Windsor Grove Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor, Virginia.
- Location
- 23352 Courthouse Highway, Windsor, Virginia 23487
- CMS Provider Number
- 495347
- Inspections on file
- 13
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Windsor Grove Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident needs, resulting in residents with complex behavioral and medical conditions not receiving required one-to-one supervision. Staff assignment records and interviews confirmed that only two CNAs were often scheduled for shifts where five residents needed individual supervision, and documentation of supervision was lacking. Residents reported delays in care, and staff described being unable to safely cover all required duties due to ongoing staffing shortages and the absence of a formal staffing policy.
Certified Nurse Aides did not receive annual performance evaluations or regular in-service education based on those reviews, as confirmed by personnel file reviews and staff interviews. The Administrator attributed this lapse to frequent changes in nurse management, resulting in missed competency assessments and training opportunities.
Staff failed to prevent significant medication errors for two residents, including missed and delayed antipsychotic injections for a resident with schizophrenia and improper administration of Midodrine without following blood pressure parameters for another resident. Nursing staff did not consistently document actions taken when medications were unavailable or ensure required assessments were completed before administration.
A resident with morbid obesity and multiple complex medical conditions was not provided with a bed of appropriate size, resulting in discomfort, difficulty moving, and fear of falling. Despite the resident's repeated concerns and visible struggle to adjust in the bed, staff did not address the issue until after it was observed by surveyors. Interviews with staff confirmed that bed size should be matched to resident needs, but this was not done in a timely manner.
A resident with severe cognitive impairment developed multiple pressure injuries, but the responsible party was not promptly notified of these changes in condition as required by facility policy. Although treatment was initiated and the wound care physician was involved, the responsible party only learned of the wounds days later through a physician follow-up call.
A resident with severe cognitive impairment and total dependence on staff was found with facial bruising of unknown origin. The facility delayed reporting the incident to the Department of Health beyond the required two-hour window and failed to complete the necessary investigation documentation, including witness statements and investigation notes, as outlined in facility policy.
A resident with severe cognitive impairment and total dependence on staff was found with facial bruising of unknown origin. The facility did not complete or document a thorough investigation as required by policy, including missing witness statements and investigation notes, despite reporting the incident to the state and Adult Protective Services.
A resident with a recently replaced hip and a history of falls was not provided with a care plan intervention for fall mats, despite requests from the resident's spouse and discussions among the IDT. Observations confirmed the absence of fall mats, and staff interviews indicated the omission of this intervention in the care plan, failing to address the risk of injury from falls.
Facility staff did not update a care plan to reflect a resident's self-catheter care and failed to ensure that the interdisciplinary team attended care conferences for two residents. One resident independently managed Foley catheter care without this being reflected in the care plan, and staff were unclear about their roles in assisting. For two other residents, care conferences were attended only by social services staff and either the resident or a family member, with no participation from nursing, dietary, or therapy departments, and concerns raised by the residents and family were not addressed.
A resident with severe cognitive impairment and a pacemaker returned from an ER visit with physician orders for urgent cardiology follow-up to address a low pacemaker battery. Facility staff failed to schedule the required cardiology appointment, missing the physician's order, as confirmed by both administrative and nursing staff during interviews and documentation review.
A resident with severe cognitive impairment and dementia did not receive required toenail care, resulting in long, thick, discolored toenails. Despite a care plan and a podiatry referral order, staff were unaware of the resident's condition, and confusion existed regarding responsibility for toenail care. The facility's policy lacked clarity on departmental responsibility, leading to the deficiency.
Three residents did not have valid DNR documentation on file, including missing physician signatures and incorrect or unsigned forms, despite facility policy requiring proper advance directive records. As a result, staff and EMS would not be able to honor the residents' DNR wishes in an emergency.
A resident with multiple chronic conditions did not receive prescribed morning medications, missed evening doses of metoprolol ER and potassium chloride on two occasions, and had several shifts without documented vital sign monitoring as ordered. The DON confirmed that these physician orders were not followed.
Two residents with visual impairments did not receive necessary vision services, including eye exams and corrective lenses, despite documented needs and physician orders. Staff failed to schedule appointments or include the residents on service lists, and communication lapses between nursing, activities, and administrative staff contributed to the deficiency.
Two residents with significant medical needs were observed to have long, thick, and discolored toenails, with one experiencing pain due to toenails catching on bedcovers. Neither resident had recent documentation of podiatry or foot care, and staff confirmed that foot care had not been provided as needed.
Multiple deficiencies were identified, including failure to provide consistent one-to-one supervision for a resident with aggressive behaviors, leaving a syringe with an unknown substance unattended in a resident's room, and inadequate supervision of a resident with dementia and balance issues who sustained a hip fracture after an unwitnessed fall. Staff interviews and record reviews confirmed lapses in supervision and safety protocols.
A resident with severe cognitive impairment and multiple medical conditions experienced a weight loss of over 17% in five months due to the facility's failure to ensure adequate nutrition. Dietary interventions were inconsistently implemented, and supplements were delayed, resulting in continued weight decline despite ongoing documentation of significant weight loss by the dietician.
Surveyors found that medications and biologicals were not properly stored or labeled in several medication carts and a medication room. Loose, unidentified tablets and capsules were present, discontinued medications were not separated for return or destruction, and topical medications were stored with oral medications. Staff interviews confirmed these practices did not align with facility policy, and regular inspections failed to prevent these deficiencies.
A visually impaired resident with a history of neuromuscular bladder dysfunction and diabetes was allowed to perform his own urinary catheter care without proper staff assistance or training in infection prevention measures. Observation showed improper technique, including the use of a single basin and reusing washcloths, contrary to facility policy. Staff interviews revealed a lack of clear instruction and oversight regarding catheter care responsibilities.
A resident with multiple medical conditions and full ADL assistance was found to have a significant ant infestation in their room, specifically around a bag and chair. The resident was unaware of the infestation, and the issue was identified by a CNA during a facility tour. The room was subsequently added to the pest control log and treated, but the initial failure to prevent or promptly address the pest issue constituted a deficiency.
Failure to Provide Sufficient Staffing and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 106 residents, including not ensuring a licensed nurse was present on each unit during every shift. On multiple occasions, staffing records and interviews confirmed that only two CNAs were scheduled for shifts where five residents required one-to-one supervision as part of their care plans. These residents had complex medical and behavioral needs, such as dementia with agitation, physical aggression, wandering, and inappropriate behaviors, yet did not consistently receive the required supervision. Staff assignment sheets and behavior monitoring documentation showed that one-to-one supervision was not provided as required, particularly during night shifts, and staff reported it was impossible to meet these needs with the available personnel. Observations during the survey revealed that staff were sometimes assigned to supervise more than one resident at a time, and at other times, residents who required one-to-one supervision were left without any assigned staff. Interviews with CNAs and the staffing coordinator confirmed ongoing staffing shortages, with staff unable to complete required monitoring and documentation. The Director of Nursing acknowledged the absence of a formal staffing policy or a policy for one-to-one supervision, and that nursing judgment was used to determine supervision needs without physician orders or defined timeframes. Additional findings included reports from residents about delays in receiving assistance, with some stating they had to wait for help or were told they could not return to bed due to insufficient staff. The Social Services Director indicated that staffing shortages prevented all required interdisciplinary team members from attending care conferences. Staff also reported being asked to cover multiple units, which they felt was unsafe and put their professional licenses at risk. The administrator confirmed multiple open CNA, LPN, and RN positions and the lack of a staffing policy.
Failure to Provide Timely CNA Performance Reviews and In-Service Education
Penalty
Summary
Certified Nurse Aides (CNAs) at the facility did not receive required performance evaluations at least once every 12 months, nor did they receive regular in-service education based on the outcomes of such reviews. Personnel files for four CNAs showed no documented evidence of performance evaluations or related in-service education, despite their employment ranging from several months to over a year. Interviews with additional CNAs revealed that some had not received performance reviews or competency training since starting at the facility, with one CNA stating she had only received one performance review in three years and never received competency training. The Administrator confirmed that due to multiple changes in nurse management, the facility had not completed competencies and performance evaluations for CNAs. This lack of regular performance assessment and training was identified through interviews and record reviews, and it was noted that this had the potential to negatively impact resident care.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
Facility staff failed to ensure that two residents were free from significant medication errors. For one resident with diagnoses including dementia and schizophrenia, staff did not administer Risperdal Consta injections every two weeks as ordered by the physician. The medication was missed on multiple occasions, with gaps between doses and no oral antipsychotic coverage provided despite manufacturer recommendations for missed doses. Documentation showed that the medication was sometimes not available, and there was a lack of follow-up to ensure timely administration. Interviews with nursing staff revealed uncertainty about who was responsible for managing the resident's psychiatric medications and inconsistent notification of the appropriate parties when the medication was unavailable. For another resident with a history of alcohol abuse, anemia, hypertension, and cognitive deficits, staff failed to administer Midodrine according to the physician's parameters. The order specified that the medication should be held if the systolic blood pressure was above 110, but there were multiple instances where blood pressure was not assessed before administration, or the medication was given despite readings above the specified threshold. Review of the medication administration records for several months showed repeated failures to follow the prescribed parameters, including both missed assessments and inappropriate administration. Interviews with the unit manager confirmed that staff did not consistently follow the required procedures for medication administration, including checking blood pressure before giving Midodrine and holding the medication when parameters were not met. The deficiencies were brought to the attention of the facility administrator, but no additional information was provided at the time of the survey.
Failure to Provide Appropriate Bed Size for Resident with Morbid Obesity
Penalty
Summary
Facility staff failed to provide reasonable accommodation for a resident with morbid obesity, whose BMI was 47.8 and weight was 334 pounds. The resident, admitted with multiple complex diagnoses including acute and chronic respiratory failure, hypertensive heart and chronic kidney disease, diabetes, chronic pulmonary edema, sleep apnea, and a mood disorder, reported that the bed provided was too small. The resident expressed difficulty moving in the bed, a fear of falling, and a need for bed rails for support. Observations confirmed that there was less than three inches of space on either side of the mattress, and the resident was seen struggling to adjust his position. Despite staff being present in the room on multiple occasions, no action was taken to address the resident's concerns about the bed size until after the survey observations. Interviews with staff, including an LPN and the DON, acknowledged that bed size should be tailored to the resident's needs and that safety assessments for bed rails are required. However, the clinical record and staff actions showed that the resident's size and comfort needs were not initially accommodated, resulting in the resident remaining in an inappropriately sized bed until the issue was later addressed.
Failure to Promptly Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to promptly notify the responsible party of a significant change in condition for one resident with severe cognitive impairment and total dependence on staff for activities of daily living. According to facility policy, the resident, attending physician, and resident representative must be promptly notified of any change in status or condition, including the development of new wounds. The resident was admitted with dementia and was at risk for pressure injuries. On a weekly skin integrity review, the resident was found to have an unstageable deep tissue injury to the right hip, a stage two pressure ulcer to the left hip, and moisture-associated dermatitis to the sacrum. Treatment was initiated, and the wound care physician was involved as documented. However, the responsible party was not notified of the wounds until several days after their discovery. The initial wound evaluation and management summary confirmed the presence of the wounds, but the responsible party only became aware after the physician called for a follow-up, at which point she realized she had not been previously informed. The Director of Nursing and Assistant Director of Nursing confirmed that the wounds were discovered and treatment started, but notification to the responsible party did not occur until several days later, contrary to facility policy.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had a primary diagnosis of dementia, was found with bruising to the right forehead, right eye, bridge of nose, and slight bruising under the left eye. The injury was discovered in the morning, and the resident was evaluated by a nurse practitioner and sent to the emergency department for further assessment. The responsible party was notified, and the resident returned to the facility later that day with no abnormal findings from the CT scan. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the Department of Health within two hours, the initial report was filed more than three hours after the injury was noted. Additionally, the facility did not have a completed investigation, witness statements, or investigation notes on file as required by their policy. The current administrator confirmed these documentation gaps and stated that the expected procedures were not followed at the time of the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident was found with bruising to the face, including the forehead, right eye, bridge of the nose, and under the left eye, and was sent to the emergency department for evaluation. The facility's policy required a detailed investigation, including obtaining statements from the victim, suspects, and witnesses, as well as securing physical evidence and filing an incident report. However, there was no completed investigation on file, no witness statements, and no investigation notes available for review. Interviews revealed that staff present at the time of the incident could not recall any disputes or events leading to the injury, and some staff involved were no longer employed at the facility. The administrator confirmed the absence of required documentation related to the investigation. The facility did file an initial report with the state health department and notified Adult Protective Services, but the lack of a thorough and documented investigation was identified as a deficiency.
Failure to Address Fall Risk and Hip Protection in Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for one resident who had a history of hypertensive heart disease with heart failure, a recently replaced artificial hip joint following a cerebrovascular event, and depression. The resident was admitted for therapy following a hip fracture and required assistance with activities of daily living. Despite being cognitively intact, the resident experienced two falls since admission, as reported by his wife, who expressed concerns about the risk of re-injury to the recently replaced hip and requested the use of fall mats, which she had observed being used for other residents. Observations on multiple occasions confirmed that no fall mats were present at the resident's bedside. Interviews with facility staff, including an LPN and the Physical Therapy Director, revealed that while interventions to maintain resident safety were discussed in interdisciplinary meetings, the care plan did not include the use of fall mats as an intervention to reduce the risk of injury from falls. The deficiency was identified when the care plan review showed the omission of this intervention, despite the resident's history and the family's expressed concerns.
Failure to Revise Care Plan and Ensure Interdisciplinary Team Participation
Penalty
Summary
Facility staff failed to review and revise the care plan for a resident who was performing self-catheter care. The resident, who had a history of neuromuscular bladder dysfunction and multiple urinary tract infections, was observed performing his own Foley catheter care. The care plan did not reflect that the resident was independently managing this aspect of his care, and staff interviews revealed a lack of awareness and guidance regarding the resident's self-care practices. The CNA involved was not informed to assist with catheter care beyond emptying the Foley, and the LPN stated that CNAs were responsible for catheter care as part of ADLs. The Assistant Director of Nursing acknowledged that CNAs should help with Foley care and indicated a need for resident education on proper care techniques. Additionally, the facility failed to ensure that the interdisciplinary team (IDT) was present at care plan meetings for two residents. For one resident with Wernicke's encephalopathy and intact cognitive status, care conference records showed that only social services staff and the resident or responsible party attended, with no participation from other required departments such as nursing, dietary, or therapy. The resident did not recall attending any care conferences and had ongoing concerns about social security, community transition, and personal belongings that were not addressed in these meetings. For another resident with severe cognitive impairment due to dementia, care conference records similarly indicated that only social services staff and a family member attended, with no other departments present. The family member reported inconsistent communication about care changes and concerns regarding pressure ulcers, activity participation, and hydration. Staff interviews confirmed that nursing and other departments were not consistently invited or present at care conferences, and there was no system in place to ensure attendance or documentation of participation. The Social Services Director cited staffing shortages as a reason for the lack of interdisciplinary involvement and did not escalate the issue to administration.
Failure to Schedule Cardiology Follow-Up for Pacemaker Battery Replacement
Penalty
Summary
Facility staff failed to ensure that services were provided in accordance with professional standards of quality for one resident with multiple complex medical conditions, including hypertension, high cholesterol, dementia, depression, muscle weakness, cognitive and communication deficits, insomnia, and a pacemaker. The resident, who was severely cognitively impaired and unable to follow simple instructions or feed herself, returned from a recent emergency room visit with discharge instructions that included urgent follow-up with a cardiologist for pacemaker battery replacement and an outpatient ultrasound for thyroid nodules. Upon review, it was found that while the facility staff followed up on the thyroid nodule recommendation, they failed to schedule the required cardiology appointment for pacemaker battery replacement as ordered by the physician. Both the administrative staff responsible for transportation and the LPN unit manager confirmed that no cardiology appointment had been scheduled for the resident, and the need for follow-up was missed upon the resident's return from the ER. This omission was only identified during the survey, and the lack of scheduled follow-up was confirmed through interviews and documentation review.
Failure to Provide Toenail Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate activities of daily living (ADL) care related to toenail care for one resident with severe cognitive impairment and a primary diagnosis of dementia. The resident's care plan required staff to check, trim, and clean nails on bath day and as necessary, and to report any changes to the nurse. The resident had an order for a podiatry referral to clip toenails, but there was no documentation that the resident had been seen by a podiatrist since admission. Observations revealed the resident had long, thick, discolored toenails, and the resident reported waiting several years to see a podiatrist. Interviews with facility staff indicated confusion regarding responsibility for toenail care. CNAs believed they were to notify the nurse if toenail care was needed, and the nurse would then notify social services to schedule a podiatry visit. The LPN and DON confirmed this process, but neither was aware of the resident's current toenail condition. The facility's foot care policy did not specify which department was responsible for toenail care, contributing to the lack of action. As a result, the resident did not receive necessary toenail care, and the issue was not identified or addressed by staff.
Failure to Maintain Valid Advance Directive Documentation for DNR Orders
Penalty
Summary
The facility failed to ensure that three residents had valid advance directive documents on file, specifically regarding Do Not Resuscitate (DNR) orders. For one resident with hypertensive heart disease and heart failure, the care plan and facility records indicated DNR status, but the Durable Do Not Resuscitate Order from the Virginia Department of Health lacked a physician's signature, rendering it invalid. Despite the resident being cognitively intact and on hospice, the absence of a valid physician signature meant the DNR order could not be honored. Another resident with dementia and severe cognitive impairment was listed as DNR in the order summary, but the only advance directive document on file was for the resident's deceased spouse, not the resident herself. The responsible party confirmed the resident's DNR status, but no valid documentation existed in the medical record. Facility staff acknowledged the error and confirmed that the necessary documents were missing or incorrect. A third resident with multiple diagnoses, including severe cognitive impairment, had a DNR form in the clinical record that was unsigned by the authorized person, making it invalid. Staff interviews confirmed that without a signature, the DNR order was not legal, and the resident would receive CPR in an emergency. Facility policy required that valid advance directives be obtained, documented, and placed in the resident's record, but this process was not followed for these residents, resulting in incomplete or invalid documentation for their code status.
Failure to Follow Physician's Orders for Medication Administration and Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were followed for one resident, as evidenced by a review of records, interviews, and facility policy. The facility's policy requires medications to be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. For the resident in question, who had diagnoses including hypertension, chronic kidney disease, major depressive disorder, atrial fibrillation, and vitamin B-12 deficiency, the physician had ordered multiple medications and regular vital sign monitoring. Record review revealed that there was no documented evidence that the resident received their morning medications as ordered over a specified period. Additionally, there was no documentation that the evening doses of metoprolol tartrate ER and potassium chloride were administered on two separate days. The records also showed missing documentation of vital signs on several day and night shifts as ordered. The Director of Nursing confirmed in an interview that the medications should have been administered as ordered, but they were not.
Failure to Provide Vision Services to Residents with Visual Impairment
Penalty
Summary
Facility staff failed to ensure that two residents received necessary vision services. One resident, with a history of primary open-angle glaucoma and diabetes, was coded as having moderate visual impairment and required corrective lenses. Despite care plan interventions to arrange consultations with an eye care practitioner and physician orders for an eye exam and eyeglasses, there was no documentation that these services were provided. Staff interviews revealed that the resident had requested assistance obtaining glasses, but no appointment was made, and the resident was not included on the list for the vision van visit. The resident reported being blind and only able to see people as gray shadows, and staff acknowledged awareness of the need but did not follow through with scheduling the required services. Another resident, with diagnoses including dementia, schizophrenia, and severe cognitive impairment, also did not receive routine vision screening since admission. The resident expressed difficulty seeing and an inability to recall the last eye examination. Review of the clinical record confirmed that the resident had not been seen by an optometrist since admission. Administration staff confirmed that routine vision screenings should occur annually and that the resident had not been scheduled for such services. Interviews with staff and review of facility documentation indicated a lack of communication and follow-through in identifying and scheduling residents in need of vision services. The process relied on unit managers to notify the person responsible for arranging appointments, but this did not occur for the affected residents. As a result, both residents with documented visual impairments did not receive timely or appropriate vision care as required.
Failure to Provide Timely Foot Care for Residents
Penalty
Summary
Facility staff failed to provide appropriate foot care for two residents who required assistance with activities of daily living. Both residents had long, thick, and discolored toenails, with one resident reporting that her toenails were getting caught in bedcovers and causing pain. Observations revealed that neither resident had received recent podiatry care, and there was no documentation in their clinical records indicating that foot or podiatry care had been provided. One resident did not recall seeing a podiatrist, while the other stated it had been a long time since her last visit. During interviews, staff acknowledged the lack of recent podiatry care and indicated that the residents would be added to the schedule for the next podiatry visit. The facility did not have an independent foot care policy, and the only documentation available was a health care agreement for podiatry services. The deficiency was identified through direct observation, record review, and staff interviews, which confirmed that necessary foot care had not been provided to the affected residents.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for multiple residents, resulting in several deficiencies. One resident with a history of cerebral infarction, severe vascular dementia with agitation, and memory deficit was involved in multiple incidents of verbal and physical aggression toward other residents. Despite documented care plans and psychiatric recommendations for one-to-one supervision, there were periods when the resident was left unsupervised, including overnight, and there was no physician order for the required supervision. Staff interviews confirmed inconsistent implementation of one-to-one supervision, and the facility lacked a formal policy or physician order protocol for such supervision. Another deficiency was observed when a syringe containing an unknown clear liquid was found unattended on a resident's dresser. The resident had diagnoses including bipolar disorder and PTSD. The presence of the syringe was confirmed by an LPN, who acknowledged it should not have been left in the room. The DON stated that staff are expected to ensure syringes are not left in resident rooms, indicating a lapse in following established safety protocols regarding hazardous items. A third incident involved a resident with vascular dementia and significant balance and gait issues who sustained a right hip fracture after an unwitnessed fall in the bathroom. The resident's care plan identified a high risk for falls and included interventions such as ensuring appropriate footwear and anticipating needs. However, the fall occurred when the resident was alone, and staff interviews indicated the resident was often in his room and did not like to leave for therapy. The fall was unwitnessed, and the resident was found on the floor by staff, resulting in hospitalization and surgery for a hip fracture.
Failure to Prevent Significant Weight Loss Due to Inadequate Nutrition Management
Penalty
Summary
Facility staff failed to ensure adequate nutrition for a resident with multiple medical conditions, including dementia, depression, muscle weakness, and cognitive and communication deficits. The resident was severely cognitively impaired, unable to follow instructions, feed herself, or engage in meaningful conversation. Despite being admitted with a weight of 184.4 pounds, the resident experienced a significant weight loss of over 17% within five months, dropping to 151 pounds. The clinical record showed that while dietary interventions such as large protein portions and liquid protein supplements were ordered, these were not consistently reflected in the resident's meal tickets or diet orders, and some supplements were not added until months after significant weight loss had occurred. Dietician notes indicated ongoing concerns about the resident's weight, with repeated documentation of significant weight loss triggers and adjustments to dietary interventions. However, there was a lack of timely and coordinated implementation of these interventions, and communication with the dietician was unsuccessful during the survey. The resident's weight continued to decline despite these measures, and the facility did not provide further information when the deficiency was brought to the administrator's attention.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored or labeled in multiple medication carts and a medication room. In several instances, loose tablets, capsules, and partial pills were found in drawers, with staff unable to identify the medications or their intended recipients. Discontinued medications, such as cipro and permethrin cream, were found in medication carts and storage rooms instead of being separated for return or destruction as per facility policy. Additionally, a narcotic blister pack was found taped closed, and topical medications were stored alongside oral medications, contrary to policy requirements. Staff interviews confirmed that these practices were not in line with facility expectations, and that loose or unidentified medications were typically discarded in sharps containers. The facility's policy required medications to be stored in an orderly manner, with external and internal use medications separated, and discontinued or expired medications removed from active storage. However, observations revealed that these procedures were not consistently followed. Staff were unable to provide documentation for medication start and stop dates in the electronic medical record, and regular inspections of medication storage areas did not prevent the accumulation of loose, unidentified, or improperly stored medications. These findings were confirmed by both administrative and nursing staff during the survey.
Failure to Provide Infection Prevention Support for Visually Impaired Resident Performing Catheter Self-Care
Penalty
Summary
Facility staff failed to ensure that a visually impaired resident received appropriate training and assistance with infection prevention measures during self-care of a urinary catheter. The resident, who had a history of neuromuscular bladder dysfunction, diabetes, and visual impairment, was assessed as cognitively intact but required varying levels of assistance with activities of daily living, including being dependent for toileting hygiene and requiring partial to maximal assistance with personal hygiene. Despite these needs, the resident reported performing his own catheter care, and staff interviews confirmed that CNAs were not instructed to assist the resident with this task beyond emptying the catheter. Observation of the resident's catheter care revealed improper technique, including the use of a single basin for both washing and rinsing, and reusing washcloths, which does not align with the facility's policy for urinary catheter care. The CNA assisting the resident acknowledged the error, stating that two basins should have been used—one for soapy water and one for rinsing. The CNA also indicated she had not been informed to assist the resident with catheter care aside from emptying the Foley catheter. Further interviews with nursing staff and facility leadership confirmed a lack of clear guidance and training for staff regarding their role in assisting the resident with catheter care. The facility's policy required specific steps for catheter care, including the use of separate washcloths and basins, but these procedures were not followed during the observed care. The resident's medical record indicated a history of urinary tract infections, underscoring the importance of proper infection prevention practices.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program for one resident, as evidenced by the presence of a large number of ants in and around a bag, chair, and wall in the resident's room. The resident, who had diagnoses including hemiplegia, hemiparesis, dysphagia, chronic congestive heart failure, and dementia, required assistance with all activities of daily living but had no cognitive impairment. During an initial tour, the resident was unaware of the ants or the contents of the bag. The issue was identified by staff, who then added the room to the pest control log for treatment. A review of the pest control log confirmed that the room was treated the following day. The deficiency was communicated to the Administrator and Director of Nursing during an end-of-day meeting. No additional documentation was provided regarding the incident.
Latest citations in Virginia
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A cognitively impaired resident with multiple medical conditions and severe behavioral disturbances repeatedly engaged in verbal and physical aggression toward other residents and staff, including yelling profanities, ramming a wheelchair, attempting to strike a resident using a walker, kicking another resident near an elevator, and kicking and punching a nurse. Behavior notes documented that these incidents occurred frequently and that simple separation and moving the resident to a quiet area were ineffective. Staff interviews confirmed that the resident’s behavior was unpredictable, triggered when his demands were not met immediately, and directed at various residents and staff. Although psychiatric documentation and the care plan called for identifying triggers, redirection, 1:1 staffing, and psychosocial interventions, staff responses remained largely reactive, and one documented altercation involving two residents was not investigated or summarized, resulting in a failure to protect residents from abuse.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
The facility failed to report and investigate an incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed the wheelchair of one resident and attempted to strike another, prompting staff to separate the residents and complete skin assessments. Two other residents, one with heart failure, kidney disease, dysphagia, and a cognitive communication deficit, and another with cerebral palsy and psychiatric diagnoses, were upset following the altercation, and documentation later showed that one had been pushed. Despite the DON being informed and the facility’s abuse policy requiring prompt reporting of all alleged abuse, no incident synopsis or investigation was completed or reported to the state agency for the residents involved in this altercation, and the administrator later acknowledged that an investigation and incident summary should have been completed.
The facility failed to investigate a resident-to-resident abuse incident in which a cognitively impaired resident with multiple comorbidities yelled at another resident in the dining area, then rammed a wheelchair and attempted to strike two cognitively intact residents with significant medical and psychiatric histories. Staff separated the residents and performed skin assessments that showed no injuries, but the involved residents were upset. Despite documentation that one resident had been pushed and an abuse policy requiring immediate review and investigation of all allegations or observations of abuse, the DON did not initiate an incident synopsis or investigation because staff had intervened before further harm occurred, and the administrator later confirmed that no investigation or incident summary was completed for this event.
A resident with multiple diagnoses, including dementia and severe cognitive impairment, had a behavior care plan that listed an intervention of "1:1 supervision as indicated" without defining when it should start, whether it was continuous or behavior-based, what behaviors would trigger it, or how long it should last. During interview, the DON explained that staff initiate 1:1 supervision when the resident becomes aggressive toward another resident and continue it until the resident deescalates, and acknowledged the care plan lacked needed specificity. This incomplete and non-measurable care plan for behavior management led to the cited deficiency.
A cognitively impaired, fully ambulatory resident with Wernicke’s encephalopathy and severe deficits engaged in sexual acts with another resident and was later found partially unclothed in a female resident’s room, despite care plan directives for immediate separation and 1:1 monitoring that staff were unaware of and did not implement. The resident had a documented pattern of wandering, entering other residents’ rooms during personal care, exit seeking, and a prior elopement through a courtyard gate, yet an elopement assessment later incorrectly denied a history of elopement and minimized safety and privacy risks. A Wander-Guard was ordered but not consistently in place or care planned, the courtyard gate alarm was found turned off with no staff present while residents were in the courtyard, and required abuse and elopement incidents were not properly reported or investigated per federal, state, and facility policy, resulting in Immediate Jeopardy and substandard quality of care findings.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Protect Residents From Ongoing Aggression and Abuse by a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.
Removal Plan
- Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
- Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
- The facility will continue attempts to find alternative placement for Resident #1.
- All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
- Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
- All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
- All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
- Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
- No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
- New hire orientation will include abuse-policy training as part of the new hire process.
- All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
- Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
- The Medical Director was notified of the situation.
- The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Report and Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.
Failure to Specify Parameters for 1:1 Supervision in Behavior Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Supervise High-Risk Wanderer and Prevent Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident-hazard-free environment and provide adequate supervision for residents with known wandering, exit-seeking, and sexually disinhibited behaviors. One resident with Wernicke’s encephalopathy, severe cognitive impairment (BIMS score of 99), and full ambulatory ability was repeatedly documented as wandering into other residents’ rooms, disrupting care, and seeking exits. Nursing notes showed that this resident attempted to leave the enclosed courtyard by pushing open the gate, was observed going to numerous exit doors and setting off a door alarm, and wandered throughout multiple units. Despite a physician’s order for a Wander-Guard device and an elopement risk care plan focus, the resident removed the Wander-Guard and it was not replaced, and on the day of survey no Wander-Guard was found on the resident. The elopement event when the resident exited the courtyard gate was not reported to the state agency. Surveyors also identified environmental hazards and lack of supervision related to the courtyard exit. The courtyard gate, which opened to the parking lot, was equipped with an audible alarm and keyed lock, but surveyors found the alarm in the off position and were able to open the gate without any alarm sounding. No staff were present in the courtyard while four residents were there, and surveyors waited approximately five minutes at the open gate with no staff response. The Maintenance Director stated that the alarm had been shut off by someone, that multiple keys were “floating around,” and that he could not account for all of them. He also confirmed that the gate did not have a Wander-Guard alarm. These conditions demonstrated that exit doors and the courtyard gate were not secured or supervised adequately to prevent resident elopement. The facility also failed to protect the cognitively impaired resident from engaging in sexual activities he could not consent to and failed to protect other residents from his behaviors. Progress notes documented that this resident was found on his knees performing oral sex on another male resident who was lying on his bed, and later was found sitting on the side of a female resident’s bed with his pants off while she was fully clothed under the covers. The cognitively impaired resident had no recollection of the sexual event. A psychiatric evaluation documented dementia, Wernicke’s encephalopathy, and altered mental status. The care plan was updated to include a psychosocial problem related to sexual/physical contact with another resident and later to require 1:1 continuous monitoring for behaviors, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. The sexual incident between the two male residents and the subsequent intrusion into the female resident’s room were not reported to the state agency. The surveyors concluded that withholding required supervision for a resident known to be a danger to himself and others constituted neglect and contributed to Immediate Jeopardy related to accidents, hazards, abuse, and neglect. In addition, documentation and assessment processes related to elopement and behavior were deficient. An elopement evaluation completed after the resident’s documented elopement incorrectly indicated no history of elopement and minimized the impact of his wandering on safety and privacy, despite prior notes of him entering other residents’ rooms during personal care and attempting to exit the building. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR throughout the resident’s stay. The facility’s incident and abuse investigation files contained only limited documentation related to the sexual incident between the two male residents, lacked the original initial report allegedly faxed to the state agency, and had no fax confirmation for either the initial or follow-up reports. These omissions and inaccuracies in assessment, care planning, implementation, and reporting contributed to the identified deficiency and Immediate Jeopardy. During the survey, additional observations confirmed ongoing failures in supervision and hazard control. On the initial tour, the cognitively impaired resident was observed walking alone from his unit to the main dining room without supervision. The courtyard gate alarm, when later tested, sounded briefly and then went silent without any staff response. Staff interviews revealed a lack of awareness of critical care plan elements, including the 1:1 supervision requirement for the resident with severe cognitive impairment and sexually disinhibited behavior. Collectively, these actions and inactions demonstrated that the facility did not ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, elopement, and non-consensual sexual contact, resulting in Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified skin assessment areas will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
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