facility documentation and pest control logs revealed that, despite having a contract for monthly pest control services, the program was not effective, as all units continued to report pest issues. The dietary manager reported that the dishwasher had been out of service, and repair technician notes indicated a significant roach infestation inside the dishwasher, including roach excrement and egg sacs. Even after extermination efforts, pests persisted, and the technician advised further extermination before repairs. The administrator was made aware of these concerns, but no additional information was provided during the survey.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
Multiple residents experienced discomfort due to inadequate temperature regulation within the facility. Several residents, including those with cognitive impairments and chronic medical conditions such as Parkinson's disease, heart failure, dementia, and diabetes, reported feeling cold over several days. Observations confirmed that room temperatures were as low as 65 degrees, and residents were seen using extra blankets and clothing to keep warm. Despite complaints, the heating system was not turned back on, as the maintenance director stated that corporate instructions were to leave it off in anticipation of warmer weather. Some residents did not receive additional blankets when distributed, and staff and leadership did not express concerns when interviewed about these issues. Sanitation and cleanliness were also found to be deficient throughout the facility. Observations included the presence of roaches on medication carts, in resident rooms, and in shower areas. There were also reports and direct observations of foul odors, particularly urine and feces, in hallways and shower rooms. Shower rooms were found to be dirty, with stained curtains, unflushed toilets, and soiled linens left on the floor. Housekeeping staff acknowledged challenges in maintaining cleanliness due to ongoing resident care and a lack of replacement supplies, such as clean shower curtains. Facility documentation and interviews confirmed persistent pest control issues, with pest infestations even affecting kitchen equipment such as the dishwasher. Environmental maintenance was lacking, as evidenced by damaged walls with deep scratches and unpainted patches, missing or jagged floor tiles, and the presence of debris and dead pests in resident rooms. Some rooms lacked homelike decorations and had strong odors. Maintenance records revealed ongoing problems with the heating and cooling systems, including a nonfunctional chiller and leaking air conditioning units. Work orders and internal communications documented delays in repairs and unresolved issues with essential equipment, such as the dishwasher and oven, further contributing to an environment that was not clean, safe, or comfortable for residents.
Failure to Respond to Resident Council Grievances and Concerns
Penalty
Summary
Facility staff failed to act promptly on grievances and recommendations raised by the Resident Council over a three-month period. Resident interviews and review of meeting minutes revealed that residents consistently reported concerns regarding food quality, facility temperature, staffing shortages, pest issues, and the lack of regular bedtime snacks. Residents, including those with diabetes, stated that snacks were not reliably distributed, with some snacks left at the nursing station and not provided to non-ambulatory residents. There were also reports of nursing staff consuming snacks intended for residents. The Dietary Manager confirmed that only diabetic residents were supposed to receive snacks, as per the dietary contract, and that nursing staff were responsible for distribution. However, residents reported that this process was inconsistent and inadequate. Documentation review showed that the facility did not provide written responses to the concerns raised in Resident Council meetings. The Activities Director and Activities Assistant were unable to promptly provide all requested meeting minutes, and only partial documentation was submitted. The facility's policy affirms residents' rights to form and participate in resident groups to discuss facility issues, but there was no evidence that the facility responded to or addressed the council's documented grievances.
Failure to Notify Providers of Resident Refusals of Care and Services
Penalty
Summary
Facility staff failed to notify the appropriate medical provider regarding refusals of care and services for two residents. One resident, with diagnoses including Parkinson's disease, heart failure, and dementia with depression and anxiety, was noted to refuse medications most days. The care plan identified behavioral issues such as refusal of medications and ADL care, but the Psychiatric-Mental Health Nurse Practitioner (PMHNP) was not informed of the resident's ongoing nonadherence to prescribed psychiatric medications. During an interview, the PMHNP stated he was unaware of the medication refusals and had not been notified, despite considering medication adjustments. The PMHNP also observed significant cognitive decline and behavioral symptoms during his visit. Another resident, with diagnoses including muscle weakness, major depressive disorder, and seizures, frequently refused ADL and incontinent care. Although the refusal was sometimes reported to the physician and family, staff interviews revealed that the physician was not notified every time the resident refused care. The resident's refusals were care-planned, and the nurse practitioner was aware of the behavior but not consistently informed of each refusal. Observations included a strong urine odor in the resident's room and soiled bedding, indicating ongoing refusal of care.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
Facility staff failed to ensure that medications were administered according to professional standards for one resident with multiple diagnoses, including Parkinson's disease, heart failure, and dementia with depression and anxiety. The resident was known to refuse medications and other care, as documented in the care plan, which included interventions such as administering medications as ordered and assigning familiar staff. During an interview, an LPN stated that the resident had not received any pain medication following a dental procedure, attributing this to the resident's tendency to refuse medications and aggravate nurses. The LPN also described a practice of not preparing medications in advance for this resident, instead asking if the resident would take medications before removing them from the cart. On the day in question, the resident initially refused all medications during the morning pass but later accepted pain medication for significant mouth pain, which was then administered. The LPN's statements indicated that the process for offering and administering medications deviated from professional standards, which require verification and preparation of medications prior to administration, as well as confirmation of medication rights at multiple steps. The facility's leadership did not provide comments or express concerns when interviewed about these findings.
Failure to Provide Required Showers and Personal Hygiene Assistance
Penalty
Summary
Facility staff failed to provide necessary services to maintain good grooming and personal hygiene for two residents who were unable to perform self-care. One resident, who was bedbound and required extensive assistance with all activities of daily living except feeding, reported waiting 12 hours for incontinence care, stating that no staff responded to her needs during the night shift. She also reported not having had a shower or hair wash in months. Clinical records confirmed that only bed baths were documented for this resident in February and April, with no showers or hair washing recorded. Additionally, a physician's note indicated the presence of skin redness associated with incontinence, recommending frequent brief changes, which were not consistently provided according to the resident's account. Another resident, also dependent on staff for all aspects of ADL care and requiring a walker or wheelchair, was observed with food stains on clothing, food residue in the mouth, and stained blankets. This resident stated he had not received a shower since admission and expressed a desire for one. Clinical records showed that only bed baths were provided, with no documentation of showers or hair washing since admission. Staff interviews confirmed that residents were supposed to receive two showers per week, including hair washing, unless refused, and refusals were to be documented by nursing staff. Facility policy required CNAs to obtain patient assignments at the start of each shift, including information on bathing needs, and to report incomplete tasks to the oncoming shift. The policy also emphasized the importance of making rounds, addressing immediate patient needs, and promptly responding to call lights. Despite these policies, documentation and interviews revealed that the required personal hygiene care, specifically showers and hair washing, was not provided to the two residents in question.
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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