Portside Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portsmouth, Virginia.
- Location
- 4201 Greenwood Drive, Portsmouth, Virginia 23701
- CMS Provider Number
- 495201
- Inspections on file
- 22
- Latest survey
- January 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Portside Health & Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide accurate assessments for four residents, leading to deficiencies in their care plans. A resident with end-stage renal disease was not coded for dialysis in the MDS, despite having a care plan and physician orders for it. Two residents were incorrectly coded for discharge disposition, with one being discharged home instead of to a hospital, and another transferred to a hospital instead of home. Additionally, a resident was not interviewed for pain assessment, leaving a section of the MDS incomplete. These issues were acknowledged by the MDS coordinator and reported to the facility's administrative staff.
The facility failed to develop baseline care plans for two residents within 48 hours of admission. One resident's care plan did not include PTSD or anticoagulation monitoring, despite relevant diagnoses and prescriptions. Another resident's care plan omitted dialysis and oxygen therapy, and fluid restrictions were not implemented as ordered. Interviews with LPNs confirmed these omissions, and the deficiencies were reported to the facility's administrative staff.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in monitoring anticoagulant therapy, administering medications, and using prescribed splints. Residents were not monitored for side effects of medications, and care plans lacked necessary components for safety and treatment adherence.
The facility failed to update care plans for four residents, omitting the use of bed rails and an indwelling catheter despite physician orders and observations. This oversight was confirmed by LPNs and acknowledged by administrative staff, indicating a lapse in ensuring care plans reflect current needs and safety measures.
Two residents experienced deficiencies in care due to the facility's failure to administer medications and treatments as ordered. One resident with vascular wounds did not receive benzocaine and telfa pads, causing pain and bleeding. Another resident did not receive blood pressure medications and insulin consistently, with documentation gaps in the MAR. These issues highlight a lack of adherence to physician orders and proper documentation.
A resident with ESRD and severe cognitive impairment did not receive proper monitoring for fluid restriction, as required by their care plan. The facility's MAR showed multiple instances of exceeded fluid limits, and an LPN acknowledged the failure to follow orders, possibly due to agency nurses' unfamiliarity with documentation. The facility's policy on intake verification was not followed, leading to the deficiency.
The facility staff failed to monitor two residents for side effects from their anticoagulant medication, Eliquis. Despite physician orders and standard nursing practices requiring monitoring for bleeding, the medication administration records lacked evidence of such monitoring. Interviews with LPNs confirmed the necessity of this practice, but it was not documented. The facility's administrative staff were informed of these deficiencies.
The facility failed to maintain sanitary conditions in the kitchen and nourishment room. Dust and rust were found on kitchen fans, and expired nutritional supplements were discovered in the nourishment room. The dietary manager and maintenance director had unclear responsibilities for fan cleaning, and the central supply staff acknowledged the expired supplements should have been discarded.
The facility failed to conduct and document bed inspections for four residents before using bed rails, as required by policy. Observations showed residents with bed rails in place, but no evidence of prior safety inspections. The maintenance director could not find inspection records before a facility-wide inspection, and the issue was reported to the administrative staff.
A resident was found with a Breyna inhaler on their bedside table without a physician's order or assessment for self-administration. The clinical record and care plan lacked documentation for self-administration, and staff were unaware of the requirements for bedside medication storage. The facility's administration was informed of the issue.
A resident with end-stage renal disease and other conditions was unable to access their call light, which was found on the floor between beds. The resident was not cognitively impaired and required supervision for daily activities. An LPN confirmed the call light was not within reach, contrary to facility policy, and the issue was reported to administrative staff.
The facility failed to provide written notifications to residents and/or their responsible parties upon hospital transfers for three residents. Despite phone notifications, no written documentation was given, and the facility lacked a policy for such notifications. The administration was informed, but no further documentation was provided.
A facility failed to provide evidence of a bed hold notice for a resident transferred to a hospital. The resident, who was rapidly declining, was transported with necessary documents, but no bed hold notice was documented. Interviews and document reviews confirmed the absence of the required notice, despite facility policy mandating its provision.
A resident with limited ROM in the right hand did not receive the recommended splinting device as per OT evaluation. The care plan and physician's orders lacked directives for splinting, and staff interviews revealed a lack of awareness and documentation of the required treatment. The facility's administrative staff was informed of the issue.
A facility failed to provide appropriate care for a resident with an indwelling catheter. The resident was observed with a catheter bag improperly positioned, and there was no documentation of catheter care in the MAR for several months. The care plan did not address the use of the catheter, and staff interviews confirmed the lack of evidence for catheter care. The issue was brought to the attention of the facility's administration.
A resident was continuously administered oxygen at 2 L/min via nasal cannula without a physician's order, as required by facility policy. Despite documentation of oxygen use in the resident's progress notes and during a follow-up visit with a physician, no order was found in the clinical record. An LPN confirmed the absence of an order and acknowledged the resident's continuous oxygen use since hospital discharge.
A facility failed to provide trauma-informed care for a resident with PTSD, CHF, and CVA. The resident's care plan did not include PTSD, despite the resident expressing feelings of hopelessness. Staff interviews confirmed that specific care for PTSD should have been documented, as required by the facility's policy. The deficiency was reported to the facility's administrative staff.
A resident did not receive a physician visit for 127 days, exceeding the required 60-day interval for recertification visits. A doctor confirmed the visit schedule, but the facility could not provide a policy for physician visits. The issue was communicated to the facility's leadership team.
A resident with a history of fractures and mobility dependence fell from bed during ADL care when a CNA left her unattended in an unsafe position. The resident attempted to reposition herself and fell, resulting in further fractures. The DON and an LPN confirmed the CNA's actions were unsafe and contributed to the fall.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to provide accurate assessments for four residents, leading to deficiencies in their care plans. Resident #25, who was admitted with end-stage renal disease, sepsis, and bilateral osteoarthritis, was not accurately coded for dialysis treatment in the Minimum Data Set (MDS) assessment. Despite having a comprehensive care plan and physician orders indicating dialysis treatment, the MDS did not reflect this, which was acknowledged by the MDS coordinator as an oversight. Resident #124 was incorrectly coded in the MDS as being discharged to a short-term hospital, while documentation showed that the resident was discharged home with their spouse. Similarly, Resident #125 was coded as being discharged home, but records indicated that the resident was transferred to a hospital from a doctor's office due to concerns about a surgical site. These discrepancies were identified during a closed record review and acknowledged by the MDS coordinator, who stated that modifications would be made. For Resident #10, the facility staff failed to complete the pain assessment interview in the MDS. The resident, who was moderately impaired in making daily decisions, was not interviewed for pain, leaving Section J0800 of the MDS blank. The MDS coordinator admitted that the interview should have been conducted and attributed the omission to an oversight. These deficiencies were brought to the attention of the facility's administrative staff, including the administrator and director of nursing, but no further information was provided before the survey exit.
Failure to Develop Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents within 48 hours of their admission, as required by their policy. For one resident, identified as R176, the baseline care plan did not include PTSD, despite the resident having a diagnosis of PTSD, CHF, and CVA. The resident was not cognitively impaired and required moderate assistance for mobility and eating. Additionally, the care plan failed to include monitoring for anticoagulation therapy, even though the resident was prescribed Eliquis, an anticoagulant. Interviews with LPNs confirmed that care plans should include specific care for PTSD and monitoring for anticoagulation therapy. Another resident, identified as R177, was admitted with diagnoses including ESRD, convulsions, and atrial fibrillation. The baseline care plan did not address dialysis, despite the resident having a physician's order for dialysis three times a week. The care plan also failed to include oxygen therapy, even though the resident was prescribed continuous oxygen via nasal cannula. Furthermore, the facility did not implement the fluid restriction as ordered, with records showing repeated exceedances of the prescribed fluid limits. Interviews with LPNs confirmed that care plans should include specific care for residents receiving dialysis and oxygen therapy. The facility's policy requires the development of a baseline care plan within 48 hours of admission to provide effective and person-centered care until a comprehensive assessment and care plan are developed. The deficiencies were brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional vice president of operations.
Deficiencies in Care Plan Implementation and Monitoring
Penalty
Summary
The facility staff failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. For Resident #15, the staff did not monitor for side effects of anticoagulant therapy as outlined in the care plan. Despite a physician's order for Eliquis, there was no evidence of monitoring for bleeding complications, which is a critical aspect of anticoagulant therapy. Interviews with staff revealed a lack of adherence to the care plan, which should have included regular monitoring and documentation of potential side effects. Resident #75's care plan was incomplete, lacking necessary components for anticoagulation monitoring. The resident, who was severely cognitively impaired, was on Eliquis, yet the care plan did not address monitoring for signs of bleeding or implementing fall prevention strategies. This oversight was acknowledged by the nursing staff, who confirmed that such monitoring should have been included in the care plan to ensure the resident's safety and well-being. For Resident #8, the facility staff failed to administer blood pressure medications and insulin as per physician orders. The care plan required administering medications as ordered, but there were multiple instances where blood pressure medications were given despite contraindications, and insulin doses were missed. Additionally, Resident #70's care plan did not include the use of an elbow splint, despite recommendations from occupational therapy. Observations and interviews indicated that the splinting therapy was not documented or implemented as required, highlighting a gap in the resident's care plan and execution.
Failure to Update Care Plans for Bed Rails and Catheter Use
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plans for four residents, leading to deficiencies in their care. For Resident #23, the care plan did not include the use of bed rails, despite a physician's order and an enabler-restraint observation indicating their necessity for bed mobility and safety. Similarly, Resident #70's care plan lacked documentation of bed rails, which were observed in use and supported by a physician's order and enabler-restraint observation. Licensed Practical Nurse #3 confirmed that the care plans should have included the bed rails to inform staff of their purpose. Resident #20 also had a care plan that failed to document the use of bed rails, even though they were observed in use and supported by a physician's order. The interdisciplinary team did not update the care plan to reflect this, as confirmed by LPN #3. Additionally, Resident #89's care plan did not include documentation related to the use of an indwelling catheter, despite its presence and a physician's order for catheter changes. The Medication Administration Record (MAR) lacked evidence of catheter care, and LPN #4 acknowledged the care plan's role in guiding patient care. The facility's administrative staff, including the administrator and director of nursing, were informed of these concerns, but no further information was provided before the survey exit. The deficiencies highlight a failure to update care plans to reflect current physician orders and observations, which is essential for ensuring appropriate care and safety for residents.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility staff failed to administer medications and treatments according to physician orders for two residents, leading to deficiencies in care. For one resident with vascular wounds on both legs, the staff did not apply benzocaine and telfa pads as ordered, resulting in dressings sticking to the wounds and causing pain and bleeding during removal. The resident reported that the facility often ran out of non-adhesive dressings, which contributed to the issue. Observations confirmed that the required telfa pads were not used, and the wound care nurse was unaware of the need to apply benzocaine, indicating a lack of adherence to the physician's treatment plan. Another resident did not receive their prescribed blood pressure medications, amlodipine and carvedilol, as ordered. The medication administration records (MAR) showed instances where the medications were either given despite blood pressure readings below the specified parameters or not documented as administered at all. This inconsistency in medication administration was confirmed through interviews with the resident and staff, highlighting a failure to follow the physician's orders and document the administration properly. Additionally, the same resident experienced issues with insulin administration, with several doses not documented as given according to the MAR. The resident reported not receiving insulin consistently, and the records showed multiple instances of blank entries for insulin administration. This lack of documentation and adherence to the physician's orders for insulin administration further exemplifies the facility's failure to provide care as prescribed, potentially impacting the resident's diabetes management.
Failure to Monitor Fluid Restriction for Resident with ESRD
Penalty
Summary
The facility staff failed to adequately monitor and adhere to fluid restriction orders for a resident, identified as R177, who was admitted with diagnoses including end-stage renal disease (ESRD), convulsions, and atrial fibrillation. The resident was severely cognitively impaired, dependent on others for mobility, transfers, and eating, and required oxygen. The baseline care plan indicated a need for fluid restriction due to increased nutrition and hydration risk. A physician's order specified a fluid restriction of 1200cc per 24 hours, with detailed instructions for distribution between dietary and nursing staff. However, a review of the medication administration records (MAR) for November and December revealed multiple instances where the fluid restriction was exceeded on both day and evening shifts. An LPN confirmed that the fluid restriction orders were not consistently followed, suggesting that agency nurses might not have been aware of the documentation process. The facility's policy required licensed nurses to verify and investigate any variances in fluid intake, but this was not adhered to, leading to the deficiency. The administrative staff, including the administrator, director of nursing, and regional vice president of operations, were informed of these concerns.
Failure to Monitor Anticoagulant Therapy in Residents
Penalty
Summary
The facility staff failed to ensure that two residents, identified as Resident #15 and Resident #176, were free from unnecessary medications due to inadequate monitoring of their anticoagulant therapy with Eliquis. For Resident #15, the clinical record showed a physician's order for Eliquis 5 mg twice daily for atrial fibrillation, but there was no evidence of monitoring for side effects such as bleeding from 11/12/24 to 12/11/24. An LPN confirmed that monitoring for bleeding should be documented on the medication administration record (MAR) as per the facility's anticoagulation policy, which was not done in this case. Similarly, Resident #176, who was admitted with diagnoses including PTSD, CHF, and CVA, was prescribed Eliquis 5 mg twice daily. However, the MAR lacked evidence of anticoagulation monitoring. Interviews with LPNs revealed that monitoring for bleeding and bruising is a standard nursing practice and should be documented on the MAR, but this was not followed. The facility's administrative staff, including the administrator and director of nursing, were informed of these deficiencies, but no further information was provided before the survey exit.
Sanitation and Expired Supplements Deficiency
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the kitchen and nourishment room, as observed during a survey. In the kitchen, two 12-inch round fans located in the dishwasher area were found to have visible dust and rust on their cages. The dietary manager stated that the dietary staff were responsible for cleaning the fans, but the maintenance director, who was new to the facility, was unsure of the cleaning schedule and had not received any requests to clean the fans. The facility's Equipment Cleaning and Sanitation Policy required a comprehensive cleaning schedule, which was not evidenced in practice. In the Unit two nourishment room, seven 8-ounce cartons of Novasource renal 19% nutritional supplement were found with expired use-by dates. The LPN stated that nurses checked the dates of items in the refrigerator, while central supply was responsible for stocking supplements. The central supply staff acknowledged that the expired supplements should have been discarded and noted that the specific supplement was slower to move due to limited resident use. The facility's Nourishments and Supplements Policy did not provide guidance on handling use-by dates, contributing to the oversight.
Failure to Conduct Bed Inspections Prior to Bed Rail Use
Penalty
Summary
The facility staff failed to conduct and document bed inspections for four residents prior to the use of bed rails, as required by the facility's policy. Observations were made of residents in bed with bilateral upper bed rails in place, but there was no evidence of bed inspections for safety prior to their use. The facility's policy mandates that bed inspections should be conducted annually and as needed when bed or mattress configurations change, with inspection checklists maintained for a minimum of three years. For Resident #23, a physician's order indicated the use of bed rails related to bed mobility, but the comprehensive care plan did not document the use of bed rails. Similarly, for Resident #70, a physician's order documented bed rails as tolerated, but the comprehensive care plan failed to evidence their use. Resident #10's comprehensive care plan mentioned bed rails to be used as ordered, but there was no physician order for bed rails. Resident #20 had a physician order for bed rails as tolerated, but the comprehensive care plan did not document their use. The maintenance director, OSM #3, stated that bed inspections were conducted quarterly or at a minimum annually, but he was unable to find any records of inspections prior to a facility-wide inspection conducted on 12/10/24. The lack of documentation and evidence of bed inspections prior to the use of bed rails for these residents was brought to the attention of the facility's administrative staff, including the administrator and director of nursing, but no further information was provided before the survey exit.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility staff failed to assess a resident, identified as Resident #32, for the self-administration of medication, specifically the Breyna respiratory inhaler. During an observation, the inhaler was found on the resident's bedside table, and the resident stated that he keeps it there for use when needed. However, a review of the clinical record did not show any physician order permitting the resident to self-administer the medication, nor was there an assessment conducted to determine the resident's capability to do so safely. Additionally, the comprehensive care plan for the resident, dated several months prior, lacked any documentation regarding self-administration of medications. Interviews with facility staff, including an LPN, revealed a lack of awareness about the requirements for residents to keep medications at the bedside, with the LPN incorrectly stating that the inhaler should not be kept there. The facility's administrative staff, including the administrator and the director of nursing, were informed of the issue, but no further information was provided before the survey exit.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility staff failed to accommodate the needs of a resident, identified as R25, by not ensuring the call light was accessible. R25, who was admitted with diagnoses including end-stage renal disease, sepsis, and bilateral osteoarthritis, was assessed as not cognitively impaired and required supervision for various activities. During an observation, the call bell was found on the floor between beds, and R25 was unaware of its location. This indicates that the resident's needs were not met as they could not reach the call bell when needed. An interview with an LPN confirmed the call device was on the floor and not within reach of R25, which did not accommodate the resident's needs. The facility's policy requires that call lights be within easy reach when residents are in bed or confined to a chair. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional vice president of operations, but no further information was provided before the survey exit.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility staff failed to provide written notification to residents and/or their responsible parties upon transfer to the hospital for three residents. For Resident #16, the staff did not provide a written notification when the resident was transferred to the hospital due to vomiting coffee ground emesis. The responsible party was notified by phone, but no written documentation was given, and the facility lacked a policy for such notifications. Interviews with staff confirmed that written notifications were not provided, and the administration was informed of this issue. Resident #9, who was cognitively intact, was transferred to the hospital without written notification to the responsible party. The resident experienced a rapid decline and was transported by paramedics. Although the responsible party was notified by phone, there was no evidence of written notification. The facility's administrative staff was made aware of the deficiency, but no further documentation was provided to address the issue. For Resident #90, who was severely cognitively impaired, the facility also failed to provide written notification to the responsible party upon transfer to the hospital following an unwitnessed fall. The resident's family was informed by phone, but no written notice was given. The facility's administration was notified of the deficiency, but no additional information was provided before the survey exit.
Failure to Provide Bed Hold Notice for Hospital Transfer
Penalty
Summary
The facility staff failed to provide evidence of a bed hold notice for a facility-initiated transfer of a resident to a hospital. On 11/24/24, paramedics arrived to tend to the resident, who was rapidly declining and required a non-rebreather. The resident was emergently transported to a hospital with necessary documents, including a facesheet, InterAct form, medication list, and DNR form. A message was left with the resident's wife, who is the primary contact and legal representative. However, the clinical record did not show evidence that a bed hold notice was provided to the responsible party for this transfer. Interviews and document reviews revealed that the nursing staff should have sent a bed hold notice with the resident during the transfer, as per facility policy. Despite requests for evidence of the bed hold notice, the facility staff, including the director of nursing and administrative support, failed to provide documentation showing that the notice was given. The facility's Bed Hold Letter Policy requires the business office or designee to complete and send the Medicaid Bed Hold Letter to the appropriate parties, but no such evidence was found in the resident's records.
Failure to Implement Therapy Recommendations for Resident's Mobility
Penalty
Summary
The facility staff failed to provide services to maintain or improve mobility for Resident #70, who was observed with limited range of motion (ROM) in the right hand and without the recommended splinting device. The occupational therapy (OT) evaluation and plan of treatment had recommended the use of a splint to inhibit abnormal reflex patterns and improve finger flexion. However, the comprehensive care plan for the resident did not address the limited ROM or the use of any splinting devices, and there were no physician's orders for the use of a splinting device. Interviews with staff revealed that the director of rehab was aware of the discharge recommendations for restorative nursing and splinting, but the restorative aide was not informed of the treatment until the day of the interview. Documentation showed that passive ROM and splinting had not been completed since late October, despite the therapy referral to nursing for splinting and exercises. The administrative staff was made aware of the concern, but no further information was provided before the survey exit.
Failure to Provide Indwelling Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate care and services for an indwelling catheter for Resident #89. On December 10, 2024, the resident was observed in bed with an indwelling catheter bag hanging off the bedframe. The physician orders from July 8, 2024, indicated that the catheter should be changed as needed, but there was no specific order for regular catheter care. Additionally, the Medication Administration Record (MAR) for October, November, and December 2024 did not contain any documentation of catheter care being provided. The comprehensive care plan dated July 11, 2024, identified urinary incontinence due to muscle weakness, lack of coordination, dementia, and Alzheimer's, but did not include any documentation related to the use of an indwelling catheter. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that there was no evidence of catheter care for the resident. The facility's administrative staff was made aware of the deficiency, but no further information was provided before the survey exit.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility staff failed to obtain a physician's order for the administration of oxygen for a resident, identified as Resident #9. The resident was documented to be using oxygen at 2 liters per minute via nasal cannula on multiple occasions, including during a follow-up visit with a physician and after completing antibiotic treatment for pneumonia. Despite the continuous use of oxygen, a review of the resident's clinical record revealed no evidence of an order for oxygen administration. An interview with an LPN confirmed that residents receiving oxygen should have orders, and standing orders are used only in emergencies. The LPN acknowledged that the resident had been wearing oxygen continuously since returning from the hospital, yet no order was placed in the medical record. The facility's policy requires licensed clinicians to administer oxygen as ordered by a provider, with emergency administration allowed only until a provider's order can be obtained. The deficiency was brought to the attention of the facility's administrative staff, including the administrator and director of nursing.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, CHF, and CVA. The resident, who was not cognitively impaired, was admitted with PTSD listed on their problem list. However, the baseline care plan did not include PTSD as a problem, indicating a lack of specific care planning for this condition. The resident expressed feelings of hopelessness during a PHQ9 questionnaire, which was reported to the social worker, DON, ADON, and unit manager nurse. Despite these concerns, the resident refused psychiatric intervention and was prescribed Buspar. Interviews with facility staff revealed that there should have been specific care outlined for the resident's PTSD, which should have been documented in the care plan. The facility's Social Services policy requires individualized care plans for trauma and PTSD, but this was not evidenced in the resident's care plan. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional vice president of operations.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility staff failed to ensure timely physician visits for a resident, identified as Resident #127, within the required timeframe. A review of the clinical records revealed that there was no documented physician visit for the resident between June 8, 2021, and October 14, 2021, resulting in a gap of 127 days without a physician's visit. During an interview, a medical doctor confirmed that long-term care residents were supposed to be seen every 60 days for recertification visits, with visits alternated between the doctor and a nurse practitioner. However, the facility was unable to provide a policy for physician visits when requested. The findings were communicated to the facility's administrative and clinical leadership team, but no further information was provided before the survey exit.
Resident Fall Due to Unsafe Positioning During Care
Penalty
Summary
The facility staff failed to ensure the safety of Resident #4 during activities of daily living (ADL) care, resulting in harm. Resident #4, who had a history of a left hip fracture and other significant medical conditions, was assessed as dependent for mobility and required assistance for rolling and positioning in bed. On the day of the incident, Certified Nursing Assistant (CNA) #1 was providing incontinent care to Resident #4 and left the resident unattended on her left side to retrieve clean linen, instructing the resident to roll back to the middle of the bed if needed. While CNA #1 was out of the room, Resident #4 attempted to reposition herself and fell from the bed, sustaining a left hip fracture and a distal right femur periprosthetic displaced comminuted fracture. The resident's cognitive abilities were intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), but she was physically dependent on assistance for safe mobility. The incident occurred because CNA #1 left the resident in an unsafe position, contrary to the resident's care requirements. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 confirmed that CNA #1's actions were unsafe and contributed to the fall. The DON acknowledged that Resident #4 was dependent for rolling and mobility, and the fall was attributed to CNA #1 leaving the room during care. CNA #1, an agency staff member, was subsequently asked not to return to the facility due to this unsafe practice.
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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