Westport Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 7300 Forest Ave, Richmond, Virginia 23226
- CMS Provider Number
- 495227
- Inspections on file
- 36
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Westport Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with an indwelling Foley catheter for obstructive uropathy, who was cognitively intact, had a care plan and physician order in place that included maintaining a catheter privacy bag. Surveyors observed the urine collection bag hanging on the hallway side of the bed without a privacy cover, making it visible from the corridor. In interview, the resident stated this was not dignified, and an LPN/unit manager confirmed that catheter bags should be covered so contents cannot be seen, acknowledging that the bag should have been covered to protect the resident’s dignity.
A resident with uropathy and an indwelling Foley catheter had a comprehensive care plan that included an intervention to maintain a catheter privacy bag. During hallway observation, the urine collection bag was seen hanging on the bed’s hallway side without a privacy bag in place. In an interview, an LPN unit manager confirmed that the comprehensive care plan serves as instructions for care and acknowledged that the catheter privacy bag intervention was not being followed. Facility administrative and clinical leadership were later informed of these findings.
A resident with a history of stroke and significant mobility impairment was left unattended in a high bed position during care, resulting in a fall and serious injury. The CNA left the room to get supplies, leaving the resident on their side without supervision, despite care plan interventions for fall risk. The resident rolled off the bed, sustaining a hematoma and an occipital condyle fracture.
Facility staff did not monitor or document the behaviors of a resident who was on the sex offender registry, despite facility policy requiring behavioral assessment and monitoring. The resident, who was cognitively intact and had multiple cardiac diagnoses, had no evidence of behavior monitoring in their records, and staff interviews confirmed the absence of such monitoring.
Facility staff administered Ativan by injection to a resident with no cognitive impairment after the resident refused the oral form, without providing an opportunity to consent to or refuse the injection. Staff interviews and record review confirmed that required consent procedures were not followed, despite facility policy mandating resident rights to refuse medication.
Staff failed to ensure a call bell was within reach for a cognitively impaired resident with mobility difficulties. The resident, unable to locate or access the call bell while in a wheelchair, was only able to reach it after an LPN intervened and attached it to the resident's shirt. Facility leadership was notified of the incident.
A resident's room was found to have a PTAC unit with vents coated in a black, greasy substance. A staff member acknowledged the vents were not clean and explained that while PTAC units are checked biweekly, this unit was missed. The administrator and DON were notified of the issue.
Facility staff did not report an abuse allegation involving a resident and a nurse to the State Agency within the required two-hour timeframe, as mandated by facility policy. Although the nurse was suspended and the resident was assessed with no visible injuries, the external report was delayed until the next day, resulting in noncompliance with abuse reporting requirements.
A resident alleged that a nurse hit him, prompting an internal assessment and suspension of the nurse. Although facility policy requires reporting abuse allegations to the state agency within two hours, the incident was not reported until the following day, exceeding the mandated timeframe.
Facility staff did not accurately complete a quarterly MDS assessment for a resident with paraplegia and other conditions. The MDS contained errors in coding the resident's functional limitations and mobility, despite the resident being dependent for mobility and using a wheelchair. Staff interviews confirmed the inaccuracies, and leadership was made aware of the findings.
Facility staff did not develop or implement a care plan for monitoring sexual or inappropriate behaviors for a resident with multiple cardiac diagnoses who was on the sex offender registry. The care plan addressed other health concerns but omitted required behavior monitoring, despite facility policy and staff acknowledgment that it should have been included.
Staff did not update care plans for two residents after significant changes in their conditions. One resident's care plan was not revised to include fall mats after a fall, and staff were unaware of the new intervention. Another resident's care plan included interventions for ambulation, despite the resident being non-ambulatory and dependent on a wheelchair. Facility policy required ongoing care plan updates, but these were not completed as needed.
Staff failed to follow professional standards by administering an incorrect dosage of Folic Acid to a resident and not properly documenting behavioral incidents, a change in condition, and a resident-initiated hospital transfer for another resident. Additionally, there was a lack of timely clarification and administration of insulin orders, resulting in missed doses.
Staff did not provide or document required ADL care—including turning/repositioning, incontinence care, and feeding—for a dependent resident with quadriplegia and an indwelling catheter. Multiple shifts lacked documentation of these essential care activities, and staff confirmed that undocumented care is considered not provided, as per facility policy.
A resident with quadriplegia and an indwelling catheter did not receive or have documented required catheter care, including regular flushes and output monitoring, as ordered by the physician and outlined in the care plan. Review of records showed multiple missed entries for catheter care and monitoring over several months, and staff confirmed that undocumented care was not performed.
A resident who was dependent on staff for feeding received a lunch meal at a temperature that was not palatable, due to a significant delay in tray delivery. Test tray temperatures were below the expected standard, and the dietary manager acknowledged frequent complaints about food temperatures, attributing the issue to slow delivery by staff. The resident confirmed the food was not good to eat at the served temperature.
Staff failed to maintain an accurate clinical record for a resident by incorrectly documenting a hospital transfer that did not occur on the recorded date. Progress notes included late entries about a change in condition and ER transfer, but subsequent documentation and staff interviews confirmed the resident was not transferred as stated. The LPN responsible for the note admitted to entering the wrong date and leaving the error uncorrected.
Staff failed to maintain sanitary food preparation and service practices, including not sanitizing thermometers between foods, handling wet silverware by the eating ends, wearing hair restraints improperly, omitting beard guards, and not obtaining holding temperatures for new food items. Gloves were not changed between handling meal tickets and food, leading to cross-contamination.
Facility staff did not implement the comprehensive care plan for a resident requiring CPAP therapy for chronic respiratory failure, COPD, and Parkinson's Disease. Although the care plan and physician's orders specified nightly use and regular cleaning of the CPAP equipment, there was no documentation on the MAR to show these interventions were carried out as ordered. Interviews confirmed the resident used the CPAP at night, but staff acknowledged the care plan was not fully implemented.
A resident with chronic respiratory failure, COPD, and Parkinson's Disease was not provided with documented evidence of CPAP respiratory care as ordered. Although the resident reported using the CPAP machine nightly, staff interviews and review of the MAR revealed no documentation of CPAP settings or maintenance, indicating that physician orders and facility policy were not followed.
A resident who was fully dependent on staff for transfers fell and sustained a pelvic fracture during a transfer with a mechanical lift. Two CNAs, one of whom was still in orientation and not fully trained on the lift, failed to position the sling correctly, resulting in the resident sliding out and falling. The incident was confirmed by staff and resident interviews, as well as clinical documentation.
A CNA who had not been checked off for competency in using a mechanical lift participated in transferring a resident who was fully dependent for transfers. The sling was not positioned correctly, and the resident slid out and fell to the floor. Facility policy required demonstration and validation of competency before operating such equipment, but this was not followed in this case.
The facility did not document or provide evidence of resolving concerns raised by the Resident Council about food options and missing belongings, as required by policy. Interviews with administrative staff confirmed the lack of written responses or documented resolutions to these issues.
Facility staff did not consistently provide required transfer documentation, such as care plans, medication lists, and provider notes, when residents were sent to the hospital. In several cases, there was no evidence that information was sent with residents or that a physician or NP documented the basis for transfer and unmet needs, as confirmed by staff interviews and record reviews.
Facility staff did not provide timely written notification of transfer or discharge to several residents, their representatives, and the ombudsman when residents were sent to the hospital for various medical reasons. Required written notices were missing from clinical records, and ombudsman notifications were delayed or undocumented, as confirmed by staff interviews and record reviews.
Facility staff did not provide written notification of the bed hold policy to residents or their representatives when several residents were transferred to the hospital for acute medical issues. Clinical records lacked documentation of the required notice, and staff interviews confirmed that bed hold agreements should accompany residents during transfers, but this was not consistently done.
A resident with ESRD, COPD, and an amputation did not consistently receive required dialysis communication forms or a bagged lunch when sent for hemodialysis. Staff interviews confirmed lapses in both communication with the dialysis facility and provision of meals, and the dietary manager was unaware the resident needed a bagged lunch, resulting in missed support during dialysis appointments.
Staff did not offer or attempt alternatives to bed rails or assess for entrapment risk before using bed rails for four residents. Clinical records lacked required documentation, and interviews with an LPN indicated a lack of awareness and policy regarding entrapment risk assessment.
Staff failed to maintain accurate and complete medical records, including a significant weight discrepancy for a resident, incomplete trauma screening, and missing documentation for held medication and a resident's departure against medical advice. Additionally, confidential records of a deceased resident were released without proper legal authorization, contrary to facility policy.
The facility did not provide evidence that the medical director participated in any of the QAPI meetings throughout 2023, despite policy requiring their quarterly attendance. Review of meeting rosters and staff interviews confirmed the absence of the medical director from all required sessions.
Staff served meals using plastic silverware and styrofoam containers for some residents after running out of proper serving supplies, resulting in meals not being presented in a dignified or policy-compliant manner.
Several residents, all cognitively intact and using wheelchairs, were unable to independently access the outdoors due to the lack of accessible, automatic doors. Manual doors required physical effort that residents could not provide, and the only automatic door required a code not given to residents. Staff confirmed that residents often needed assistance to enter or exit, and some residents reported feeling confined or having difficulty due to these barriers.
Staff failed to protect resident confidentiality by sending identifiable information, including names and care details, through unsecured text messages. Interviews revealed that some staff were unaware of the prohibition against using non-secure messaging for PHI, despite having received HIPAA training. Facility policy requires safeguarding PHI and prohibits such disclosures, but these requirements were not followed, resulting in a breach.
Staff did not ensure a clean and homelike environment for a resident, as dried tube feeding formula was observed on the resident's tube feeding pole and floor over several days. In addition, two large holes were found in the hallway outside the kitchen, caused by food carts, with maintenance staff reporting frequent repairs. These deficiencies were confirmed by housekeeping and maintenance leadership.
Staff failed to develop or implement comprehensive care plans for several residents, including missing documentation of incontinence care for a dependent resident, improper administration of respiratory medications for a resident with COPD, lack of activity care plans for two residents, and missed or late medication administration for residents with pain and chronic conditions. Staff interviews confirmed that care plans were not always followed or completed as required.
Two residents did not receive their medications within the prescribed time frames, with multiple instances of late administration documented. One resident, dependent for daily activities and with multiple diagnoses, had diabetes medications given outside the scheduled window. Another resident reported frequent delays in receiving morning and other medications, with audit reports confirming significant delays and no documentation of physician notification. Staff interviews and facility policy confirmed that these actions did not meet professional standards.
Facility staff failed to provide and document required ADL care, including incontinence care, personal hygiene, and showers, for three dependent residents. Gaps in documentation across multiple shifts and months meant there was no evidence that care was provided as required by care plans and facility policy. Staff confirmed that undocumented care could not be verified.
Staff failed to administer medications as ordered for five residents, including missed doses of anxiety, pain, and antibiotic medications, and incorrect administration of an antihypertensive despite clear parameters. In several cases, medications were available in the Omnicell but not given, and documentation was incomplete or missing.
A resident with a Foley catheter for urinary retention did not receive catheter care as ordered by the physician on multiple occasions, as evidenced by missing documentation on the TARs. An LPN confirmed that catheter care is recorded by signing the TAR, and the facility could not provide a specific policy for Foley catheter care when asked by surveyors.
Facility staff did not change a resident's colostomy pouch according to physician orders, as evidenced by blank spaces on the TAR for two consecutive months. An LPN confirmed that documentation of pouch changes is required, and the facility lacked a specific policy for colostomy care.
Staff did not consistently provide alternate menu selections or follow posted menus, resulting in a resident with complex medical needs not receiving appropriate meal choices. Kitchen staff substituted menu items due to inventory shortages, and residents were sometimes unable to receive their preferred foods. Facility policies for menu substitutions and food replacements were not consistently followed, as confirmed by staff interviews and kitchen observations.
Staff failed to provide food that was both palatable and at safe, appetizing temperatures, as reported by two residents and confirmed by surveyors and the dietary manager. During one meal service, food items were served cold or with poor taste and texture due to delays, lack of proper serving supplies, and improper tray handling, in violation of facility policy.
Staff failed to store, prepare, and serve food in a sanitary manner, with unlabeled and undated food items, food debris on kitchen equipment and floors, improper storage of personal items with food supplies, and lack of a cleaning schedule. Staff also did not use sanitizing solution when washing equipment and engaged in unsanitary practices during food preparation, contrary to facility policy.
A resident admitted for skilled services with Medicare as the primary insurance did not receive the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN Form CMS-10055). Documentation confirmed the absence of this form, and staff interviews revealed that the responsible social services director was unable to provide the necessary beneficiary notification documentation.
Staff failed to accurately complete an MDS assessment for a resident with traumatic brain injury, muscle wasting, and depression, incorrectly coding the use of limb restraints despite no supporting documentation or physician orders. The error was confirmed by the MDS Coordinator after review of records and staff interviews.
A resident with multiple complex diagnoses was admitted without evidence of a completed PASARR screening, as required by facility policy. The PASARR was only provided after surveyors requested it, and staff interviews confirmed that the screening should have been done at admission.
Two residents admitted with continuous IV cardiac drips for CHF did not have these critical treatments documented in their baseline care plans, despite clear physician orders and hospital discharge instructions. Nursing staff and facility policy confirmed that such therapies should be included in the care plan, but the omission was identified through observation, interviews, and record review.
A resident with a left-hand contracture did not receive a needed palm guard or splint, as required to maintain range of motion. The resident reported the device had been missing for some time, and staff interviews confirmed no current device was in use. Review of records showed no documentation or care plan for a splint, and no occupational therapy had been provided in the past six months.
A resident's CPAP mask was repeatedly observed left uncovered on a nightstand and not stored in a plastic bag as required by facility policy. An LPN confirmed the mask should have been covered for infection control, and facility policy specified proper storage of respiratory equipment. The issue was identified through multiple observations and staff interviews.
A resident with moderate depression and psychosocial adjustment difficulties did not receive a recommended increase in her antidepressant medication after a psychiatric consult. The psychiatric nurse practitioner advised increasing the Zoloft dose, but the order was not updated and the resident continued on the lower dose. Staff interviews indicated a lack of follow-up and communication regarding the recommendation, resulting in the deficiency.
Failure to Maintain Privacy for Catheter Collection Bag
Penalty
Summary
Facility staff failed to promote a resident’s dignity by not providing privacy for an indwelling catheter collection bag. The resident, who was cognitively intact with a BIMS score of 15/15 and had diagnoses including obstructive and reflux uropathy/neurogenic bladder, had a physician’s order for a 16 French Foley catheter and a comprehensive care plan that specifically directed staff to maintain a catheter privacy bag. During an observation from the hallway, the resident’s catheter collection bag, containing urine, was seen hanging on the hallway side of the bed without any privacy cover, making it fully visible from the corridor. When interviewed, the resident reported not being aware that the catheter bag was uncovered and stated that she did not like it and felt it was not dignified. The unit manager LPN confirmed in interview that catheter collection bags should be placed in a privacy bag or otherwise covered so the contents cannot be seen, and acknowledged that the bag should have been covered to protect the resident’s dignity. Administrative staff, including the administrator, DON, regional director of clinical services, and ADON, were informed of these findings, and no additional information was provided before survey exit.
Failure to Follow Care Plan for Catheter Privacy Bag
Penalty
Summary
Facility staff failed to follow the comprehensive care plan for a resident with an indwelling Foley catheter by not maintaining a catheter privacy bag as care-planned. The resident had diagnoses including uropathy and an order for a 16 French Foley catheter with a 10 cc balloon due to obstructive and reflux uropathy. On the most recent MDS quarterly assessment, the resident was coded as having an indwelling catheter and scored 15/15 on the BIMS, indicating cognitive intactness for daily decision-making. The comprehensive care plan, initiated on 05/05/2025 and revised on 09/08/2025, identified a catheter focus and included an intervention to maintain a catheter privacy bag. During an observation from the facility hallway on 02/03/2026 at approximately 2:40 p.m., the resident’s catheter collection bag, containing urine, was seen hanging on the hallway side of the bed without a privacy bag in place. In a subsequent interview on 02/04/2026, the unit manager LPN stated that the purpose of a comprehensive care plan is to provide instructions for a resident’s care and, after reviewing the resident’s care plan, acknowledged that the intervention to maintain a catheter privacy bag was not being followed. Administrative staff, including the administrator, DON, regional director of clinical services, and assistant DON, were informed of these findings on 02/05/2026, and no additional information was provided before survey exit.
Resident Fall Due to Inadequate Supervision and Unsafe Bed Position
Penalty
Summary
Facility staff failed to provide a safe environment for a resident with a history of cerebrovascular accident, hemiplegia, and hemiparesis, who was assessed as requiring substantial to maximal assistance for bed mobility. On the day of the incident, the resident was left unattended in bed in a high position while being cleaned. The certified nursing assistant (CNA) left the room to obtain additional supplies, leaving the resident on their side without supervision. As a result, the resident rolled off the bed, landing face down on the floor, and sustained a hematoma and an occipital condyle fracture. Clinical documentation and staff interviews confirmed that the resident's care plan identified them as being at risk for falls due to muscle weakness, poor balance, psychoactive medications, recent hospitalization, and high-risk medication use. The care plan included interventions such as placing items within reach and reminding the resident to use the call light for assistance with activities of daily living. However, the CNA did not ensure the resident's safety by either calling for assistance or gathering all necessary supplies before starting care, and left the resident in an unsafe position. Progress notes and interviews further revealed that the resident was coded as dependent for bed mobility for a significant number of shifts, and staff were expected to verify the required level of assistance before providing care. The incident occurred despite the presence of fall mats, as the bed was not in the lowest position and the resident was left unsupervised. The failure to provide adequate supervision and maintain a safe environment directly resulted in the resident's fall and injury.
Failure to Monitor Behaviors of Resident on Sex Offender Registry
Penalty
Summary
Facility staff failed to provide appropriate monitoring and care for a resident who was listed on the sex offender registry. The resident was admitted with multiple medical diagnoses, including ischemic cardiomyopathy, CHF, atrial fibrillation, and an LVAD, and was assessed as cognitively intact with a BIMS score of 15. The care plan addressed behavioral issues related to refusal of cardiac care but did not include interventions specific to monitoring for sexual or inappropriate behaviors. During the survey, it was determined that although the facility had a policy requiring behavioral assessment and monitoring, there was no evidence that staff monitored or documented the resident's behaviors related to their status on the sex offender registry. Interviews with administrative and social work staff confirmed that while the facility previously admitted residents on the sex offender registry, there was no process in place for ongoing monitoring of such residents' behaviors. Staff acknowledged that behaviors should be monitored and documented, but no such monitoring was found in the resident's records. The facility's own policy required assessment and monitoring of behaviors, but this was not implemented for the resident in question.
Failure to Obtain Consent for Psychoactive Medication Administration
Penalty
Summary
Facility staff failed to obtain consent from a resident prior to administering a psychoactive medication, Ativan, on 3/1/25. The resident was assessed as having no cognitive impairment, scoring 15 out of 15 on the BIMS, and was identified as her own responsible party. Clinical records showed no change in cognitive status and documented that the resident was offered Ativan orally, which she refused. Despite this, staff proceeded to administer Ativan by intramuscular injection without evidence that the resident was given the opportunity to consent to or refuse the injection. Staff interviews confirmed that facility policy requires resident or responsible party notification and consent prior to medication administration, and that residents have the right to refuse any medication or treatment. The staff acknowledged that, although non-pharmacological interventions were attempted and the resident refused the oral medication, there was no documentation or evidence that the resident was given the opportunity to refuse the Ativan injection. Facility policy also states that all patients have the right to refuse medications, and that nurses are responsible for providing education regarding risks, but no such documentation was found in this case.
Call Bell Not Placed Within Reach for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to accommodate a resident's need by not ensuring the call bell was within reach for a resident with cognitive impairment and difficulty walking. The resident was observed sitting in a wheelchair next to the right side of the bed and was unable to locate or access the call bell, which was draped over the left side of the headboard. When asked, the resident stated he did not know where the call bell was and was unable to maneuver his wheelchair to reach it. A licensed practical nurse later entered the room, removed the call bell from the head of the bed, and clipped it to the resident's shirt while he was in his wheelchair. The LPN confirmed that the call bell was not within the resident's reach and acknowledged it should have been accessible. Facility administrative staff, including the administrator and director of nursing, were informed of these findings during the survey.
Failure to Maintain Clean PTAC Unit Vents in Resident Room
Penalty
Summary
Facility staff failed to maintain a clean environment in one of twelve resident rooms observed, specifically in resident room [ROOM NUMBER]. During an observation, the PTAC (packaged terminal air conditioner) unit vents in this room were found to be coated with a black, greasy substance. A staff member confirmed the vents were not clean and stated that PTAC units are checked every two weeks, but this particular unit had been overlooked. The administrator and director of nursing were informed of these findings, and no additional information was provided prior to the survey exit.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
Facility staff failed to implement their abuse policy by not reporting an allegation of abuse within the required timeframe for one resident. According to the facility's policy, any alleged violations involving abuse must be reported to the State Agency immediately, but no later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. In this case, a resident alleged that a nurse hit him on the arm. The nurse denied the allegation, stating that the resident attempted to strike at her, and there was a witness to corroborate this. Upon notification, the nurse was suspended, and the administrator assessed the resident, finding no visible injuries. The resident was later transferred to the hospital for altered mental status. Documentation showed that the incident occurred and was reported internally on the same day, but the report to the State Agency was not sent until the following day, exceeding the two-hour reporting requirement. Interviews with administrative staff confirmed that the event qualified as an abuse allegation that should have been reported within two hours, as per facility policy. The delay in reporting constituted a failure to follow established procedures for timely notification of abuse allegations.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse within the required timeframe for one resident. On the date of the incident, a resident alleged that a nurse hit him on the arm in his room. The nurse denied the allegation, stating that the resident attempted to strike at her, and there was a witness to corroborate the nurse's account. Upon notification of the allegation, the nurse was suspended, and the administrator assessed the resident, finding no visible injuries. The resident was later transferred to the hospital for altered mental status. Documentation shows that the incident was reported to the state agency the following day, more than two hours after the allegation was made. Facility policy requires that any alleged violations involving abuse be reported to the state agency immediately, but not later than two hours after the allegation is made if the event involves abuse or results in serious bodily injury. Staff interviews confirmed that the event qualified as an abuse allegation and should have been reported within two hours. However, the fax confirmation indicates the report was sent the next day, exceeding the required reporting timeframe.
Inaccurate MDS Assessment for Resident with Mobility Impairments
Penalty
Summary
Facility staff failed to complete an accurate quarterly Minimum Data Set (MDS) assessment for one resident. The resident, who had diagnoses including paraplegia, atherosclerotic cardiovascular disease, and neuromuscular dysfunction of the bladder, was coded in the most recent MDS as having no cognitive impairment and being dependent for bed mobility, transfer, hygiene, and required supervision for eating. However, the MDS also indicated no impairment in lower extremity range of motion and that walking 10 feet was not attempted due to medical or safety concerns. The resident's care plan identified risks for falls related to muscle weakness, poor balance, and psychoactive medications, with interventions such as ensuring the resident wore shoes when ambulating and keeping items within reach. During staff interviews, an LPN recalled that the resident could not walk and used a wheelchair, and the MDS coordinator acknowledged errors in the MDS coding for functional limitations and mobility. The MDS coordinator stated that the RAI manual is the standard used for completing the MDS. The director of nursing, administrator, and assistant director of nursing were informed of these findings. The deficiency was identified through review of facility documents, clinical records, and staff interviews.
Failure to Develop Care Plan for Behavior Monitoring
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan addressing sexual or inappropriate behavior monitoring for one resident who was admitted with multiple medical diagnoses, including ischemic cardiomyopathy, CHF, atrial fibrillation, and an LVAD. The resident was found to be on the Virginia State Police Sex Offender Registry, but the care plan only addressed issues related to refusal of cardiac clinic appointments and daily weights, with no mention of monitoring for sexual or inappropriate behaviors. During the survey, interviews with administrative and nursing staff confirmed that monitoring for sexual or inappropriate behaviors should have been included in the care plan for a resident listed on the sex offender registry. Review of facility policies indicated that behaviors are to be assessed, monitored, and care planned, but this was not done for the resident in question. No additional information was provided prior to the survey exit.
Failure to Review and Revise Care Plans After Change in Condition
Penalty
Summary
Facility staff failed to review and revise the care plans for two residents following significant changes in their conditions. For one resident who experienced a fall, the care plan was not updated to include the new intervention of fall mats, despite documentation in the clinical record that fall mats were implemented after the incident. Observations confirmed that fall mats were not present at the bedside during subsequent checks, and staff interviews revealed a lack of awareness regarding the need for this intervention. The director of nursing acknowledged that the care plan should have been reviewed and revised after the fall, as it provides essential guidance for staff care. In another case, a resident with paraplegia and other significant diagnoses was care planned for fall prevention with interventions such as ensuring the resident wore shoes when ambulating. However, the resident was dependent for bed mobility and transfers, did not ambulate, and used a wheelchair. Staff interviews confirmed that the care plan did not accurately reflect the resident's needs, as the intervention to ensure the resident wore shoes when ambulating was not appropriate for someone who could not walk. The care plan was not revised to reflect the resident's actual functional status. Facility policy required care plans to be updated as changes occurred and reviewed quarterly, but documentation and staff interviews indicated that these requirements were not met for the two residents. The deficiencies were identified through observation, staff interviews, facility document review, and clinical record review, and were communicated to facility leadership during the survey.
Failure to Follow Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to adhere to professional standards of practice in two separate cases involving medication administration and documentation. In the first case, a licensed practical nurse (LPN) administered an incorrect dosage of Folic Acid to a resident. The physician's order specified a 1 mg dose, but the LPN used a 400 mcg tablet from house stock and attempted to approximate the correct dose by dividing the tablet, which did not match the prescribed amount. The LPN acknowledged the difficulty in using stock medications and calculating dosages, and facility policy required strict adherence to the '5 Rights' of medication administration, which was not followed in this instance. In the second case, staff failed to document significant behavioral events, a change in condition, and a resident-initiated hospital transfer. The resident exhibited behavioral disturbances, including yelling, confusion, and an altercation with staff, which escalated to the resident calling 911 and being transferred to the hospital. Despite these events, there was a lack of documentation in the medical record regarding the incident, the change in condition, and the transfer. Staff interviews confirmed that such incidents should be documented and that the physician and responsible party should be notified, but this was not done. Additionally, there was a failure to clarify physician orders for insulin administration for the same resident. The resident had overlapping orders for two types of insulin with similar sliding scale instructions. The electronic medication administration record showed that one insulin was not administered for several days while staff awaited clarification, but there was no evidence that clarification was obtained in a timely manner. This resulted in missed doses and a lack of adherence to prescribed treatment.
Failure to Provide and Document Required ADL Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically turning/repositioning, incontinence care, and feeding, for a dependent resident with quadriplegia, spinal stenosis, and a history of TIA. The resident was assessed as cognitively intact but fully dependent for bathing, transfer, dressing, toileting, and eating, and was always incontinent of bowel with an indwelling urinary catheter. The resident's care plan required assistance with all ADLs, including a two-person assist for bed mobility and specific catheter care interventions. A review of ADL documentation for several months revealed multiple instances where required care activities, including turning/repositioning, incontinence care, and feeding, were not documented on both day and night shifts. Interviews with staff confirmed that if care was not documented in the electronic record, there would be no evidence that the care was provided. The facility's policy required documentation of such care, but no further information or evidence was provided to show that the care was delivered on the dates in question.
Failure to Provide and Document Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide and document required treatment and services for a resident with an indwelling catheter. The resident, who was admitted with diagnoses including quadriplegia, spinal stenosis, and a history of TIA, was assessed as cognitively intact but fully dependent for activities of daily living. The resident's care plan and physician orders specified the need for regular catheter care every shift, daily catheter flushes, and monitoring of catheter output. However, review of the medication and treatment administration records over several months revealed multiple instances where these required treatments and monitoring were not documented as completed. Interviews with nursing staff confirmed that if catheter care was not documented, it was not performed. The facility's own urinary catheterization policy required licensed nurses to perform and document catheter care every shift. Despite these requirements, there was missing documentation for catheter output monitoring, catheter flushes, and catheter care on several shifts, indicating a failure to provide the ordered care and services for the resident's indwelling catheter.
Failure to Serve Meals at Palatable Temperatures Due to Delayed Tray Delivery
Penalty
Summary
Facility staff failed to provide food at a palatable temperature for one resident during a lunch meal service. The resident, who was dependent on staff for feeding due to quadriplegia and other medical conditions, received their meal significantly later than when trays were delivered to the unit. Specifically, the resident's tray was delivered at 12:43 PM, over 30 minutes after the trays arrived on the unit at 12:10 PM. Test tray temperatures at the time of delivery were recorded as 118.6°F for fish, 122.8°F for noodles, and 120.0°F for zucchini and tomatoes, which were acknowledged by the dietary manager as not being warm enough. The dietary manager also reported frequent complaints about food temperatures and attributed the issue to delays in tray delivery by staff. The resident confirmed during an interview that the food was only warm at best and not good to eat at that temperature. The facility's policy requires prompt delivery of food to ensure it is served at safe, palatable, and high-quality temperatures, as preferred by residents and customary practice. The deficiency was identified through observation, resident and staff interviews, and review of clinical records, with no further information provided prior to the survey exit.
Inaccurate Clinical Record of Resident Hospital Transfer
Penalty
Summary
Facility staff failed to maintain an accurate clinical record for one resident by incorrectly documenting a transfer to the emergency room. Progress notes included late entries stating that the resident experienced shortness of breath, received a full assessment, and was transferred to the ER by EMTs. However, subsequent documentation in the clinical record did not show evidence that the resident actually went to the ER on the date in question. Additionally, a respiratory evaluation note from later that morning indicated the resident was stable, with no shortness of breath or need for suction, and remained on room air. Interviews with nursing staff revealed discrepancies in the documentation. The RN who regularly cared for the resident stated that the resident was never sent to the hospital on the date documented and that the nurse who wrote the change in condition note did not work on the unit at that time. The LPN who authored the late entry notes admitted to mistakenly entering the wrong date for the hospital transfer, as she had documented the event after the fact and was unsure how to correct the error. The facility's policy requires that recorded entries be complete and contain essential information, which was not met in this instance.
Failure to Maintain Sanitary Food Preparation and Service
Penalty
Summary
Facility staff failed to prepare and serve food in a sanitary manner during a lunch meal service. Observations included a dietary aide not sanitizing a thermometer between checking temperatures of different foods, instead using the same paper towel repeatedly. Another dietary aide handled clean, wet silverware by touching the eating ends with gloved hands and placing them upside down in containers and on trays, while also wearing long braids outside of a hair net that hung over food trays. A third dietary aide, who had a goatee, was not wearing a beard guard while preparing bagged turkey and cheese sandwiches, and mayonnaise packets were placed in direct contact with the sandwich bread. Additionally, new food items added to the steam table were served without obtaining holding temperatures, and gloves were not changed between handling meal tickets and food items, leading to potential cross-contamination. Interviews with dietary staff and review of facility policies confirmed that proper procedures were not followed. Staff acknowledged that hair nets should cover all hair, beard guards should be used for facial hair, and alcohol wipes should be used to sanitize thermometers between foods. Policies also required that gloves be changed after touching contaminated surfaces and that silverware be completely dried before use. These lapses in food handling and personal hygiene practices were directly observed and confirmed by staff interviews and policy review.
Failure to Implement CPAP Care Plan for Resident with Respiratory Conditions
Penalty
Summary
Facility staff failed to implement the comprehensive care plan for a resident who required CPAP therapy for conditions including chronic respiratory failure, COPD, and Parkinson's Disease. The resident was cognitively intact but required maximal assistance for mobility and other activities of daily living. The care plan, dated 11/29/24, specified the use of CPAP as ordered, with detailed instructions for nightly use, daily and weekly cleaning of the equipment, and monitoring for proper placement. However, during the survey, the CPAP machine was observed in the resident's room, and there was no evidence on the medication administration record (MAR) that the CPAP settings or interventions had been documented or implemented as ordered prior to the night shift on 3/10/25. Interviews with the resident confirmed that he used the CPAP machine at night and found it beneficial. An LPN acknowledged that if there was no evidence of the CPAP intervention being carried out, the care plan would not have been implemented. The administrator and director of nursing were made aware of the issue. Review of facility policy confirmed the requirement for individualized care plans to be developed and implemented by licensed nurses in coordination with the interdisciplinary team. No further information was provided prior to the survey exit.
Failure to Document and Provide Ordered CPAP Respiratory Care
Penalty
Summary
Facility staff failed to provide evidence of appropriate respiratory care services for one resident with chronic respiratory failure, COPD, and Parkinson's Disease. The resident was observed to have a CPAP machine in his room and reported using it at night to help him sleep. The resident's care plan included interventions for CPAP use as ordered, and the physician's order specified nightly use of the CPAP with particular settings, as well as daily and weekly cleaning instructions for the equipment. However, there was no documentation on the medication administration record (MAR) of the CPAP settings or evidence that the CPAP was being used and maintained as ordered prior to the survey date. Interviews with staff confirmed that documentation of CPAP use and settings should be present on the MAR, and in the absence of such documentation, the orders were not being followed. The facility's policy required that respiratory therapy equipment be administered and maintained per provider orders and current standards of practice. Despite these requirements, the facility did not provide evidence that the resident's respiratory care needs were being met according to the physician's orders and facility policy.
Improper Mechanical Lift Use Leads to Resident Fall and Injury
Penalty
Summary
Facility staff failed to prevent an avoidable accident involving a resident who was completely dependent on staff for transfers and had no cognitive impairment. During a transfer using a mechanical lift, the resident fell from the lift and sustained a fractured pelvis, resulting in significant pain. The incident occurred when two CNAs, one of whom was still in orientation and had not been checked off on safe use of the lift, attempted to transfer the resident. Interviews and documentation revealed that the sling was not positioned correctly under the resident's lower body, and the CNAs were unsure about the proper procedure. One CNA admitted to not being fully trained on the lift, while the other was unaware of her colleague's lack of training. The resident reported that the sling was not placed all the way down to her knees and described jerking motions during the transfer, which contributed to her sliding out of the sling and falling to the floor. Staff interviews confirmed that both CNAs were present during the incident, and one was on orientation without having been signed off for safe use of the mechanical lift. The charge nurse and other staff were not present in the room at the time of the fall but responded after hearing the resident's distress. The improper use of the mechanical lift and lack of adequate staff training directly led to the resident's fall and injury.
CNA Operated Mechanical Lift Without Demonstrated Competency, Resulting in Resident Fall
Penalty
Summary
Facility staff failed to ensure that a certified nursing assistant (CNA) had demonstrated competency in the use of a mechanical lift prior to operating it with a resident who was completely dependent on staff for transfers. The CNA in question, who was still in orientation and had not been checked off for safe use of the Hoyer lift, participated in transferring a resident using the lift. The resident was cognitively intact but physically dependent, requiring full assistance for transfers. During the transfer, the CNA operated the lift remote while another CNA assisted with securing the sling. The sling was not positioned correctly under the resident's lower body, and the resident subsequently slid out of the sling and fell to the floor. Interviews with staff and the resident confirmed that the CNA operating the lift had not been signed off for competency, and the improper sling positioning contributed to the fall. The resident reported that the sling was not placed all the way down to her knees and described jerking motions during the transfer, which led to her slipping out. Facility policy required that CNAs demonstrate competency in mechanical lift use before operating such equipment, with documentation and validation by a nursing trainer or staff development coordinator. Despite this policy, the CNA was allowed to participate in the transfer without having completed the required competency check, directly leading to the incident.
Failure to Document and Resolve Resident Council Concerns
Penalty
Summary
The facility failed to provide evidence of resolving concerns raised by the Resident Council regarding issues with food, menus, alternate meals, and missing belongings. Review of Resident Council Minutes from December 2022 through October 2024 showed no documentation of how these concerns were addressed or resolved. During an interview, the DON confirmed that there was no evidence of resolution or communication of outcomes to residents. The facility's own policy requires the administrator to review, sign, and respond in writing to concerns presented by the council, but no such documentation was available for review.
Failure to Provide Required Documentation and Information During Resident Transfers
Penalty
Summary
Facility staff failed to provide required documentation and information during resident transfers and discharges to the hospital for multiple residents. In several instances, there was no evidence that essential documents, such as the transfer and discharge report, medication lists, care plans, or progress notes, were sent with the residents at the time of transfer. For example, one resident with a history of paraplegia, post hemorrhagic anemia, and pseudomonas was transferred to the hospital due to increased bloody drainage from wounds, but the transfer form was not completed and there was no evidence of documents sent with the resident. Additionally, there was no provider note post-transfer in the clinical record. Another resident was transferred to the hospital on two separate occasions for acute medical issues, including shortness of breath, low oxygen, elevated temperature, and low blood pressure. In both cases, the clinical record did not contain evidence that information was provided to the hospital staff, nor was there documentation from a physician or nurse practitioner regarding the basis for discharge or the resident needs that could not be met at the facility. Staff interviews confirmed that it was not standard practice for providers to document such notes, and the facility did not have a specific policy requiring this documentation. Further, for another resident transferred for shortness of breath and pain, the care plan was not evidenced as sent to the hospital, and the transfer document checklist did not indicate what documents were provided. In another case, there was no evidence that a physician or nurse practitioner wrote a progress note explaining the reason for transfer and why the resident's needs could not be met at the facility. These deficiencies were identified through closed record review, staff interviews, and review of facility policies.
Failure to Provide Timely Written Notification of Transfer or Discharge
Penalty
Summary
Facility staff failed to provide timely written notification of transfer or discharge to residents, their representatives, and the ombudsman as required. Multiple instances were identified where residents were transferred to the hospital due to changes in their medical condition, such as increased bloody drainage from wounds, shortness of breath, low oxygen levels, elevated temperature, and gastrointestinal bleeding. In these cases, the clinical records did not contain evidence that written notices were given to the residents or their responsible parties at the time of transfer. Staff interviews confirmed that written notices should be provided and documented in the electronic clinical record, but this was not done for several residents. For several residents, including those with significant medical histories such as paraplegia, post hemorrhagic anemia, and a history of DVT, the facility did not document that written notifications were provided at the time of hospital transfer. In some cases, staff only communicated the transfer telephonically or left messages for responsible parties, but did not provide or document the required written notice. Additionally, the facility failed to provide timely notification to the ombudsman regarding resident transfers, with some notifications being sent months after the actual transfer events. Interviews with facility staff, including LPNs and administrative staff, revealed a lack of consistent process for ensuring written notifications were provided and documented. The facility also did not have a specific policy regarding written notice of transfer to residents, their representatives, or the ombudsman. Review of the ombudsman fax records showed missing documentation for certain months, further evidencing the failure to notify the ombudsman as required.
Failure to Provide Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified through closed record reviews and staff interviews, revealing that multiple residents were transferred to the hospital without receiving the required bed hold notice. The absence of documentation or evidence that the bed hold policy was communicated was noted in the clinical records for several residents. One resident, who had diagnoses including paraplegia, post hemorrhagic anemia, and pseudomonas, was transferred to the hospital following increased bloody drainage from wounds. The clinical record review showed no evidence that a bed hold notice was provided at the time of transfer. The resident was cognitively intact, as indicated by a perfect BIMS score, and required maximum assistance for most activities of daily living. The transfer documentation was incomplete, and no bed hold information was sent with the resident. Similar deficiencies were found for three other residents who were transferred to the hospital for various acute medical conditions, such as shortness of breath, low oxygen levels, elevated temperature, and nausea/vomiting. In each case, the clinical records lacked documentation that the bed hold policy was provided to the resident or their representative. Staff interviews confirmed that a bed hold agreement should be sent with residents during hospital transfers, but the facility did not have evidence of compliance with this requirement.
Failure to Provide Dialysis Communication and Meals
Penalty
Summary
Facility staff failed to provide appropriate dialysis care and services for one resident with end stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), and a left above the knee amputation. The resident was dependent for toileting, bathing, and hygiene, and was cognitively intact. The care plan included monitoring for complications related to ESRD and providing a therapeutic diet as ordered. Physician orders specified hemodialysis three times weekly. However, review of the medical record revealed missing dialysis communication forms for several dates, indicating a lack of documented communication with the dialysis facility. Interviews with the resident and staff confirmed that the resident did not consistently receive a bagged lunch to take to dialysis, as required. The dietary manager was unaware that the resident needed a bagged lunch, and the resident was not included on the list of those requiring one. The facility's policy required initiation of a dialysis communication form prior to sending a patient for dialysis, but this was not consistently done. These failures resulted in the resident not always receiving necessary communication and nutritional support during dialysis appointments.
Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
Facility staff failed to implement required procedures regarding the use of bed rails for four residents. In each case, staff did not offer or attempt appropriate alternatives to bed rails before their use, nor did they assess the residents for risk of entrapment. Observations confirmed that the residents were using bilateral or quarter bed rails in the upright position, but clinical records lacked documentation of any alternatives being considered or attempted, as well as any assessment for entrapment risk. Interviews with an LPN revealed that alternatives such as a single bed rail, grab bar, or wedges should be considered and documented prior to bed rail use, but this was not done. The LPN also stated there was no awareness of an assessment tool for entrapment risk in the facility. When the administrator and DON were informed of these concerns, the facility was unable to provide a specific policy addressing the offering or attempting of alternatives or the assessment for entrapment risk prior to bed rail use.
Deficiencies in Medical Record Documentation and Confidentiality
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation for several residents, as well as to safeguard resident-identifiable information. For one resident with severe cognitive impairment and multiple diagnoses, there was a significant discrepancy in recorded weights, with a 100-pound difference between two entries and no subsequent reweigh or clarification until prompted by a dietician. Staff interviews confirmed that the medical record was not complete or accurate, and the process for reweighing and documentation was not followed as required. In another instance, the facility released a deceased resident's medical record to an individual who had not provided legal documentation verifying their status as next of kin or executor of the estate. The facility's own policy required such verification, but the records were released without proper authorization. Staff interviews revealed that the release occurred without clearance from the corporate compliance representative, and there was no evidence in the clinical record to support the individual's legal right to the information. Additional deficiencies included failure to document the reason for holding a resident's medication, incomplete trauma-informed screening for a resident with PTSD, and inaccurate documentation of the date and time a resident left the facility against medical advice. In each case, staff interviews and record reviews confirmed that required documentation was missing or incomplete, and facility policies regarding medical record management and confidentiality were not followed.
Lack of Medical Director Participation in QAPI Meetings
Penalty
Summary
The facility failed to provide evidence of medical director participation in all four QAPI (Quality Assurance and Performance Improvement) meetings held in 2023. Review of QAPI committee rosters from November 2022 to October 2024 showed that the medical director did not attend or call into the meetings on 3/21/23, 6/29/23, 8/28/23, and 11/28/23. The administrator confirmed that while monthly QAPI meetings were held with various staff, the medical director was expected to attend quarterly but did not participate in any of the 2023 meetings. The facility's QAPI policy requires the medical director to be a member of the committee, along with the administrator, DON, infection preventionist, and at least two other designated employees. No further information or evidence of medical director involvement was provided prior to the survey exit.
Undignified Meal Service Due to Inadequate Supplies
Penalty
Summary
Facility staff failed to serve meals in a dignified manner on one of four units when, during meal service, kitchen staff began using plastic silverware and styrofoam takeout containers for the last one and a half food carts. This occurred because the kitchen ran out of pellets, which are used to keep food warm, and covers needed to complete the tray line. The director of dietary services, who was newly assigned to the facility, confirmed she was still assessing the kitchen's needs. Facility policy requires that meals be person-centered, nourishing, palatable, attractive, and served at a safe and appetizing temperature, but the observed practice did not meet these standards.
Failure to Accommodate Resident Access to Outdoors Due to Inaccessible Doors
Penalty
Summary
Facility staff failed to reasonably accommodate the needs and preferences of four residents regarding independent access to the outdoors. Multiple residents, all of whom were cognitively intact as indicated by perfect BIMS scores, reported difficulty or inability to independently exit and re-enter the building due to the lack of accessible, automatic doors. The only automatic door in the facility required a code that was not provided to residents, while other doors required manual operation, which was not feasible for residents using wheelchairs or with significant physical limitations. Staff interviews confirmed that residents often had to rely on others to open doors for them, and administrative staff acknowledged that a work order for automated doors had been pending for several months. Residents described specific incidents where their attempts to access the outdoors were hindered. One resident, who used a wheelchair and was assessed as a safe smoker, stated he could exit by pushing the door with his footrest but could not re-enter without assistance, and recounted an incident where he cut his forearm attempting to do so. Another resident with quadriplegia described being able to exit using his wheelchair but being unable to return inside independently, also mentioning a past injury from the door. Both residents indicated that the lack of automatic doors directly impacted their ability to move freely and safely. Additional residents reported feeling confined due to facility policies and physical barriers. One resident stated that doors were locked at a set time each evening, preventing access to the outdoors and causing anxiety. Another resident expressed frustration with the lack of handicapped-accessible doors and noted that the outdoor ramp was in disrepair, making independent access both difficult and unsafe. Staff interviews corroborated that residents did not have access to the code for the automatic door and that manual doors were challenging for wheelchair users. The facility's own Resident Rights policy, which guarantees dignity and self-determination, was not upheld in these instances.
Breach of Resident Confidentiality via Unsecured Text Messaging
Penalty
Summary
Facility staff failed to maintain the confidentiality of resident information for three residents by sending text messages containing identifiable resident information through unsecured applications. The text messages included residents' names, room numbers, and details about their care and experiences within the facility. These messages were not sent using encrypted or secure messaging platforms, as confirmed by staff interviews and document reviews. Staff members involved, including a clinical liaison and the director of activities, acknowledged during interviews that they either were unaware of the prohibition against using unsecured text messages for resident information or had not used secure applications for such communications. One staff member admitted to previously making this mistake but now uses encrypted applications, while another stated he was not aware that unsecured texting of resident names was not allowed, despite having received confidentiality training. Another staff member recognized that sending such information via unsecured text is a HIPAA violation. The facility's policy on confidentiality and HIPAA compliance was reviewed and clearly prohibits the unauthorized disclosure of protected health information (PHI), including through unencrypted external devices or unsecured communication methods. The policy also requires all employees to safeguard PHI and receive training on HIPAA upon hire and annually. Despite these requirements, the staff's actions resulted in the disclosure of resident information through unsecured means, constituting a breach of confidentiality.
Failure to Maintain Clean and Homelike Environment for Resident and Common Areas
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for a resident who was observed lying in bed on multiple occasions with dried tube feeding formula present on the base of the tube feeding pole and on the floor. The director of housekeeping confirmed that resident rooms are cleaned daily and that substances such as dried formula should be cleaned by either nursing or housekeeping staff. Upon inspection, the director of housekeeping identified the substance as dried tube feeding formula and acknowledged that the area was not clean or homelike, as required by facility policy. Additionally, the facility staff did not maintain the hallway outside the kitchen in a homelike condition. Two large holes were observed in the drywall near the kitchen, which the dietary manager could not explain. The maintenance director later confirmed that the holes were caused by food carts and that he repairs similar damage about twice a month, with staff using an electronic system to report such issues. The presence of these holes and the need for frequent repairs indicate a failure to maintain the environment in accordance with facility standards.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for multiple residents, resulting in deficiencies in care delivery. For one resident with severe cognitive impairment and total dependence for ADLs, the care plan for incontinence required frequent checks and changes of briefs, but documentation was missing for several shifts, and staff interviews confirmed that if care was not documented, there was no evidence it was performed. Another resident with COPD had a care plan requiring specific administration of respiratory medications, including waiting between inhalers and rinsing the mouth after use. Observation revealed that an LPN administered two inhalers consecutively without the required wait time and did not assist the resident in rinsing their mouth, contrary to physician orders and the care plan. Additional deficiencies included the failure to develop care plans addressing activities for two residents, despite assessments indicating the importance of activities to them. In both cases, the activities director acknowledged that care plans for activities were missing, even though assessments documented the residents' preferences and needs. For one of these residents, the care plan also lacked interventions for multiple care needs, including Alzheimer's disease, hypertension, and other chronic conditions, leaving the interventions section blank. Further, the facility failed to implement care plans for medication administration for residents with pain and other chronic conditions. For one resident, a scheduled dose of gabapentin for neuropathic pain was not documented as administered, despite the medication being available in the facility's backup system. Another resident experienced multiple instances where medications were administered late, sometimes by several hours, for a range of conditions including pain, constipation, infection, and depression. Staff interviews confirmed the expectation that care plans should be followed and updated as needed, but the documented evidence showed repeated lapses in timely and accurate care plan implementation.
Failure to Administer Medications Within Prescribed Time Frames
Penalty
Summary
Facility staff failed to administer medications as ordered for two residents, resulting in a deficiency related to not meeting professional standards of quality. One resident, admitted with diagnoses including COPD, diabetes mellitus, and sleep apnea, was found to have medications such as Trulicity and Humalog administered outside the prescribed time frames. The resident was cognitively intact but required total dependence for most activities of daily living. Staff interviews confirmed that medications are to be administered within one hour before or after the scheduled time, and that administering outside this window does not meet professional standards. Another resident, also cognitively intact, reported not receiving morning medications until late in the day, sometimes after 11:00 a.m., with other medications also being given late. Review of the Medication Administration Audit Report revealed multiple instances where medications were administered significantly later than scheduled, including doses given several hours past the prescribed times. There was no documentation in the nurse's notes indicating that the medical doctor or nurse practitioner was notified about the late administration or the reasons for the delays. Facility policy requires medications to be administered within 60 minutes of the scheduled time, except for those tied to mealtimes. Despite this policy, the audit and staff interviews confirmed repeated failures to adhere to these standards for the two residents. The findings were communicated to facility leadership, and no further information was provided prior to the survey exit.
Failure to Provide and Document ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care for three dependent residents, as evidenced by missing documentation and staff interviews. One resident with severe cognitive impairment and physical limitations, including hemiplegia and aphasia, was coded as dependent for multiple ADLs such as bathing, transferring, dressing, and toileting. Review of this resident's care plan indicated the need for frequent incontinence care, but ADL records showed multiple instances where incontinence care was not documented on both day and night shifts. Staff confirmed that if care was not documented, there was no evidence it was provided. Another resident, who was not cognitively impaired but was dependent for ADLs due to decreased mobility, also had significant gaps in documentation for incontinence care across several months. The care plan for this resident required frequent checks and hygiene for incontinence, but numerous shifts lacked any record of care being provided. Staff interviews reiterated that documentation in the electronic system was the only evidence of care, and if missing, the care could not be verified. A third resident did not have documentation of receiving showers, personal hygiene, or oral hygiene on multiple dates across two months. ADL records for this resident were blank for several night shifts, and staff interviews confirmed that personal hygiene and showers should be provided and documented regularly. The facility's own policy required that care and observations be reported and recorded, but this was not consistently done for these residents.
Failure to Administer Medications per Physician Orders
Penalty
Summary
Facility staff failed to administer medications according to physician orders for five residents. In several cases, medications such as buspirone, oxycodone/acetaminophen, gabapentin, daptomycin, and Norvasc were either not given as ordered or were administered incorrectly. For example, one resident did not receive buspirone for anxiety on two occasions, with no documented reason in the progress notes, despite the medication being available in the Omnicell system. Another resident missed doses of oxycodone/acetaminophen and gabapentin for pain management, with staff documenting that the medications were 'awaiting pharmacy delivery,' even though the medications were available in the Omnicell. A resident admitted with an order for intravenous daptomycin did not receive the first dose until 48 hours after admission due to a delay in entering the physician order into the computer system. Another resident did not receive a scheduled dose of gabapentin for diabetic neuropathy on the evening of admission, despite the medication being available in the Omnicell. In each of these cases, staff interviews confirmed that the expected process was to check the Omnicell for medication availability and administer the medication if present, but this was not consistently followed. Additionally, a resident with an order for Norvasc to be given only if systolic blood pressure was above 130 received the medication on multiple occasions when their blood pressure was below this threshold. Staff acknowledged that the medication should not have been administered under these circumstances. The facility's own policy required nurses to take appropriate steps to ensure medications were provided as ordered, but this was not adhered to in these instances.
Failure to Provide and Document Foley Catheter Care per Physician Orders
Penalty
Summary
Facility staff failed to provide Foley catheter care as ordered by the physician for one resident with a history of urinary retention. Physician's orders specified that Foley catheter care was to be provided every shift, but a review of the resident's treatment administration records (TARs) for April and May 2023 showed that catheter care was not documented as provided on several day shifts, as indicated by blank spaces on the TARs. During an interview, an LPN confirmed that catheter care is evidenced by signing off on the TAR, and the absence of signatures indicated the care was not performed or not documented. Additionally, the facility was unable to provide a specific policy regarding Foley catheter care when requested by surveyors. No further information or documentation was provided by the facility prior to the survey exit.
Failure to Provide Ordered Colostomy Care and Documentation
Penalty
Summary
Facility staff failed to provide colostomy care and services as ordered for one resident. The resident had a physician's order, dated 11/19/22, to change the colostomy pouch every two to three days and as needed, with the treatment administration records (TARs) for April and May 2023 reflecting this schedule. However, review of the TARs for those months showed blank spaces, indicating that the colostomy pouch changes were not documented as completed during that time. An LPN confirmed that nurses are expected to sign off on the TAR when the colostomy pouch is changed. The facility was unable to provide a specific policy regarding colostomy pouch care.
Failure to Provide Alternate Menu Selections and Follow Posted Menus
Penalty
Summary
Facility staff failed to provide alternate menu selections and did not consistently follow posted menus, resulting in at least one resident not receiving appropriate meal choices. A resident with quadriplegia, a colostomy, and a history of significant weight loss and malnutrition reported that the menu posted was not accurate with what was delivered, and that alternate menu items were often unavailable or substituted incorrectly. Staff interviews confirmed that residents were sometimes unable to receive their preferred alternate menu items due to lack of inventory, and that substitutions were made without following the established menu or policy. Observations in the kitchen revealed that meals prepared did not match the posted menus on multiple occasions. For example, baked fish was prepared instead of hamburgers due to lack of ground beef, and regular French fries were served instead of sweet potato fries. Additionally, cake was served without icing because the kitchen did not have any icing available. These substitutions were not documented on the menu, and staff indicated that inventory shortages led to last-minute changes without proper communication or adherence to policy. Review of facility policies showed that menu substitutions should be made after discussion with the director of food and nutrition services, and that suitable food replacements should be verbally offered if a resident does not eat a served item. However, interviews and documentation revealed that these procedures were not consistently followed, and that the director of food and nutrition services had only recently started and was still adjusting ordering practices. The administrator and other leadership were made aware of these findings during the survey.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
Facility staff failed to serve food that was palatable and at a safe, appetizing temperature during at least one observed meal. Two residents reported dissatisfaction with the taste and temperature of the food, describing it as unpalatable and often cold. Direct observation of the kitchen revealed that while food was initially prepared at appropriate temperatures, issues arose during meal service. Staff ran out of necessary serving supplies, such as silverware, pellets, and dome lids, and resorted to using plastic utensils and Styrofoam containers. Additionally, there was insufficient space in the meal carts, resulting in some trays being placed on top of the carts. By the time the last trays were served, significant drops in food temperature were documented, with several items measured well below recommended serving temperatures. Surveyors and the dietary manager noted that many food items were cool to the taste, dry, or had an unappealing texture, particularly those thickened or pureed. The facility's own policy requires prompt delivery of food to ensure it is safe, palatable, and served at the proper temperature, but this standard was not met during the observed meal service.
Failure to Maintain Sanitary Food Storage and Preparation Practices
Penalty
Summary
Facility staff failed to store, prepare, and serve food in a sanitary manner in the kitchen, as observed during a survey. In the freezer, there were two wrapped packages without labels, dates, or use-by dates. Various dry food items, such as tortillas, cake mix, and pasta, were left out on a table instead of being stored in the pantry. Two clear plastic storage bins containing food or powder were found, one of which was cracked, and an uncovered container of thickener was also present. The steamer, ovens, tilt griddle, and stove all had visible food debris, burned-on food, and spills, with additional food debris found on the floor beneath these appliances. There was no cleaning schedule in place, and the dietary manager was unaware of any such documentation. Other unsanitary practices were observed, including an empty peanut butter jar stored under a food prep table with sanitizer buckets, and improper storage of personal items such as backpacks and shoes in the dry storage area alongside food supplies. The ice machine room contained towels and an empty cigarette pack on the floor. Opened packages of graham crackers and saltine crackers were found in the storage area, and vacuum attachments were stored on the same shelf as food. Additionally, a sleeve of Styrofoam cups and unwrapped plastic cups were found on the floor under a rack with paper products. During food preparation, staff failed to follow proper sanitizing procedures. The afternoon cook washed equipment in the three-compartment sink but did not use sanitizing solution, as none was present in the sinks. Staff were also observed drinking from a cup stored under the food prep table while preparing sandwiches, which was acknowledged by the dietary manager as not being allowed. Facility policies required all foods to be covered, labeled, and dated, and mandated a comprehensive cleaning schedule for food service areas, but these procedures were not followed.
Failure to Provide Required Beneficiary Notification for Medicare Services
Penalty
Summary
Facility staff failed to provide required beneficiary notification to a resident who was admitted for skilled services with Medicare as the primary insurance. The resident, who was not cognitively impaired according to the most recent BIMS assessment, was still residing in the facility at the time of the survey. Documentation review showed that the resident received a welcome packet with general information and resident rights, but there was no evidence that the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN Form CMS-10055) was provided. The Beneficiary Protection Notification Review form for this resident confirmed that the form was not found. During staff interviews, the director of social services, who had just started in her role, acknowledged responsibility for beneficiary notices but was unable to provide the required documentation for this resident. The facility's policy indicated that the ABN is to be used to notify beneficiaries or their responsible parties when care will not be covered by Medicare B, but no further information or documentation was provided to demonstrate compliance with this requirement.
Inaccurate MDS Assessment Due to Incorrect Restraint Coding
Penalty
Summary
Facility staff failed to provide an accurate Minimum Data Set (MDS) quarterly assessment for one resident who had diagnoses including traumatic brain injury, muscle wasting, and depression. The MDS assessment coded the resident as having moderate cognitive impairment and requiring maximal assistance for several activities of daily living. However, the assessment also indicated the use of limb restraints less than once daily, despite no evidence in the resident's medical record, physician orders, or care plan to support the use of restraints during the relevant look-back period. Observations conducted over several days did not reveal the resident being placed in restraints, and a review of orders from several months showed no documentation for restraint use. The MDS Coordinator confirmed that the restraint coding was incorrect and acknowledged that there was no supporting documentation or care plan for restraint use. The deficiency was identified through observations, staff interviews, and review of clinical and facility records.
Failure to Complete PASARR Screening on Admission
Penalty
Summary
Facility staff failed to ensure that a preadmission screening and resident review (PASARR) was completed for one resident upon admission. The resident, who was admitted with diagnoses including quadriplegia, neurogenic bowel/bladder, and delusional disorders, did not have evidence of a completed PASARR in the clinical record at the time of admission. The PASARR was only provided later, after the deficiency was identified during the survey. Review of the resident's records showed a comprehensive care plan addressing depression and a recent MDS assessment indicating no cognitive impairment, but there was no documentation of a PASARR prior to or at the time of admission. Staff interviews confirmed that social services are responsible for completing PASARRs on admission, and the facility's policy requires review and completion of PASARRs before admission. The deficiency was acknowledged by facility leadership when presented by surveyors.
Failure to Include Continuous IV Cardiac Drips in Baseline Care Plans
Penalty
Summary
Facility staff failed to develop complete baseline care plans for two residents who were admitted with continuous intravenous (IV) cardiac drips for congestive heart failure (CHF). For the first resident, the admission nursing assessment documented the presence of a PICC line and continuous Milrinone infusion, as well as the resident being alert and oriented. Despite this, the baseline care plan did not include documentation of the Milrinone Lactate continuous infusion, even though physician orders and hospital discharge instructions specified its use for heart failure management. Similarly, the second resident was admitted with a Dobutamine IV drip for CHF, with the admission assessment noting intravenous access and the ongoing infusion. The baseline care plan for this resident also failed to document the Dobutamine infusion, despite clear physician orders and discharge instructions indicating the need for continuous administration of the medication. Interviews with nursing staff confirmed that the baseline care plan is intended to guide resident care and should include all critical treatments, such as continuous IV cardiac drips. Facility policy also requires that intravenous inotropic therapy be included in the care plan. The omission of these essential treatments from the baseline care plans was identified through observation, resident and staff interviews, clinical record review, and facility document review.
Failure to Provide Contracture Management Device for Resident
Penalty
Summary
Facility staff failed to provide appropriate care for a resident with a left-hand contracture, specifically by not ensuring the use of a palm guard or splint as needed to maintain or improve range of motion. The resident reported that she previously had a brace, but it had been missing for some time, and she was unable to move her hand. Review of the clinical record and physician orders did not show any documentation regarding a brace or splint for the resident. Additionally, there was no evidence of occupational therapy services provided to the resident in the past six months. Interviews with facility staff, including the occupational therapist and an LPN, confirmed that the resident had previously used a palm guard with red foam but that no such device was currently in use or available. The facility's policy required device assessments on admission, quarterly, and as needed, with documentation and care planning for any devices in use. However, there was no documentation or care plan reflecting the use of a splint or palm guard for this resident, and staff were unaware of any such device being in use at the time of the survey.
Failure to Store CPAP Mask in Sanitary Manner
Penalty
Summary
Facility staff failed to maintain respiratory equipment in a sanitary manner for one resident who required CPAP therapy. Multiple observations over several days revealed that the resident's CPAP mask was repeatedly left uncovered on the nightstand, not stored in a plastic bag as required by facility policy. The mask was found behind the CPAP machine and out of the resident's reach, but still exposed to the environment. A review of the resident's clinical record showed a physician's order for nightly CPAP use with specific settings and instructions to use sterile water. During an interview, an LPN confirmed that the mask should have been stored in a plastic bag to prevent contamination, citing infection control concerns. Facility policy also documented the requirement to store respiratory equipment in plastic storage bags when not in use. The deficiency was brought to the attention of administrative and nursing leadership, but no additional information was provided before the survey exit.
Failure to Implement Psychiatric Medication Recommendation
Penalty
Summary
Facility staff failed to follow up on a psychiatric consult recommendation for a resident diagnosed with moderate depression and experiencing significant psychosocial adjustment difficulties. The psychiatric nurse practitioner evaluated the resident and recommended an increase in the resident's antidepressant, Zoloft, from 50 mg to 100 mg daily. However, the resident continued to receive only 50 mg as documented in the medication administration record, and the recommended dose increase was not implemented. Interviews with the resident and staff revealed that the process for acting on psychiatric recommendations involved review and approval by the resident's in-house physician, but this step was not completed. The assistant director of nursing was unaware of the recommendation, and the facility's policy required provider review of consulting recommendations, which did not occur in this case. As a result, the resident did not receive the recommended adjustment to her medication regimen.
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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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