Virginia Beach Healthcare And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Virginia Beach, Virginia.
- Location
- 1801 Camelot Drive, Virginia Beach, Virginia 23454
- CMS Provider Number
- 495237
- Inspections on file
- 23
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Virginia Beach Healthcare And Rehab Center during CMS and state inspections, most recent first.
A medication cart was found unlocked and unattended in a resident-accessible area, with no authorized staff present. The assigned LPN had left the building to make a phone call, leaving the cart unsecured, which was acknowledged as a mistake by both the LPN and the Unit Manager. Facility policy requires medication carts to be locked when not under direct observation by authorized personnel.
Two residents with cognitive impairments eloped from the facility, and staff failed to report these incidents to the State Survey Agency within the required timeframe. One resident was found in the parking lot 16 hours after elopement, while the other was discovered by family members. Both residents had care plans indicating a risk for elopement, but the facility did not adhere to its policy of immediate reporting.
Two residents at the facility eloped despite being identified as at risk for elopement. One resident, with a history of suicidal ideations and dementia, left the facility at night and was found in the parking lot. The incident was reported to the state agency 16 hours later. Another resident, with depression, was found by family in the parking lot, expressing a desire to leave against medical advice. Both residents had wander guards, but the facility's measures were insufficient to prevent their unsupervised departure.
A resident with contracted fingers developed a pressure sore from fingernails pressing into the palm, which became infected and led to cellulitis. The facility staff failed to apply the necessary palm guard, and the resident's diet was insufficient, contributing to significant weight loss and malnutrition. The pressure sore was only identified after infection, requiring hospitalization for intravenous antibiotics.
The facility failed to maintain a sanitary and homelike environment, with issues such as leaking ceilings, debris, and pest infestations observed across all units. Residents reported dissatisfaction with cleanliness, maintenance, and food quality, citing lukewarm meals and laundry delays. Specific rooms had additional deficiencies like stained ceiling tiles and black spots on walls, causing resident concern. The administration did not provide comments or a plan to address these issues.
The facility staff failed to provide food that is palatable, attractive, and at an appetizing temperature due to the use of Styrofoam containers while the dishwasher was inoperable. Residents across all units complained about receiving cold food, as meals sat on carts for extended periods before being served. The Resident Council documented ongoing concerns about food quality, portion sizes, and meal variety, which were not addressed by the administration.
The facility experienced multi-system failures, including inadequate laundry services, unsanitary kitchen conditions, and failure to prevent resident-to-resident abuse. These issues persisted for months, affecting resident care and quality of life. The administration was aware of these problems but failed to resolve them, leading to the administrator's departure and the Regional President of Operations stepping in as Acting Administrator.
The facility's assessment was not tailored to its specific needs, lacking details on essential components such as compliance processes, contracts, and health information technology. It also failed to evaluate the physical environment, with issues like inoperable washing machines. The Acting Administrator recognized the need for more detailed information to accurately reflect the facility's operations.
The facility failed to maintain a sanitary environment, with mold, pests, and unsanitary conditions observed throughout. Residents reported symptoms consistent with mold exposure, and maintenance issues were prevalent, including broken washing machines and an inoperable dishwasher. The facility's infection control practices were inadequate, leading to potential health risks for residents.
The facility failed to maintain a sanitary and safe environment, with issues such as a damp mildew smell, unsanitary shower rooms, and unclean ice machines. Observations included live roaches near an ice machine, black substances in shower areas, and strong urine odors. The maintenance schedule for ice machines was not followed, and cleaning logs were blank.
The facility failed to address grievances raised by the Resident Group, as residents reported that their concerns were not acted upon despite being communicated multiple times. Issues included improper medication administration, inadequate linen changes, unprofessional staff, insufficient meal variety, and insufficient staffing levels. The Activity's Director confirmed that grievances were presented to department heads, but no feedback was provided to the residents.
A facility failed to protect residents from abuse and neglect, as a resident with mild cognitive impairment and a language barrier repeatedly abused three other residents. Despite complaints and staff witnessing the abuse, the facility did not report the incidents to the state agency, did not fully investigate, and failed to protect the victims. The facility's documentation was incomplete and inaccurate, and their policies on abuse were not implemented.
The facility failed to implement its abuse policies, resulting in repeated abuse and neglect of residents. A resident with mild cognitive impairment abused two others, and the facility did not report the incidents to the state agency or protect the victims. The administrator's documentation was incomplete and contained errors, leading to a lack of investigation and protection for the residents involved.
A resident with mild cognitive impairment and a language barrier repeatedly abused her roommates in an LTC facility. Despite complaints and witnessed incidents, the facility failed to protect the victims, report the abuse to the state agency, or fully investigate the incidents. The administrator's incomplete and erroneous documentation contributed to the lack of investigation by Adult Protective Services.
A facility failed to prevent and report abuse by a resident against others, including two known residents and an unknown third. Despite complaints, the facility did not act until abuse was witnessed, and documentation was incomplete and incorrect. The facility did not follow its abuse policy, leaving residents unprotected.
The facility failed to provide comprehensive care plans for two residents, leading to significant deficiencies. One resident with contractures did not have an individualized care plan for palm guards, resulting in a pressure sore and infection. Another resident exhibited aggressive behaviors and abused three other residents, but the facility did not conduct behavior monitoring or obtain a timely psychiatric consult. The facility's failure to implement its abuse policy and protect residents from a known abuser was evident, as allegations were not reported to the state agency, and no additional supervision was provided.
Two residents in an LTC facility experienced deficiencies in care due to staff failing to follow professional standards. One resident did not receive the full duration of cardiac monitoring as ordered, while another missed six doses of prescribed antibiotics. Frequent staff turnover and reliance on agency nurses contributed to these issues.
Two residents in an LTC facility did not receive adequate ADL care, including hygiene and showers, due to staff turnover and reliance on agency staff. One resident with severe cognitive impairment had long, dirty fingernails and only two baths in 30 days, while another cognitively intact resident reported not receiving scheduled baths, impacting her comfort and pain management. The facility's DON and Administrator acknowledged the deficiencies, citing leadership changes and staffing challenges.
A resident with dementia and a language barrier was not provided timely psychiatric care or a comprehensive care plan, resulting in aggressive behaviors and abuse towards other residents. The facility failed to monitor the resident's behavior, implement effective communication strategies, or follow its abuse policy, leaving other residents unprotected.
The facility staff failed to administer significant medications to several residents, leading to multiple deficiencies. A resident missed a dose of Lisinopril due to the absence of a nurse, while another experienced missed doses of multiple medications due to not being in the room. A serious drug interaction was not addressed for another resident, and critical medications were not procured or administered for a fourth resident. Additionally, a resident's antibiotic treatment was compromised due to missed doses. These deficiencies highlight significant lapses in medication administration and documentation.
The facility staff failed to manage medications properly on two units. On Unit 3, an LPN had expired Humalog and Fiasp insulin pens, and undated Toujeo pens. On Unit 4, the B cart had undated over-the-counter medications, including Senna and Ferrous Sulfate. The LPNs acknowledged the expectation to date medications upon opening, and the DON confirmed this during a debriefing.
The facility's pest control program was ineffective, as evidenced by the presence of roaches, fruit flies, and large flies throughout the facility. Dead roaches were found in the kitchen, and live roaches were observed near the ice machine, which also had standing water and a dripping drainage pipe. Despite monthly pest control services, pests remained visible, and the Administrator was informed of these issues.
The facility did not maintain an effective training program for all new and existing staff, as evidenced by incomplete training transcripts. During a final interview, the facility's leadership did not express any concerns about this deficiency.
The facility staff failed to ensure that all staff members completed the required training on residents' rights and facility responsibilities. A review of training transcripts showed incomplete education among staff, which was confirmed during staff interviews. In a final interview, the facility's leadership did not express any concerns about these findings.
The facility staff did not ensure that all staff members completed the required training for the Quality Assurance and Performance Improvement (QAPI) program. A review of training transcripts showed incomplete training, and during a final interview, no concerns were raised by the facility's leadership.
The facility failed to ensure all staff completed required Compliance and Ethics training, as revealed by a review of training transcripts. During a final interview, the Administrator, Interim Administrator, DON, and regional Nurse Consultants had no comments or concerns.
The facility failed to ensure all CNAs completed the mandatory twelve hours of education annually, which is essential for addressing their areas of weakness and the special needs of residents. This deficiency was identified through a review of Staff Education and Relias training transcripts. During a final interview, the facility's leadership did not express any concerns about this issue.
The facility staff did not complete the required training for behavioral health care, as revealed by a review of Staff Education and Relias training transcripts. During a final interview, the Administrator, Interim Administrator, DON, and two regional Nurse Consultants did not express any concerns about the incomplete training.
A resident was allowed to self-administer trazodone without an assessment to determine clinical appropriateness. The resident reported keeping the medication by his bedside, but now faces difficulty obtaining it. Facility staff confirmed that residents must be screened for safety and cognitive ability and have a lock box for medication storage, but no such screening was documented. The facility's policy requires physician authorization and adherence to procedures for self-administration.
Two residents experienced non-functioning clocks in their rooms, impacting their ability to know the correct time. Despite complaints, staff failed to address the issue, with one resident's clock stuck at 11:50 and another's at 4:50. The Regional Nurse Consultant confirmed the importance of accurate clocks for resident orientation, and facility leadership acknowledged the deficiency.
The facility failed to accurately complete the PASARR for two residents, not coding a resident with a serious mental illness despite diagnoses of PTSD, anxiety disorder, OCD, and major depressive disorder. The resident was on psychotropic medications and had a care plan addressing depression. Interviews revealed the PASARR was not coded for serious mental illness due to a lack of recent treatment, despite ongoing medication and positive depression screenings. No concerns were raised by the administration during a final interview.
A resident with an ileostomy experienced a deficiency in discharge planning due to the facility's failure to address skin issues and align with the resident's discharge goals. Despite the resident's and family's preference for discharge back to an ICF, improper care of the ileostomy led to skin irritation, preventing the transition. The facility did not facilitate the discharge even after the resident's skin healed, resulting in the resident remaining in LTC unnecessarily.
A resident with an ileostomy experienced improper care due to the use of an incorrect size ostomy wafer, which exposed too much skin and was cut too large. The resident's sister reported delays in changing the colostomy bag, leading to skin irritation. An LPN confirmed the incorrect wafer size during an observation. The resident's physician's orders specified a 1 3/4 cm wafer and regular bag checks, which were not followed, resulting in a deficiency.
A resident experienced significant weight loss and malnutrition due to insufficient meal portions and lack of adherence to dietary orders. The facility failed to monitor the resident's weight as recommended, and nutritional supplements were not consistently provided. Additionally, the resident developed a pressure sore that progressed to cellulitis, requiring hospitalization, due to improper management of contractures and lack of prescribed palm guard application.
The facility failed to staff an RN for at least 8 consecutive hours a day, 7 days a week, potentially affecting all residents. A review of the nursing schedule revealed no RN coverage for 8 consecutive hours on two specific days. This deficiency was confirmed by a Corporate Nurse Consultant, who acknowledged the lack of coverage on those dates.
A resident with depression, anxiety, and a history of trauma did not receive adequate mental health and psychosocial services in a facility. The resident experienced multiple falls, hospitalization, and behavioral issues, yet the facility failed to reinstitute long-standing medication therapy and provide consistent psychiatric evaluations. Erratic medication management and insufficient staff training further contributed to the deficiency.
A resident with a language barrier and mild cognitive impairment exhibited aggressive behaviors towards other residents, which were not adequately addressed by the facility. The social worker failed to provide necessary services, and the facility did not implement a comprehensive care plan or timely psychiatric consultation. The incidents were not properly documented or reported, resulting in multiple instances of abuse.
The facility failed to administer medications as ordered for two residents, including essential drugs for atrial fibrillation and dementia, and did not document the reasons for missed doses. Additionally, the facility lacked a proper system for managing controlled drugs, with inconsistencies in narcotic disposal processes. Another resident did not receive prescribed antibiotics due to unavailability, highlighting issues with pharmacy coordination and medication access.
A kitchen staff member was observed preparing food with a beard guard that only partially covered his facial hair, contrary to the facility's policy requiring full coverage. The cook stated that the provided beard guards did not fit properly. A corporate employee confirmed the expectation of full facial hair coverage.
The facility failed to maintain essential equipment, with a non-functional dishwasher and two broken washing machines impacting operations. The dishwasher had been down for weeks, and although a new one arrived, it was not installed until the survey. Laundry services were also affected, with only one working washer for 180 beds, leading to linen shortages and delays.
A resident with multiple diagnoses, including Parkinson's and COPD, did not receive medications as ordered due to staffing issues. The resident's medication administration record showed missed doses, and an LPN confirmed that inadequate staffing contributed to this failure, which did not meet professional standards.
A resident with chronic conditions requiring extensive assistance for ADLs did not have consistent documentation for incontinence care and grooming. Interviews revealed care frequency depended on staffing, and the resident reported delays in care. Despite these issues being communicated to facility leadership, no additional information was provided before the survey exit.
A resident with multiple health conditions, including dementia and COPD, did not receive consistent urinary catheter care as required by physician orders. Documentation was missing for several shifts, and an LPN confirmed that care was not provided if not documented. Facility leadership was informed of these findings.
A resident experienced significant weight loss due to the facility's failure to provide consistent feeding assistance. Despite a care plan addressing the risk of malnutrition, documentation of feeding assistance was missing for numerous shifts. Interviews revealed that the resident often waited long periods for assistance and sometimes did not receive it at all.
The facility failed to provide sufficient staffing to meet the needs of two residents, leading to deficiencies in care. One resident, with chronic conditions, experienced delays in feeding assistance due to inadequate staffing on evening shifts. Another resident, with multiple health issues, missed medication doses as no nurse was scheduled after certain hours. Staff interviews confirmed the facility was understaffed, affecting care quality.
The facility failed to provide timely meals and snacks, with breakfast and lunch consistently delivered late to units 2A and 2B. Pantry inspections revealed a lack of essential snacks, and staff interviews indicated budget constraints and staffing shortages. Residents reported not being offered snacks at bedtime, highlighting the facility's inability to meet residents' needs and preferences.
A resident with chronic kidney disease and other conditions was observed being fed by a CNA who was standing, which was deemed disrespectful. The resident confirmed that CNAs often stand while feeding her, which she does not like. The facility's administrative staff were informed of these findings.
A resident with chronic conditions and significant care needs was not involved in care planning, and the facility failed to provide evidence of care plan meetings or communication with the resident's family. The MDS coordinator admitted to not having documentation of notifications sent to the responsible party, and the facility's administrative staff were made aware of these findings.
A resident with chronic kidney disease and other conditions experienced significant weight loss, but the facility failed to notify the family after initial communication. Despite dietary interventions and monitoring, there was no further family contact regarding the resident's condition. The administrative staff was informed of these findings.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
Facility staff failed to ensure that a medication cart was kept locked or under the direct observation of authorized staff in an area accessible to residents. During an observation tour, a medication cart was found unlocked outside the nursing station with no authorized staff in sight. The Unit Manager was unaware of the nurse assigned to the cart's whereabouts. Shortly after, the assigned LPN returned from outside the building, stating she had been making a phone call and acknowledged that leaving the cart unlocked and unattended was a mistake. The facility's policy requires that only licensed nurses, pharmacy personnel, or those lawfully authorized to administer medications have access to medications, and that medication carts must be locked when not attended by authorized personnel. Interviews with the Unit Manager and the LPN confirmed that the cart was left unattended and unlocked, contrary to facility policy. No further comments or concerns were voiced by facility leadership during the final interview.
Failure to Report Resident Elopements Timely
Penalty
Summary
The facility staff failed to prevent the elopement of two residents, which was not reported to the State Survey Agency within the required timeframe. Resident #217, who had a history of suicidal ideations and unspecified dementia, eloped from the facility and was found in the parking lot. The incident was not reported until 16 hours later, despite the requirement to report such events within 2 hours. The resident's care plan indicated a risk for elopement, with interventions including checking the wander guard function and conducting elopement risk assessments. Similarly, Resident #223, diagnosed with depression, was found by family members in the parking lot after eloping. The facility staff did not complete a Facility Synopsis of the event, and the incident was not reported to the State Survey Agency. The resident's care plan also identified a risk for elopement, with similar interventions as Resident #217. The facility's policy mandates immediate reporting of such incidents, but this was not adhered to in both cases.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent elopement for two residents, leading to deficiencies in care. Resident #217, who had a history of suicidal ideations and dementia, eloped from the facility late at night and was found in the parking lot. Despite having a wander guard, the resident managed to leave the building, and the incident was not reported to the state agency until 16 hours later. The resident's care plan identified them as at risk for elopement, but the interventions in place were insufficient to prevent the incident. Resident #223 also eloped from the facility, as observed by their family in the parking lot. This resident had a history of depression and was assessed as at risk for elopement. Despite wearing a wander guard, the resident left the facility, expressing a desire to leave against medical advice. The facility staff attempted to persuade the resident to stay, but the resident's wander guard was removed upon discharge. The incident was not properly documented in a facility synopsis, although an elopement incident report was completed. Both residents were identified as at risk for elopement through the facility's Elopement Risk Tool Assessment, yet the measures in place failed to prevent their unsupervised departure. The facility's policy required regular checks of wander guard function and placement, but these measures were not effective in preventing the elopements. The incidents highlight a deficiency in the facility's ability to adequately supervise and protect residents at risk of elopement.
Failure to Prevent and Treat Pressure Ulcer Leads to Hospitalization
Penalty
Summary
The facility staff failed to prevent, assess, identify, and treat an avoidable pressure ulcer for a resident with contracted fingers of the left hand. The resident developed a pressure sore injury from his fingernails pressing into his palm, which became infected and resulted in cellulitis. This infection led to the resident being hospitalized for treatment with intravenous antibiotics for 10 days. The facility staff were unaware of the wound prior to the infection and had not been applying the resident's hand splint (palm guard) to prevent the wound. The resident, who had a history of stroke with left hemiplegia, dementia, contractures, and other medical conditions, was suffering from significant weight loss and malnutrition, which increased his debility and inability to heal. Despite being at risk for skin breakdown due to immobility and contractures, the facility staff did not consistently use palm guards to protect the resident's skin. The pressure sore injury was only identified after it became infected, requiring hospitalization. The resident's diet was also insufficient in quantity and did not meet the ordered caloric intake, contributing to his malnutrition. The facility's failure to conduct regular skin assessments and monitor the resident's nutritional status contributed to the development and progression of the pressure sore. The resident's care plan did not include specific instructions for the use of palm guards, and staff were unaware of the need for these devices. Additionally, the facility did not administer antibiotics promptly after the cellulitis was identified, further delaying treatment and contributing to the resident's hospitalization.
Unsanitary Conditions and Maintenance Failures in LTC Facility
Penalty
Summary
The facility failed to maintain a sanitary, comfortable, and homelike environment across all units and some common areas, leading to a substandard quality of life for residents. Observations included water leaking from the ceiling in the lobby, debris and dark spots in corridors, and unsanitary conditions in resident rooms, such as soiled floors, clogged toilets, and strong odors. Residents expressed dissatisfaction with the cleanliness and maintenance of their living spaces, reporting issues like unanswered call bells, uncleaned rooms, and pest infestations. The facility's administration did not provide comments or concerns when these issues were presented. The facility also failed to provide sanitary conditions in the kitchen and common areas, with dead roaches found in the dry storage area and live roaches near the ice machine. The ice machine area was unsanitary, with standing water and a black slimy substance. Residents complained about lukewarm or cold food due to an inoperable dishwasher and the use of Styrofoam containers. Additionally, there was a shortage of linens and delays in laundry services due to broken washing machines, which the director of housekeeping acknowledged. Specific units and rooms were observed with additional deficiencies, such as wet and stained ceiling tiles, cobwebs, and black spots on walls. Residents expressed frustration and concern over these conditions, with one resident fearing for their health due to the black spots. Maintenance staff attempted to address some issues, such as replacing ceiling tiles and cleaning walls, but the underlying problems persisted. The facility's administration was informed of these findings but did not provide further information or a plan to address the deficiencies.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility staff failed to serve food that is palatable, attractive, and at an appetizing temperature for residents across all four units. This deficiency was primarily due to the use of Styrofoam takeout containers for food service, necessitated by an inoperable dishwasher from August 9, 2024, to October 10, 2024. Residents consistently complained about receiving cold food, as the meals sat on carts in the hallways for 10 to 20 minutes before being served by CNAs. Despite food temperatures being within safe ranges during a kitchen inspection, the delay in distribution led to lukewarm or cold meals, which residents found unappetizing. The Resident Council documented ongoing food-related concerns that were not addressed by the administration. Complaints included watery oatmeal, insufficient portions, incorrect meal tickets, and a lack of alternative meal options. Residents also expressed dissatisfaction with the quality and variety of food, noting issues such as overcooked chicken, uncooked potatoes, and a lack of fresh fruits and vegetables. These issues persisted over several months, as evidenced by Resident Council meeting notes from April to September 2024, indicating a pattern of neglect in addressing dietary concerns.
Multi-System Failures in Facility Operations and Resident Care
Penalty
Summary
The facility experienced a multi-system failure affecting various aspects of resident care and facility operations. Deficiencies were identified in environmental services, sanitary conditions, infection control practices, medication storage and administration, and resident abuse prevention. Specifically, the facility had inadequate laundry services with only one working washing machine for several months, leading to a shortage of clean linens and gowns for residents. Staff members were observed apologizing for using the last gowns during incontinence care rounds, and interviews confirmed ongoing issues with laundry services. Additionally, the kitchen was found to have unsanitary conditions, including rodent activity, roaches, and an unsanitary ice machine, which raised concerns among residents about the food quality. The facility also failed to protect residents from abuse, as there were incidents of resident-to-resident abuse that were not adequately addressed. The survey team reviewed maintenance and pest control logs, as well as Resident Council minutes and grievance logs, which indicated that the administration was aware of these issues for several months without resolution. The facility's administrator, who had been employed for four weeks, acknowledged the laundry issues and stated that incorrect parts had been ordered for the washing machines. However, the problems persisted, and the administrator was no longer employed at the facility by the end of the survey. The Regional President of Operations assumed the role of Acting Administrator and was informed of the survey findings.
Facility Assessment Lacks Specificity and Detail
Penalty
Summary
The facility failed to create a facility-specific assessment to determine the necessary resources for resident care during both regular operations and emergencies. The assessment, which was 22 pages long, was based on a template and lacked specific details relevant to the facility. It was not reviewed by the Quality Assurance Process Improvement (QAPI) Committee, as indicated by the blank review date. The assessment did not include essential components such as a compliance hotline, grievance process, Resident Council, Family Council, or QAPI. Additionally, it failed to list contracts, memoranda of understanding, or agreements with third parties, and did not describe the process for overseeing services to meet resident needs. The assessment also inadequately addressed health information technology resources, merely stating the use of PointClickCare for electronic health records without detailing secure information transfer processes. There were concerns about residents not receiving timely access to their medical records. Furthermore, the assessment did not evaluate the physical environment necessary for resident care, as evidenced by the inoperability of washing machines for at least two months. The Acting Administrator acknowledged the need for more detailed information in the assessment to accurately reflect the facility's operations.
Inadequate Infection Control and Sanitation in LTC Facility
Penalty
Summary
The facility staff failed to maintain a safe, sanitary, and comfortable environment, leading to the transmission of communicable diseases and infections across all resident living units and communal spaces. Observations revealed the presence of wet mold on floors, walls, ceiling tiles, and other areas, as well as unsanitary conditions in shower rooms, laundry facilities, and the main kitchen. The ice machines were not kept clean, with one machine found to have standing water and live cockroaches around it, and mold growing underneath. The maintenance director admitted to inadequate cleaning schedules and lack of documentation for the ice machines. Residents reported symptoms such as headaches, sore throats, asthma, and other respiratory issues, which were consistent with exposure to mold and damp environments. Interviews with residents revealed ongoing issues with mold and mildew in their rooms, with maintenance staff merely painting over affected areas instead of addressing the root cause. The maintenance director discovered non-operational blowers in the ceiling, which could have prevented the condensation and mold growth, but no testing had been conducted to determine the extent of mold presence. The facility also faced issues with pest control, as fruit flies, large flies, and cockroaches were noted throughout the building. Laundry services were inadequate due to broken washing machines, leading to a shortage of linens and delayed return of personal clothing. The kitchen was found to be unsanitary, with dead cockroaches, food debris, and an inoperable dishwasher, resulting in the use of Styrofoam containers for meals. These conditions contributed to residents receiving lukewarm or cold food, further impacting their quality of life.
Unsanitary Conditions and Maintenance Failures
Penalty
Summary
The facility staff failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed significant issues, including a damp mildew smell, wet ceiling tiles, unsanitary shower rooms, and unclean ice machines. Specifically, the ice machine located in a closet across from the dining room had standing water on the floor, a rubber mat with live roaches, and a drainage pipe dripping onto the floor. The area emitted a damp and mildew odor, and the ice machine filter date was illegible with no documentation of a cleaning schedule or inspection. The maintenance person stated that ice machines were wiped down monthly, sanitized quarterly, and filters changed every six months, but the policy for ice machine cleaning was not followed as evidenced by blank cleaning logs. Further observations in various shower rooms across different units revealed unsanitary conditions. These included wet washcloths left on floors, dirty and stained floors, black substances in grout lines and shower areas, and strong urine odors. Broken toilet paper holders, rust stains, and personal items without names were also noted. The administrator was informed of these concerns during an end-of-day meeting, but no further information was provided.
Failure to Address Resident Group Grievances
Penalty
Summary
The facility staff failed to adequately address grievances raised by the Resident Group, as evidenced by the lack of response or action taken on multiple issues voiced by the residents. During a Resident Group meeting, it was unanimously agreed by the attendees that their grievances were not being acted upon, despite being communicated multiple times. The group's President noted that the Activity's Director (AD) facilitated the meetings and ensured that grievances were communicated to the relevant departments, but no feedback or resolution was ever provided to the residents. A review of six months of Resident Group meeting minutes revealed numerous unresolved concerns, including improper medication administration, inadequate linen changes, unprofessional nursing staff, insufficient meal variety and portions, lack of resident shopping trips, unclean rooms, and insufficient staffing levels. The AD confirmed that grievances were presented to department heads during morning meetings but admitted to not receiving any feedback to relay back to the residents. The facility's administrative staff, including the Administrator and Director of Nursing, did not provide any comments or express concerns when interviewed about these issues.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by the repeated willful abuse of three residents by another resident. The facility did not report the abuse to the state agency, did not fully investigate the incidents, and failed to protect the victims during the investigation. The abuse involved physical and verbal aggression, including kicking, hitting, and spitting, and was witnessed by staff but not adequately addressed. Resident #68, who was cognitively intact, reported being abused by her roommate, Resident #521, who had mild cognitive impairment and a language barrier. Despite repeated complaints, the facility staff did not take action until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to another room, where she continued to exhibit aggressive behavior towards her new roommate, Resident #20, and later towards an unknown resident. The facility's documentation and reporting of the incidents were incomplete and inaccurate. The Administrator's report contained errors and was not submitted correctly to the state agency, resulting in no investigation by Adult Protective Services. The facility's policies on abuse were not implemented, and there was no added staff supervision for the known abuser, leading to further incidents of abuse.
Failure to Implement Abuse Policies and Protect Residents
Penalty
Summary
The facility failed to implement its abuse policies, resulting in repeated willful abuse and neglect of residents. The staff did not report the abuse to the state agency, failed to fully investigate the incidents, and did not protect the victims during the investigation. This involved four known residents, with one resident being the perpetrator of abuse against two others. The facility's documentation and interviews revealed that the abuse was not reported to the state agency, and the facility did not follow its own policies for investigating and protecting residents from abuse. Resident #68, who was cognitively intact, reported being physically and verbally abused by her roommate, Resident #521, who had mild cognitive impairment and a language barrier. Despite repeated complaints to the staff, no action was taken until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to a room with Resident #20, who also experienced abuse. The facility's records showed that Resident #521 continued to exhibit aggressive behavior, including hitting and spitting on Resident #20, and threatening another unknown resident after being moved to a third room. The facility's administrator failed to complete the Facility Reported Incident (FRI) documentation properly, resulting in the state agency not receiving the report. The administrator's synopsis contained errors, such as incorrect BIMS scores, and implied that the victim was responsible for triggering the abuse. The facility did not conduct a thorough investigation or provide adequate protection for the residents involved. Additionally, there was no added staff supervision for Resident #521 to prevent further abuse, and no police report was filed despite the suspicion of a crime.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, and failed to protect the victims during the investigation. This involved four residents, including two victims and one perpetrator. The abuse was perpetrated by a resident with mild cognitive impairment and a language barrier, who was involved in multiple incidents of physical and verbal abuse against her roommates. Despite repeated complaints from the victims, the facility staff did not take timely or adequate action to protect the residents or report the incidents to the appropriate authorities. Resident #68, who was cognitively intact, reported being physically and verbally abused by her roommate, Resident #521. Despite her complaints to the staff, no action was taken until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to another room, where she continued her aggressive behavior towards her new roommate, Resident #20. Resident #20, also cognitively intact, reported being yelled at, spit on, and physically assaulted by Resident #521. The staff witnessed the abuse but failed to document the full extent of the injuries or report the incident to the state agency. The facility's administrator failed to complete the Facility Reported Incident (FRI) documentation correctly, resulting in the state agency not receiving the report. The administrator's synopsis contained errors, including an incorrect assessment of Resident #521's cognitive status, which contributed to the lack of investigation by Adult Protective Services. The facility's policies on abuse were not implemented, and there was no added staff supervision for Resident #521 to prevent further abuse. The facility's failure to protect residents from a known abuser and to report and investigate the incidents fully resulted in a deficiency in their care standards.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility staff failed to prevent repeated willful abuse and neglect, failed to fully investigate the abuse, failed to report the abuse to the state agency, and failed to protect the victims during the investigation. The incidents involved four residents, with Resident #521 being the perpetrator of abuse against Residents #68, #20, and an unknown third resident. Despite repeated complaints from Resident #68 about being abused by Resident #521, the facility staff did not take action until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to a room with Resident #20, where further abuse occurred. The facility's documentation and reporting of these incidents were inadequate. The Administrator's synopsis of the abuse was incomplete, unsigned, and contained errors, such as incorrectly stating Resident #521's cognitive status. The report to the state agency was not received due to an incorrect fax number, and the facility did not conduct a thorough investigation or provide adequate protection for the residents involved. The facility's policy on abuse was not implemented, and there was no added staff supervision for Resident #521 to prevent further abuse. The facility's failure to report and investigate the abuse incidents properly resulted in a lack of protection for the residents. The Administrator's response to the situation was insufficient, and the facility did not follow its own policies for handling abuse allegations. The lack of a comprehensive investigation and failure to report the incidents to the appropriate authorities left the residents vulnerable to further abuse.
Failure to Provide Comprehensive Care Plans and Protect Residents from Abuse
Penalty
Summary
The facility staff failed to provide a comprehensive care plan for two residents, leading to significant deficiencies in their care. Resident #73, who had contractures with splints and palm guards required to prevent further contracture and maintain skin integrity, did not have an individualized care plan for the palm guards. This oversight resulted in a pressure sore injury from the resident's fingernails pressing into his palm, which became infected and led to cellulitis. The infection necessitated hospitalization for treatment with IV antibiotics. The facility staff were unaware of the wound prior to the infection and had not been applying the resident's hand splint consistently, which contributed to the injury. Resident #521 exhibited aggressive behaviors and signs of distress that were not assessed or care planned by the facility staff. The resident, who had a language barrier and mild cognitive impairment, abused three other residents in the facility. The staff failed to obtain a timely psychiatric consult, conduct behavior monitoring, or provide a comprehensive care plan for emotion regulation. This lack of intervention resulted in the willful abuse of other residents, including physical aggression and intimidation. Despite repeated complaints from the victims, the facility staff did not take adequate measures to protect the residents or investigate the allegations of abuse. The facility's failure to implement its abuse policy and protect residents from a known abuser was evident in the handling of Resident #521's case. The allegations of abuse were not reported to the state agency, and the facility did not provide additional staff supervision to prevent further incidents. The psychiatric evaluation for Resident #521 was delayed, and no psychosocial or behavioral services were provided despite the resident's aggressive behavior. The facility's inaction and lack of a comprehensive care plan for Resident #521 contributed to the continuation of abusive behavior and the failure to protect other residents from harm.
Deficiencies in Cardiac Monitoring and Antibiotic Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice for two residents, leading to deficiencies in care. For one resident, the staff did not apply a cardiac monitor for the required duration to diagnose the cause of repeated syncopal episodes. The resident, who had multiple diagnoses including chronic kidney disease and dementia, was supposed to have the cardiac monitor patch changed every seven days for a total of 30 days. However, the monitor was discontinued 14 days early without any documented reason, and the physicians were unaware of this early discontinuation. In another case, the facility staff failed to administer antibiotics as ordered for a resident with septic arthritis of the knee. The resident was prescribed oral Amoxicillin to be taken three times a day for 14 days. However, six doses were missed during the treatment period, including four consecutive doses. There was no documentation that the missed doses were communicated to the Infectious Disease Physician, nor were the missed doses compensated for by extending the treatment period. The report highlights issues with continuity of care due to frequent staff turnover and reliance on agency nurses. The facility had experienced significant staff changes, including four Directors of Nursing in less than a year, which contributed to the lack of adherence to physician orders and professional standards. The facility's failure to ensure proper medication administration and monitoring as prescribed resulted in deficiencies in the care provided to the residents.
Inadequate ADL Care and Hygiene for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care, including hygiene and showers, to two residents, resulting in deficiencies. Resident #89, who has severe cognitive impairment and requires extensive assistance, was observed with long, dirty fingernails and had only received two baths in 30 days. Despite the facility's policy of providing at least two baths per week, the resident's care plan did not include a bathing schedule, and staff were unaware of her hygiene needs. Interviews with staff revealed a lack of familiarity with the resident and inconsistent care due to high staff turnover and reliance on agency staff. Resident #68, who is cognitively intact and requires assistance for hygiene, reported not receiving the scheduled twice-weekly baths. The resident expressed concerns about staff shortages and the impact on her comfort and pain management. Bathing records confirmed that she had only received one bath in the past month, despite her requests and the facility's policy. Staff interviews indicated a lack of communication and coordination between shifts, contributing to the oversight in her care. The facility's Director of Nursing (DON) and Administrator, both relatively new to their positions, acknowledged the deficiencies and attributed them to frequent changes in leadership and staffing challenges. The surveyors highlighted the impact of these issues on the continuity of care, as evidenced by the inadequate ADL support provided to the residents. The facility did not provide any additional information or corrective actions at the time of the survey.
Failure to Address Behavioral Health Needs Leads to Resident Abuse
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with non-Alzheimer's type dementia and a language barrier, leading to multiple incidents of abuse against other residents. The resident, who spoke only Spanish, was not given a timely psychiatric consultation, and there was no comprehensive care plan addressing her emotional regulation or responses to stressors. This lack of intervention resulted in aggressive behaviors, including physical and verbal abuse towards other residents. The facility's staff did not adequately monitor the resident's behavior or implement a care plan to address her needs. Despite the resident's known language barrier and previous diagnosis of depression or bipolar disorder, no effective communication strategies or behavioral interventions were put in place. The resident's aggressive actions were not reported to the state agency, and the facility's abuse policy was not followed, leaving other residents unprotected. The facility's documentation and response to the incidents were insufficient. The psychiatric consultation was delayed, and the resident's care plan lacked focus on her dementia, language barrier, and behaviors. The facility's failure to address these issues resulted in repeated abuse incidents, with no added staff supervision or investigation into the allegations. The facility's administrator and corporate staff were unable to provide further information or documentation regarding the incidents.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to ensure that significant medications were administered to several residents, leading to multiple deficiencies. Resident #47 did not receive a scheduled dose of Lisinopril due to the absence of a nurse on the unit, resulting in severe pain and physical symptoms. Despite the medication being available, the facility staff could not explain the missed administration. Similarly, Resident #57 experienced missed doses of multiple medications, including Eliquis, Flomax, Gabapentin, and Amlodipine, due to the resident not being in the room during medication rounds. The facility's policy required nurses to return to administer missed medications, but this was not adhered to, and there was no documentation explaining the missed doses. Resident #424's case involved a failure to notify the physician or seek clarification regarding a serious drug interaction flagged by the pharmacy. The resident was prescribed Levofloxacin, which had a potential severe interaction with Citalopram, but the facility staff did not address the pharmacy's alerts. Additionally, Resident #372 did not receive several critical medications, including anti-seizure medication, insulin, and analgesics, for multiple days. The facility staff did not procure or administer these medications as ordered, leading to missed doses without any documented explanation. Resident #161's antibiotic treatment was compromised due to six missed doses, including four consecutive doses, during the prescribed course. The facility staff did not extend the antibiotic treatment to cover the missed doses, and there was no documentation explaining the omissions. The Regional Nurse Consultant emphasized the importance of completing antibiotic courses to prevent bacterial resistance, but the facility failed to ensure adherence to the prescribed regimen. These deficiencies highlight significant lapses in medication administration and documentation within the facility.
Medication Management Deficiencies in Facility Units
Penalty
Summary
The facility staff failed to adhere to proper medication management protocols on two of the four facility units, as observed during a survey. On Unit 3, an LPN was found with an opened multi-dose Humalog (insulin lispro) KwikPen and a Fiasp (insulin aspart) injection pen, both of which were past their 28-day discard date according to the manufacturer's guidelines. Additionally, two Toujeo (insulin glargine) injection pens were found opened and undated, contrary to the facility's training and competency requirements that mandate dating medications upon opening. On Unit 4, the B cart inspection revealed four bottles of over-the-counter medications that were opened and undated, including Senna, Ferrous Sulfate, Naproxen, and Chewable aspirin. The LPN on duty acknowledged that all medications should be dated when opened, and the Director of Nursing confirmed this expectation during the end-of-day debriefing. The facility's administration and nursing consultants were informed of these findings, but no further comments or concerns were raised by them at the time of the survey exit.
Ineffective Pest Control Program Leads to Roach and Fly Infestation
Penalty
Summary
The facility staff failed to maintain an effective pest control program, resulting in the presence of pests within the facility. During a kitchen inspection, two dead roaches were found in the dry storage area and one near the 3-compartment sink. Additionally, an inspection of the ice machine area revealed standing water on the floor, live roaches crawling around and under a rubber mat, and a dripping drainage pipe. The area also contained a black slimy substance and wet paper trash, emitting a smell of dampness and mildew. Throughout the survey, fruit flies and large flies were observed on all units and in common areas. Despite having monthly pest control services, the program was deemed ineffective as pests remained visible. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided.
Failure to Maintain Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the deficiency.
Deficiency in Staff Education on Resident Rights
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on residents' rights and the facility's responsibilities. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training concerning the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified during a review of facility documents and staff interviews. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the information presented.
Incomplete QAPI Training for Facility Staff
Penalty
Summary
The facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement (QAPI) program. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training for QAPI. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the incomplete training.
Non-compliance in Staff Training on Ethics
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on Compliance and Ethics. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training for Compliance and Ethics. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, they had no comments or concerns regarding the information presented.
Deficiency in CNA Education Compliance
Penalty
Summary
The facility staff failed to ensure that all Certified Nurses Aides (CNAs) completed the mandatory twelve hours of education each year. This education is crucial as it addresses each CNA's areas of weakness as determined in their performance reviews, the facility assessment, and the special needs of residents as determined by the facility staff. A review of the Staff Education and Relias training transcripts revealed this deficiency. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding this information.
Incomplete Behavioral Health Training for Facility Staff
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on behavioral health care and services. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training for behavioral health care. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the incomplete training.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility staff failed to determine the clinical appropriateness for a resident to self-administer the psychotropic medication, trazodone, which is used to treat insomnia. The resident was allowed to self-administer the medication without an assessment to ensure it was safe and appropriate for him to do so. During an interview, the resident mentioned that he used to keep the medication by his bedside and take it at his discretion, but now he has to request it, which he finds difficult. The clinical record review showed that the resident had an order for unsupervised self-administration of trazodone from September 9 to September 16, 2024, without any documented screening for safety or cognitive ability. Interviews with facility staff, including an LPN and the Clinical Nurse Consultant, revealed that residents must be screened for safety and cognitive ability and have a lock box for medication storage to self-administer medications. However, no such screening was documented for the resident in question. The facility's Medication Administration Policy states that residents are permitted to self-administer medications only when specifically authorized by the attending physician and in accordance with established procedures. The deficiency was discussed with the Administrator, but no further information was provided.
Failure to Maintain Accurate Clocks in Resident Rooms
Penalty
Summary
The facility staff failed to reasonably accommodate the needs and preferences of two residents by not ensuring the clocks in their rooms were functioning correctly. Resident #161, who was admitted with diagnoses including Primary Osteoarthritis of the Knee and Heart Failure, was observed to be alert and oriented with a BIMS score of 14, indicating no cognitive impairment. Despite being aware of the incorrect time displayed on the clock in her room, which had been stuck at 11:50, the resident's repeated complaints to staff members went unaddressed. The CNA acknowledged the issue, stating that maintenance was needed to replace the battery, but despite submitting work orders, the clock remained unfixed. Similarly, Resident #107, who had severe cognitive impairment with a BIMS score of 6, also experienced a non-functioning clock in his room, which was stuck at 4:50. This resident, admitted with conditions such as Metabolic Encephalopathy and Chronic Kidney Disease, expressed his inability to determine the time due to the faulty clock. Staff members, including those picking up food trays and delivering ice, failed to address the issue despite being informed by the resident. The Regional Nurse Consultant confirmed the importance of having accurate clocks for resident orientation and acknowledged that staff should have corrected the issue. During a debriefing, facility leadership, including the Facility Administrator and Regional President of Operations, were informed of the findings, and they agreed that clocks in residents' rooms should be accurate. No further information was provided regarding corrective actions or follow-up measures taken to address the deficiency.
Failure to Accurately Complete PASARR for Residents with Mental Illness
Penalty
Summary
The facility staff failed to accurately complete the Preadmission Screening and Resident Review (PASARR) for two residents, specifically failing to code a resident with a current serious mental illness. One resident, who was originally admitted to the facility and later readmitted after a hospital stay, had diagnoses including PTSD, anxiety disorder, OCD, personality hysterical, and major depressive disorder with severe psychotic symptoms. Despite these diagnoses and ongoing treatment with psychotropic medications, the resident's PASARR assessment did not reflect a current serious mental illness. The resident's care plan acknowledged signs of depression and risk for adverse reactions, with interventions including medication administration and referral to psychiatric services. Interviews with facility staff and family members revealed discrepancies in the PASARR coding. The Social Worker indicated that the PASARR was not coded for a serious mental illness because the resident had not been treated for a mental health disorder in two years, despite recent positive screenings for depression and ongoing medication for depression and anxiety. A family member confirmed the resident's long history of mental health issues, which had significantly impacted her life. During a final interview with the facility's administration and nursing staff, no comments or concerns were raised regarding the deficiency.
Failure in Discharge Planning for Resident with Ileostomy
Penalty
Summary
The facility staff failed to maintain an ongoing discharge planning process that aligned with the resident's and their representative's goals, resulting in a deficiency for one resident. The resident, who was admitted to the facility after surgery for colon cancer, required rehabilitation services and surgical wound care that the Intermediate Care Facility (ICF) could not provide. Despite the resident's and their family's preference for discharge back to the ICF, the facility did not adequately address the resident's skin issues related to the ileostomy, which were exacerbated by improper care, such as using the wrong size stoma wafer and not providing frequent enough ileostomy care. This lack of proper care led to skin irritation, preventing the resident from transitioning back to the community. The discharge planner noted that the resident's medical record indicated a plan to transfer back to the ICF once the surgical wound healed. However, the resident's last day of covered rehabilitation services was in May, and the wound was not healed at that time, leading to a change in the resident's discharge status to long-term care. Despite the resident's skin healing approximately two months prior to the survey, the facility had not taken steps to facilitate the resident's discharge back to the ICF, as desired by the resident and their family. The facility's failure to focus on the resident's discharge goals and needs resulted in the resident remaining in long-term care unnecessarily.
Incorrect Ostomy Appliance Size and Care Deficiency
Penalty
Summary
The facility's staff failed to apply the correct size ostomy appliance and did not provide care to an ostomy according to the physician's order for one resident. The resident, who has an ileostomy, was observed to have the wrong size wafer applied, which exposed too much skin and was cut too large. This was confirmed during an observation by an LPN, who noted that the wafer needed to be cut smaller. The resident's sister also reported that the staff used the incorrect size wafer and that it took up to six hours for the staff to change the resident's colostomy bag when it was full, causing skin irritation. The resident, who was admitted to the facility with diagnoses including ileostomy status and malignant neoplasm of the sigmoid colon, was coded as having severe memory and decision-making impairments. The physician's orders specified the use of a 1 3/4 cm wafer and outlined specific care instructions, including checking and emptying the colostomy bag every four hours. However, these orders were not followed, leading to the deficiency. The facility's corporate nurse consultant confirmed the correct wafer size and indicated that the nursing staff had been educated on this matter.
Inadequate Nutrition and Monitoring Leads to Resident's Decline
Penalty
Summary
The facility failed to provide adequate nutrition and hydration to a resident, leading to significant weight loss and malnutrition. The resident, who had severe cognitive impairment and required extensive assistance with eating, was observed receiving insufficient meal portions that did not meet the dietary orders. The meals lacked several components, including fortified pudding and pureed cookies, and were not in the quantity specified by the tray ticket. The kitchen staff admitted to running out of certain items and substituting others without proper authorization. The resident's weight was not monitored as recommended, with significant weight loss documented over several months. Despite a weight gain during a hospital stay, the resident continued to lose weight upon returning to the facility. The Registered Dietician's recommendations for weekly weight checks and dietary adjustments were not followed, and the resident's malnutrition risk was not adequately addressed. The facility also failed to provide the prescribed nutritional supplements consistently, with orders for Pro-stat liquid being discontinued after only three days. Additionally, the resident developed a pressure sore on the left hand, which progressed to cellulitis and required hospitalization. The facility did not apply the prescribed palm guard consistently, contributing to the development of the wound. The resident's contractures and pressure sore were not managed effectively, as evidenced by the lack of proper splint application and monitoring. The facility's inaction and failure to adhere to dietary and medical orders resulted in the resident's declining health and need for hospitalization.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which could potentially affect all residents. A review of the nursing schedule from November 19, 2024, through December 5, 2024, revealed that there was no RN coverage for at least 8 consecutive hours on November 30, 2024, and December 1, 2024. This deficiency was confirmed by the Corporate Nurse Consultant (CNC) #2 on December 3, 2024, who acknowledged the lack of RN coverage on the specified dates. A final interview with CNC #2 on December 4, 2024, reiterated that RN coverage should have been provided on those dates.
Inadequate Mental Health and Psychosocial Services for Resident
Penalty
Summary
The facility failed to provide adequate mental health and psychosocial services to a resident diagnosed with depression and anxiety, who also had a history of trauma and post-traumatic stress disorder. The resident, who had multiple medical conditions including cardiovascular disease, chronic kidney disease, and chronic obstructive pulmonary disease, experienced several falls, a hospitalization for a hip fracture and head injury, and exhibited behavioral issues upon returning to the facility. Despite these challenges, the facility did not reinstitute the resident's long-standing medication therapy for depression and anxiety after hospitalization, nor did they provide sufficient psychiatric evaluations or psychosocial treatments. The resident's clinical record revealed a lack of consistent psychiatric care, with only two psychiatric evaluations conducted from admission until the time of the survey. The facility's management of the resident's psychoactive medications was erratic, with rapid changes in medication regimens that could have contributed to the resident's psychological distress. The facility also failed to conduct necessary assessments, such as a CT scan following the resident's head injury, to determine the cause of the resident's distress. Additionally, the care plan lacked specific interventions for the resident's psychiatric needs, and non-pharmacological interventions were not specified or implemented. Interviews with facility staff indicated a lack of training in psychiatric and behavioral health care, and care planning meetings were not interdisciplinary, involving only the discharge planner and activities director, neither of whom were trained in healthcare. The facility's failure to provide adequate mental health services and appropriate medication management, coupled with insufficient staff training and care planning, contributed to the deficiency identified by surveyors.
Failure to Address Language Barrier and Aggression in Resident
Penalty
Summary
The facility failed to provide necessary medically-related social services to a resident who was strictly Spanish-speaking and exhibited signs of frustration and aggression. This resident, identified as Resident #521, was involved in multiple incidents of aggression and abuse towards other residents, which were not adequately assessed or addressed by the facility's social worker. Despite the resident's language barrier and signs of distress, there was no comprehensive care plan developed to address these issues, nor was there timely intervention from medical social work or psychiatric consultation. Resident #521, who had a mild cognitive impairment and spoke only Spanish, was involved in aggressive incidents with at least three other residents. The facility staff failed to monitor the resident's behavior, obtain a timely psychiatric consult, or provide a comprehensive care plan for emotion regulation. The resident's aggressive behaviors, including physical abuse and intimidation, were not properly documented or reported to the state agency, and the facility's abuse policy was not implemented to protect other residents from further harm. The facility's social worker was only involved with Resident #521 on three occasions, none of which addressed the resident's aggressive behaviors or language barrier. The social worker was not informed of the ongoing issues, resulting in a lack of documentation and intervention. The facility's failure to address the resident's needs and protect other residents from abuse highlights significant deficiencies in the provision of social services and adherence to abuse prevention policies.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to procure routine medications as ordered by the physician for two residents, leading to deficiencies in medication administration and documentation. For one resident, the staff did not sign off on the administration of 9 a.m. medications on a specific date, nor did they document why the medications were not given. The medications included essential drugs such as aspirin for atrial fibrillation and Namenda for dementia. The Director of Nursing (DON) acknowledged that the lack of documentation gives the appearance that nothing was done, highlighting a failure to adhere to the facility's Medication Administration Policy. Additionally, the facility staff did not establish a proper system for the receipt and disposition of controlled drugs, as evidenced by the presence of too many count narcotics in an unlocked file cabinet. Interviews with nurses across different units revealed inconsistencies in the process for disposing of narcotic medications. The DON demonstrated the current process for narcotic destruction, which involves locking medications in a safe until another nurse is available to witness and countersign the disposal form. Another resident did not receive oral antibiotics as per physician's orders due to the medication not being available. The resident was admitted with conditions including osteoarthritis and septic arthritis of the knee. The medication, Amoxicillin, was missed six times during the treatment course, including four consecutive doses. The Regional Nurse Consultant stated that the pharmacy should have ensured the medication was available, and the nurses should have checked the Omnicell for an available supply. The facility's acting administrator and other staff were informed of these findings during the end-of-day debriefing.
Improper Beard Guard Use by Kitchen Staff
Penalty
Summary
The facility staff failed to ensure food was prepared in accordance with professional standards for food service safety. During the preparation of the evening meal, a staff member identified as the cook was observed with a beard guard that only partially covered his facial hair. When questioned, the cook stated that the facility only provided beard guards that did not fit properly. The facility policy requires all Dining Services employees to wear approved attire, including properly restrained facial hair. A corporate employee confirmed the expectation that facial hair should be fully covered, aligning with the facility's policy. The Administrator was informed of this issue during an end-of-day meeting, but no further information was provided.
Failure to Maintain Essential Equipment in Safe Operating Condition
Penalty
Summary
The facility staff failed to maintain essential equipment in safe operating condition, specifically the dishwasher and two washing machines. During a kitchen inspection, it was observed that the kitchen staff were using Styrofoam takeout containers for food service due to the dishwasher being non-functional for several weeks. Despite the arrival of a new dishwasher, it had not been installed until the survey was conducted. Interviews with staff revealed uncertainty about the timeline of the dishwasher's downtime, with documentation showing the dishwasher was purchased in early August and arrived at the facility in late September. Additionally, the facility faced issues with laundry services due to two out of three washing machines being broken. The director of housekeeping reported a shortage of linens and delays in laundry processing, as they were operating with only one functional washing machine for 180 beds. The broken washers had been out of service since the end of September, and by the close of the survey, they had not been repaired or replaced. The administrator was informed of these concerns during the survey, but no further information was provided.
Medication Administration Deficiency Due to Staffing Issues
Penalty
Summary
The facility staff failed to meet professional standards by not administering medications as ordered for one resident. This resident, who was admitted with multiple diagnoses including sepsis, dementia, cardiomyopathy, Parkinson's, and COPD, was cognitively intact but required total dependence for most activities of daily living. The comprehensive care plan indicated the need for cardiac medications as ordered. However, a review of the medication administration record for December revealed that the 9:00 PM doses of several medications, including Atorvastatin, Sinemet, Zaleplon, and Xalatan, were missed on December 31st. An interview with an LPN revealed that staffing issues contributed to the failure to administer medications as ordered. The LPN stated that there were times when there was inadequate staffing, with no nurse scheduled for a unit or minimal CNAs available, which was not sufficient to meet the residents' needs. The LPN confirmed that not administering medications as ordered did not align with professional standards. The facility's administrative and clinical leadership were made aware of these findings, but no further information was provided before the survey exit.
Deficiency in ADL Care Documentation and Provision
Penalty
Summary
The facility staff failed to provide evidence of activities of daily living (ADL) care, specifically incontinence care and feeding assistance, for one resident. This resident was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, and was assessed as requiring extensive assistance for various ADLs. The comprehensive care plan highlighted the resident's risk for weight loss or malnutrition, necessitating specific interventions such as recording meal intake and providing supplements. However, documentation for bladder elimination and grooming was missing on multiple occasions across March, April, and May 2024. Interviews with facility staff revealed inconsistencies in the provision of incontinence care, with a certified nursing assistant indicating that care frequency depended on staffing and resident needs. The resident reported not always being kept dry and experiencing long waits for care, although noting some improvement. Despite these findings being communicated to the facility's administrative and clinical leadership, no further information was provided before the survey exit.
Failure to Provide Consistent Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate urinary catheter care for a resident, identified as Resident #4, who was admitted with multiple diagnoses including sepsis, dementia, cardiomyopathy, Parkinson's, and COPD. The resident was assessed as cognitively intact and required total dependence for various activities of daily living, including hygiene and toileting. The physician orders specified that Foley catheter care should be provided every shift, with documentation of output and monitoring for signs of infection. However, a review of the treatment administration record (TAR) for December 2023 and January 2024 revealed multiple instances of missing documentation across various shifts, indicating that the required catheter care was not consistently provided. During an interview, an LPN confirmed that if there was no documentation of Foley catheter care on the TAR, it was not provided. The facility's administrative and clinical leadership, including the administrator, assistant administrator, director of nursing, and regional directors of clinical services, were informed of these findings. No additional information was provided before the survey exit, indicating a lack of evidence to demonstrate that the required catheter care was consistently administered to the resident.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident, resulting in significant weight loss. The resident, who was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, experienced a weight decrease from 127 pounds to 99.3 pounds over the course of approximately 16 months. The resident's comprehensive care plan identified a risk for weight loss or malnutrition due to various medical conditions and required interventions such as dietician consultations and meal intake recording. However, documentation of feeding assistance was missing for multiple shifts across March, April, and May 2024, indicating a lack of consistent support. Interviews with facility staff and the resident revealed further issues. A CNA admitted to feeding residents as quickly as possible and stated that feeding assistance documentation was recorded in the ADL/CNA form. The resident reported not always receiving feeding assistance, experiencing long waits, and sometimes not being fed at all. These findings were communicated to the facility's administrative and clinical staff, but no additional information was provided before the survey exit.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility staff failed to provide sufficient staffing to meet the needs of two residents, leading to deficiencies in care. Resident #1, who was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, required extensive assistance with daily activities. The facility's staffing schedule revealed significant gaps, particularly on the evening shifts, where there were instances of no certified nursing assistants (CNAs) available. Interviews with staff and residents indicated that the staffing situation was inadequate during March and April, affecting the quality of care provided to residents, including delays in feeding assistance for Resident #1. Resident #4, admitted with sepsis, dementia, cardiomyopathy, Parkinson's, and COPD, also experienced deficiencies in care due to insufficient staffing. The resident required total dependence for most activities and had specific medication needs. However, the medication administration record showed missing doses, and the staffing sheets indicated that no nurse was scheduled after 7:00 PM on certain days. Interviews with staff confirmed that the facility was understaffed during the relevant period, impacting the ability to meet residents' needs effectively. The facility's administrative staff, including the director of nursing and the scheduler, acknowledged the staffing challenges during the survey period. The scheduler, who assumed the role at the end of April, noted that the facility was shorter staffed in previous months. Despite efforts to fill staffing gaps using an agency, the facility struggled to maintain adequate staffing levels, leading to the deficiencies observed during the survey.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility staff failed to provide snacks at bedtime and meals in a timely manner, as observed during the survey period from 5/24/24 to 5/29/24. Breakfast and lunch deliveries were consistently late for units 2A and 2B, with breakfast on 5/24/24 delivered at 9:00 AM to unit 2B, and on 5/28/24, breakfast was delivered at 8:30 AM to unit 2A and 8:55 AM to unit 2B. Lunch was also delayed, with unit 2A receiving it at 12:35 PM and unit 2B at 1:15 PM. Additionally, pantry inspections on 5/28/24 revealed a lack of variety and quantity of snacks, with several units missing essential items like applesauce, graham crackers, milk, and cheese. Interviews with staff and residents further highlighted the deficiency. An LPN mentioned that snacks were not in the budget, and sometimes essential items for medication administration were unavailable. A CNA confirmed that snacks were not usually offered at bedtime due to lack of availability. The Regional Director of Operations Culinary and the new dietary manager acknowledged staffing shortages and pantry stock issues, noting that a recent order of snacks had just arrived. Residents reported not being offered snacks at bedtime, reinforcing the facility's failure to meet residents' needs and preferences regarding meal and snack times.
Failure to Ensure Dignified Feeding Practices
Penalty
Summary
The facility failed to promote and enhance a resident's right to a dignified existence and respect. Resident #1, who was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, was observed being fed by a CNA who was standing. The resident's most recent MDS assessment indicated total dependence for transfer and bathing, and extensive assistance for other activities of daily living. The comprehensive care plan highlighted the resident's risk for weight loss or malnutrition, requiring a modified-texture diet and oral nutrition supplements. During interviews, a CNA acknowledged that feeding residents while standing is not respectful and that residents should be fed while making eye contact and sitting down. Resident #1 confirmed that CNAs often stand while feeding her, which she does not find respectful. The administrative staff, including the administrator and director of nursing, were informed of these findings, but no further information was provided before the survey exit.
Failure to Involve Resident and Family in Care Planning
Penalty
Summary
The facility staff failed to respect a resident's and their responsible party's right to participate in care planning. The resident, who was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, was unable to complete a mental status interview and required extensive assistance with daily activities. Despite these needs, the facility did not provide evidence of care plan meetings or invitations for the resident and their responsible party from August 2023 to May 2024. The most recent care plan meeting notes were dated August 2023, and there was no documentation of any subsequent meetings or communication with the resident's family regarding care planning. Interviews with facility staff revealed that the MDS coordinator was responsible for organizing care plan meetings and notifying responsible parties. However, the coordinator admitted that there was no evidence of letters sent to the resident's responsible party. The facility's administrative staff, including the administrator and director of nursing, were informed of these findings, but no further information was provided before the survey exit.
Failure to Notify Family of Resident's Weight Loss
Penalty
Summary
The facility staff failed to notify the responsible party of a significant change in condition for a resident, specifically regarding the resident's weight loss. The resident, who was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, experienced a weight decrease from 127 pounds to 99.3 pounds over a period of time. Despite the resident's comprehensive care plan highlighting the risk for weight loss and the need for regular monitoring and dietary interventions, there was no documented communication with the family about the weight loss after July 28, 2023. The registered dietician was informed by staff that the resident's son wished to be contacted about diet changes and weight loss, and a conversation with the resident's power of attorney occurred on July 28, 2023. However, subsequent progress notes and interviews revealed that there was no further communication with the family regarding the resident's continued weight loss. The dietician monitored the resident's meal intake and supplements but did not observe the resident frequently. The administrative staff, including the administrator and director of nursing, were made aware of these findings, but no additional information was provided before the survey exit.
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Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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