Woodstock Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodstock, Virginia.
- Location
- 803 South Main St, Woodstock, Virginia 22664
- CMS Provider Number
- 495315
- Inspections on file
- 22
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Woodstock Valley Health And Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not provide required supervision or safety devices for two residents with cognitive impairment who smoked, allowing them unsupervised access to lighters and cigarettes, and failed to enforce the use of smoking aprons and proper disposal of cigarette butts. Additionally, a resident at risk for elopement had monitoring interventions discontinued without reassessment or documentation, despite ongoing risk factors.
A resident with a history of PTSD and chronic pain was not given her prescribed Fentanyl patch as ordered, leading to complaints of pain and withdrawal. When she voiced her concerns, the DON escalated the situation by threatening removal under a TDO, involving police and EMS, and removing the resident's personal signs without consent. The resident was not assessed by the DON, was not included in care decisions, and experienced significant psychosocial harm as a result.
Facility staff did not provide evidence of a current hospital transfer agreement, as the only agreement on file was with the previous owner and no updated contract had been established under the new ownership. This deficiency was identified through staff interviews and document review, potentially affecting all residents.
Facility staff did not ensure that an Infection Preventionist attended QAPI committee meetings for three consecutive quarters, as required by policy. Review of meeting sign-in sheets and staff interviews confirmed the absence of the Infection Preventionist from these meetings.
Facility staff did not notify physicians when multiple medications were not administered to two residents, nor did they inform emergency contacts of significant changes in condition, such as acute illness or elopement. In both cases, only the residents, who were their own responsible parties, were notified, contrary to facility policy and staff statements that next of kin should be informed during emergencies or when the resident's capacity is in doubt.
Staff failed to provide a clean and homelike environment, as evidenced by stained linens and bed pads, dirty privacy curtains, food debris and spill stains in resident rooms, and unrepaired wall damage. Multiple staff acknowledged these deficiencies, and facility policies requiring cleanliness and maintenance were not followed.
Staff failed to follow comprehensive care plans for six residents, including not providing required smoking aprons or supervision for two residents with cognitive impairment, missing multiple medication administrations for three residents, and not completing wound care treatments or weekly wound assessments for several residents with pressure injuries or surgical wounds. Documentation was incomplete or missing, and staff interviews confirmed lapses in following care plan interventions.
Facility staff failed to administer prescribed medications and wound treatments to three residents, despite medication and supply availability, as evidenced by blank entries and lack of documentation in medication and treatment records. Nursing staff confirmed that medications should be documented as given and obtained from in-house stock if not present on the cart, but this was not consistently done.
Facility staff failed to consistently provide and document ordered pressure ulcer treatments and weekly wound assessments for two residents with pressure injuries. Missed treatments and gaps in wound measurement documentation were identified, with staff interviews revealing that changes in wound care personnel contributed to lapses in care and record-keeping.
A resident with chronic pain did not receive Fentanyl patches as ordered, resulting in missed doses over multiple periods. Documentation and interviews confirmed gaps in administration and a lack of proper recordkeeping, despite a care plan and facility policy requiring consistent pain management and monitoring.
Facility staff did not maintain adequate CNA staffing on two resident units during evening shifts, resulting in inconsistent provision of HS snacks to residents. Staffing schedules and staff interviews confirmed that only one CNA was present at times when more were needed, and residents reported not receiving snacks as required. The facility's own assessment and policy standards for staffing were not consistently met.
Facility staff did not provide the required RN coverage for at least eight consecutive hours on multiple days, and the DON served as a charge nurse on several occasions when the resident census was above 60, both in violation of facility policy. These deficiencies were confirmed through schedule reviews and staff interviews.
Annual performance reviews for four out of five CNAs were not completed as required, with administrative staff unable to clarify responsibility for ensuring timely reviews. Facility policy mandates annual review of employee training and attendance records, but this process was not followed for several CNAs.
Facility staff did not ensure that prescribed medications were available and administered as ordered for two residents, resulting in multiple missed doses of antibiotics, pain medication, antipsychotics, and medication for anemia and prostate enlargement. Documentation and staff interviews confirmed that medications were often not available in the medication cart or Omnicell, and pharmacy delivery delays led to further missed doses.
Staff failed to serve residents the correct food portions as outlined in the facility's menu and production sheets, using incorrect serving utensils for Caesar salad, lasagna, and sliced carrots. The dietary manager confirmed that the portions served did not meet the documented requirements, and leadership was notified of the deficiency.
Staff did not serve palatable food on one unit, as a test tray of lasagna, carrots, green beans, and mashed potatoes was found to be below the expected serving temperature and described as not palatable by those who sampled it. Food temperatures ranged from 112°F to 127°F, and the issue was observed and confirmed by surveyors and a dietary manager.
Staff failed to consistently provide HS snacks to residents on two units, resulting in over 14 hours between dinner and breakfast. Two residents confirmed snacks were not offered at night, and staff interviews revealed inconsistent snack distribution due to staffing issues. Dietary staff prepared and delivered snacks, but nursing staff did not always pass them out, as confirmed by internal communications and photographic evidence.
Staff were observed hand drying meal trays and placing them on the tray line before serving meals to residents. The trays, which should have been air dried to prevent contamination, were then used to serve food and delivered to resident units. This practice was confirmed by dietary management as not meeting sanitary standards.
Facility staff did not have an updated contract with the respiratory equipment provider, as the existing agreement was still under the previous owner's name, which no longer exists. This affected seven residents who received respiratory equipment services, and the executive director confirmed delays in updating contracts after a change in facility ownership.
A resident with severe cognitive impairment and swallowing difficulties was observed being fed by a CNA who stood next to the bed, rather than sitting, during feeding assistance. The resident was fully dependent on staff for eating, and the CNA acknowledged that standing while feeding was not dignified. This action did not align with the facility's policy on respecting resident dignity.
A resident with multiple medical and mental health conditions had handmade signs removed from her door by the DON without her permission, despite not being cognitively impaired. The removal was abrupt and done without prior discussion, causing the resident significant distress. Staff confirmed the resident was upset, and facility policy on resident rights was not followed, as there was no evidence the signs posed an immediate health or safety risk.
Staff failed to secure a resident's clinical record when an LPN, after being asked by another LPN and with involvement from a former staffing coordinator, printed and handed over a progress note related to backdated medication orders. The document was later destroyed by the receiving LPN, but the incident resulted in a breach of confidentiality, contrary to facility policy.
A resident was discharged without documented evidence that written instructions were provided, home medications were arranged in advance, or information on home health provider options and quality measures was given. Staff interviews revealed inconsistent practices regarding discharge documentation and medication arrangements, and the facility did not follow its policy to present comparative provider data to the resident or family.
Facility staff did not develop a baseline care plan within 48 hours for a newly admitted resident with complex needs, including a PICC line, incontinence, multiple wounds, a colostomy, and insulin therapy. Staff interviews confirmed the absence of the required care plan, and the administrator acknowledged it was not completed as per facility policy.
Staff failed to follow professional standards by administering pain medications without current physician orders for one resident, relying on medication cards rather than active orders, and later entering backdated orders without direct physician authorization. For another resident, staff did not administer prescribed heart failure medications when the resident was sleeping, made no further attempts to give the medications, and did not notify the physician, despite the absence of orders to hold the medications. These actions did not comply with facility policy or accepted nursing practice.
Facility staff did not obtain a physician's order for an incentive spirometer for a resident and failed to store the device in a sanitary manner, leaving the mouthpiece uncovered on the nightstand. An LPN confirmed that orders and proper storage are required, but no policy was provided by the facility.
A resident was administered tramadol and oxycodone by an RN without a current physician's order after returning from a hospital stay. The nurse relied on medication cards in the cart instead of verifying active orders in the MAR or computer system, resulting in the administration of unnecessary medications.
A resident was administered tramadol and oxycodone without a valid physician order after returning from a hospital stay, as previous orders had been discontinued. An RN assumed the medications were still prescribed based on medication cards and administered them without direct physician consultation, later entering backdated orders into the system. The physician did not recall approving these orders, and other staff members were not directly involved or aware of the late entries.
Staff did not maintain accurate medical records for three residents, including documenting assessments after discharge, recording medication administration that did not occur, and failing to document critical interventions during a resident's change in condition. These actions resulted in incomplete and inaccurate records, contrary to facility policy.
Staff did not follow infection control protocols when an LPN performed wound care on a resident with a stage four pressure injury without wearing a gown, despite clear facility policy and posted CDC guidance requiring enhanced barrier precautions for such high-contact care activities.
The facility did not accurately post daily nurse staffing information, as required, for an entire month. The postings failed to specify the total number and actual hours worked by RNs, LPNs, and CNAs per shift, instead only listing licensed and unlicensed staff totals. Additionally, the posted information was sometimes outdated, and staff interviews confirmed the process did not meet policy requirements.
Failure to Supervise Smoking and Elopement Risk Residents
Penalty
Summary
Facility staff failed to provide adequate supervision, monitoring, and use of safety devices, and did not fully implement their smoking policy for two residents. One resident, with moderate cognitive impairment and nicotine dependence, was observed independently accessing a lighter from a personal bag, lighting cigarettes for themselves and another resident, and smoking outside without a required smoking apron or proper receptacles for cigarette butts. The resident's care plan and smoking evaluation indicated the need for a smoking apron and supervision, but these interventions were not in place at the time of the incident. Staff interviews confirmed that smoking materials were not securely stored, and residents could access cigarettes and lighters outside of designated times and areas, contrary to facility policy. Another resident, with severe cognitive impairment and dementia, was observed holding and storing partially smoked cigarettes in personal belongings, smoking unsupervised, and discarding cigarette butts in unsafe areas such as mulch with dried leaves. This resident's care plan and smoking evaluation identified them as an unsafe smoker requiring direct supervision and a smoking apron, but these interventions were not provided. Staff interviews revealed that the resident often picked up cigarette butts from the ground and smoked them, and that staff did not consistently monitor or control access to smoking materials or enforce the use of safety equipment. Additionally, the facility failed to maintain interventions for a resident assessed as being at risk of elopement. The resident, with cognitive impairment and a history of exit-seeking behavior, had a WanderGuard device ordered and care plan interventions for monitoring, but these were discontinued without documented reassessment or justification. The resident was later observed ambulating in the facility without a WanderGuard and was not located on the secure unit, despite ongoing risk factors. Facility policy required ongoing assessment and communication of interventions for residents at risk of elopement, but these procedures were not followed.
Removal Plan
- Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials.
- The responsible party for both Resident #10 and Resident #11 were notified of the incidents.
- The current smoking area on the locked dogwood unit is no longer designated as a smoking area.
- Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit.
- If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.].
- A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit.
- The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container.
- Current residents will be re-educated on the facility smoking policy.
- Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy.
- If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy.
- The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record.
- Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times.
- Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking.
- The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents.
- All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift.
- A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke.
- The Executive Director or designee will make visual observations of the smoking times on Rosewood to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol.
- The Executive Director or designee will make observations of the courtyard on the locked Dogwood unit to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area.
- Findings of the observations will be monitored by the RVPO or RDCS.
- The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance.
- Findings of the above audits will be reported to the QAPI Committee for additional oversight.
Failure to Protect Resident from Mental Abuse and Neglect
Penalty
Summary
Facility staff failed to protect a resident from mental and verbal abuse, resulting in psychosocial harm. The resident, who was cognitively intact and had a history of PTSD, depression, and chronic pain, did not receive her prescribed Fentanyl patch as ordered, leading to complaints of pain and withdrawal symptoms. When the resident voiced her concerns and posted signs about her rights and lack of medication, the DON escalated the situation by threatening to have the resident removed from the facility under a temporary detention order (TDO) and involved police and EMS, despite the resident not exhibiting behaviors that warranted such action. The DON also removed the resident's personal signs from her door without consent, further agitating the resident and exacerbating her PTSD symptoms. Multiple staff interviews and documentation confirmed that the resident was not assessed by the DON or other medical personnel prior to the involvement of law enforcement. The resident was not given the opportunity to participate in decisions about her care or to refuse treatment before the escalation. Staff and the Ombudsman reported that the DON's actions were intimidating, retaliatory, and not based on an accurate assessment of the resident's condition. The resident was left feeling scared, embarrassed, and experienced ongoing psychosocial distress, including increased anxiety and night terrors related to the incident. The facility's own investigation, as well as reports from the Ombudsman and Adult Protective Services, substantiated that the resident's rights were violated and that there was neglect in the timely administration of pain medication. The DON's actions, including the threat of a TDO, removal of personal property, and lack of direct assessment, were identified as the primary factors leading to the resident's psychosocial harm and the deficiency cited in the report.
Lack of Updated Hospital Transfer Agreement
Penalty
Summary
Facility staff failed to provide evidence of an updated hospital transfer agreement, as required for ensuring residents can be transferred quickly to a hospital when necessary. Document review showed that the only available agreement was with the previous owner, a company that no longer exists, and there was no current contractual agreement with a hospital under the new ownership. During staff interviews, the executive director explained that the process of updating contracts with all vendors, including hospitals, had been slow due to the recent acquisition of multiple facilities by the new company. No updated agreement was presented prior to the survey exit, potentially affecting all 86 residents in the facility. No specific residents or their medical conditions were mentioned in the report, and the deficiency was identified through staff interviews and document review.
Infection Preventionist Absent from QAPI Committee Meetings
Penalty
Summary
Facility staff failed to ensure that the required Infection Preventionist attended the Quality Assurance and Performance Improvement (QAPI) committee meetings for three consecutive quarters, covering the periods from October 2024 through June 2025. Review of QAPI meeting sign-in sheets for these quarters did not show the signature of an Infection Preventionist, as required by facility policy. During interviews, the executive director confirmed that an Infection Preventionist was supposed to attend these meetings and acknowledged that there was no documentation to show their attendance during the specified timeframes. The facility's policy states that the QAPI committee must be interdisciplinary and include, at a minimum, the Infection Preventionist, and must meet at least quarterly.
Failure to Notify Physician and Emergency Contacts of Changes in Condition and Missed Medications
Penalty
Summary
Facility staff failed to notify the emergency contact of changes in condition and the physician of medications not administered for two residents. For one resident, staff did not inform the physician when multiple medications, including antibiotics, antidiabetics, and heart failure medications, were not administered over several months due to reasons such as unavailability or the resident being asleep. Documentation in the electronic medication administration record (eMAR) did not show evidence of physician notification for these missed doses, nor were there parameters in the physician orders for holding medications under certain conditions, such as when the resident was sleeping or had low blood pressure. Additionally, the same resident experienced significant changes in condition, including lethargy, labored breathing, confusion, and low oxygen saturation, as well as another episode of labored breathing and pallor. In both instances, only the resident, who was their own responsible party, was notified, and there was no documentation that the next of kin or emergency contacts were informed, despite facility policy requiring such notification in emergencies or when the resident may not be able to understand the situation. For another resident, who was also their own responsible party, staff failed to notify the next of kin after the resident was found outside the facility, which was considered a change in condition. The resident was returned inside, a wander guard was applied, and safety checks were initiated, but only the resident was notified. Staff interviews confirmed that, according to facility policy, the next of kin should have been notified in these situations, especially when the resident's ability to act as their own responsible party was in question during an emergency.
Failure to Maintain Clean, Homelike Environment and Room Repairs
Penalty
Summary
Facility staff failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by multiple observations and staff interviews. One resident's bed was found with a large brown stain on the blanket over several days, and three reusable bed pads in the laundry room were observed to have large brown and yellow stains despite being washed. Staff interviews confirmed that stained linens were a recurring issue, and the executive director acknowledged that the stained bed pads were not suitable for use. The account manager for environmental services reported ongoing problems with linen supply and laundering, including issues with bleach dispensing in washing machines. In several resident rooms, privacy curtains were found to be dirty and stained, despite the facility's stated practice of monthly cleaning and as-needed laundering. The account manager for environmental services confirmed that the curtains were not clean and agreed they did not present a homelike environment. Additionally, one resident room was observed to have food debris and spill stains next to and under the beds on multiple occasions, and the environmental services manager acknowledged awareness of the unacceptable room condition. Further observations revealed that some resident rooms were not maintained in good repair, with gouges in the walls exposing plasterboard and unpainted plaster patches. The plant operator and maintenance director stated that repairs were typically made when reported by staff, but walk-throughs to check for needed repairs were inconsistent. He agreed that the rooms required repair and did not present a homelike environment. Facility policy requires the provision and maintenance of clean, good-condition linens and a sanitary, orderly, and comfortable environment, which was not met in these instances.
Failure to Implement Comprehensive Care Plans and Required Interventions
Penalty
Summary
Facility staff failed to implement comprehensive care plans for six residents, resulting in multiple deficiencies related to the delivery of care and safety interventions. For two residents with cognitive impairment and nicotine dependence, staff did not provide required smoking aprons or direct supervision while the residents smoked, despite care plans and facility policy specifying these interventions. Observations showed these residents smoking independently, without protective equipment or staff oversight, and using personal lighters, contrary to documented care plan interventions. For three residents, staff did not administer medications as ordered or document reasons for missed doses. Medication administration records (MARs) and electronic MARs (eMARs) revealed blank entries or notes indicating medications were not available, but there was no evidence of physician notification or follow-up documentation. This included missed doses of antipsychotic, antihypertensive, antiplatelet, diabetic, and pain medications, as well as intravenous antibiotics and other critical therapies. In some cases, nurse interviews confirmed that the care plan was not consistently followed or that documentation was incomplete. Additionally, staff failed to provide wound care treatments and complete required weekly wound assessments for several residents with pressure injuries or surgical wounds. Treatment administration records (TARs and eTARs) showed missed wound care on multiple dates, and there was a lack of documentation regarding the missed treatments or wound measurements. Interviews with nursing staff and administrators indicated lapses in wound tracking and assessment processes, particularly following staff turnover and the departure of a wound care nurse practitioner.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
Facility staff failed to administer medications and treatments according to physician orders for three residents. For one resident, multiple doses of gabapentin, insulin glargine, and spironolactone were not administered as ordered, as evidenced by blank entries or notes such as "on order" or "pharmacy to send" in the electronic medication administration record (eMAR). The facility's Omnicell inventory indicated that these medications were available in stock at the time. Interviews with nursing staff confirmed that medications should be documented as given in the eMAR, and if not available on the cart, staff were expected to check the Omnicell stock. The facility's policy required medications to be administered as ordered by the physician. Another resident did not receive multiple prescribed medications, including atorvastatin, clopidogrel, Edarbyclor, Miralax, Mirapex, montelukast, gabapentin, magnesium oxide, and insulin lispro, during two evening medication passes. The medication administration record (MAR) was blank for these times, and there was no documentation in the nurse's notes explaining the missed doses. The resident's care plan included interventions to administer these medications as ordered for conditions such as hypertension, diabetes, hyperlipidemia, constipation, and pain management. Additionally, this resident did not receive wound care treatments for an abdominal wound as ordered every three days, with several missed treatments documented as blank on the treatment administration record (TAR) and no corresponding nurse's notes. A third resident did not receive melatonin as ordered for insomnia on multiple dates, as shown by blank spaces on the MAR. The facility's supply list confirmed that melatonin was available in-house. Nursing staff interviews indicated that if a medication was not on the cart, it should be obtained from the facility's stock or Omnicell. The executive director and other administrative staff were made aware of these concerns during the survey, and no further information was provided prior to exit.
Failure to Provide and Document Pressure Ulcer Care and Assessments
Penalty
Summary
Facility staff failed to provide ordered pressure ulcer treatments and appropriate documentation for two residents with pressure injuries. For one resident, there were multiple instances in January and February where prescribed wound care treatments, including cleansing, application of medicated ointments, and dressing changes, were not documented as completed in the electronic treatment administration record (eTAR). The clinical record did not contain explanations or documentation regarding these missed treatments. The resident's care plan noted multiple Stage 2 and Stage 3 pressure injuries present on admission, with contributing factors such as decreased mobility, incontinence, poor nutrition, and non-compliance with treatment. For another resident, staff did not consistently provide or document pressure injury treatments on several dates across July, August, and September. Additionally, there was a lack of weekly wound assessments, including measurements and descriptions of wound progress, for an unstageable pressure injury that later progressed to Stage 4. The care plan required weekly documentation of wound measurements and characteristics, but the clinical record showed gaps in this documentation. Interviews with staff revealed that changes in personnel, including the departure of a wound care nurse practitioner and an assistant director of nursing, contributed to lapses in wound tracking and assessment. Both residents had care plans that included interventions for pressure injury management, such as administering treatments as ordered and monitoring wound healing. However, the facility failed to ensure that treatments were consistently provided and documented, and that required wound assessments were completed as specified in the care plans. There was no evidence in the clinical records to account for the missed treatments or assessments on the identified dates.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication as ordered for a resident with chronic pain, resulting in missed doses of a Fentanyl transdermal patch. The resident, who was cognitively intact and able to make daily decisions, reported experiencing withdrawal symptoms such as nausea and diarrhea after not receiving her pain patch as prescribed. Documentation revealed that the Fentanyl patch was not administered for a 12-day period in March, and additional missed doses occurred in September, with gaps of up to six days between administrations. Medication administration records, narcotic sign-off sheets, and nurse's notes confirmed these missed doses, and there was a lack of documentation explaining the omissions on certain dates. The resident's care plan specified the need for analgesic medication to be administered as ordered and for monitoring of side effects and effectiveness every shift. Despite this, the facility did not ensure consistent administration of the Fentanyl patch according to physician orders. Interviews with staff and review of records verified the missed doses and lack of documentation for some scheduled administrations. The facility's pain management policy required provision of pain management services consistent with professional standards and the resident's care plan, but this was not followed in the resident's case.
Insufficient Nursing Staff Resulting in Missed Resident Care Needs
Penalty
Summary
Facility staff failed to maintain sufficient nursing staff to meet the needs of residents on both the Dogwood and Rosewood units, as evidenced by staffing schedules and interviews. On multiple occasions, only one CNA was scheduled for the 3:00 p.m. to 11:00 p.m. shift despite a facility census ranging from 71 to 79 residents per unit. Staff interviews confirmed that the usual practice was to have two CNAs per unit during this shift, but there were times when only one CNA was present for several hours. The former staffing coordinator reported that she was not permitted to use agency staff to fill gaps, and efforts to call in additional staff were not always successful. The facility's own assessment tool indicated a need for 4-6 CNAs per unit for evening and night shifts, but this standard was not consistently met. Resident interviews revealed that snacks were not consistently provided during the night shift, with both resident council presidents from each unit stating that residents were not offered snacks. Staff interviews corroborated this, with CNAs and administrative staff acknowledging that the distribution of HS (hours of sleep) snacks was inconsistent due to insufficient staffing. The dietary department prepared and delivered snacks to the nurse's stations, but it was the responsibility of the nursing staff to distribute them, which did not always occur. The facility's policy requires sufficient staff to ensure resident safety and meet care needs, but documented staffing levels and staff accounts demonstrated that this requirement was not met on several occasions.
Failure to Maintain Required RN Coverage and Improper Assignment of DON as Charge Nurse
Penalty
Summary
Facility staff failed to provide required registered nurse (RN) coverage for at least eight consecutive hours per day on multiple dates, as evidenced by a review of nursing schedules and staff interviews. Specifically, there was no RN coverage for eight consecutive hours on five separate days, and the director of nursing (DON) confirmed that only one other RN was employed at the facility besides herself. The facility's own policy requires RN coverage for at least eight consecutive hours per day, seven days per week, but this standard was not met for 16 out of 31 days reviewed. Additionally, the DON served as a charge nurse on several occasions when the resident census exceeded 60, which is contrary to facility policy stating that the DON may only serve as a charge nurse when the average daily occupancy is 60 or fewer residents. Nursing schedules and staffing postings confirmed that the DON acted as charge nurse on multiple dates despite the higher census. The DON acknowledged that she was aware of the policy but felt compelled to serve as charge nurse due to staffing shortages.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
Facility staff failed to complete annual performance reviews for four out of five certified nursing assistants (CNAs) as required. Specifically, the performance reviews for these CNAs were not conducted on an annual basis according to their hire dates. The director of nursing, who was newly appointed and had no prior experience in the role, was unaware of who was responsible for ensuring the completion of CNA performance reviews. The facility's policy requires that employee attendance and completion records for mandatory in-service trainings be reviewed at least annually, typically at the time of the performance review. No additional information or documentation was provided to address this concern prior to the survey exit. Staff interviews and facility document reviews confirmed the deficiency, with administrative staff unable to clarify responsibility for the process, resulting in missed or delayed annual reviews for multiple CNAs.
Failure to Ensure Availability and Administration of Prescribed Medications
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident with sepsis, anemia of chronic disease, and joint pain, multiple doses of Daptomycin, Epoetin Alfa-epbx, and Pregabalin were not administered on several dates in February and March. Documentation in the electronic medication administration record (eMAR) indicated that medications were either not available, on order, or awaiting delivery from the pharmacy. Progress notes reflected missed doses due to unavailability, and staff interviews confirmed that when medications were not found in the medication cart or Omnicell, the pharmacy was contacted, and the physician was to be notified if a medication was not given. Another resident with schizophrenia and an enlarged prostate did not receive multiple doses of Ziprasidone and Flomax over several dates from July through September. Review of medication administration records showed missed morning and bedtime doses of Ziprasidone and daily doses of Flomax, with staff confirming that these medications were not available in the Omnicell and were not administered as ordered. The facility's policy required medications to be administered as ordered and in accordance with professional standards, but the records and staff interviews demonstrated that this was not consistently achieved.
Failure to Serve Correct Food Portions According to Menu Requirements
Penalty
Summary
Facility staff failed to provide residents with the correct portion sizes of food as specified by the facility's menu and production sheets. Observations in the kitchen revealed that staff used incorrect serving utensils to plate Caesar salad, lasagna, and sliced carrots, resulting in residents receiving less than the required amounts. Specifically, a beige/off-white handle scoop holding three ounces was used for Caesar salad instead of the required one-cup portion, a grey handle scoop holding four ounces was used for lasagna instead of the required eight ounces, and a red handle scoop holding two ounces was used for sliced carrots instead of the required half-cup portion. The facility's menu and production count clearly documented the required serving sizes, and a disher size reference sheet was available in the kitchen. During interviews, the district manager for dietary confirmed that the serving utensils used did not match the required portion sizes and acknowledged that residents did not receive the correct amount of food for dinner. The executive director, vice president of operations, and regional director of clinical services were informed of these findings. No further information was provided prior to the survey exit.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
Facility staff failed to serve palatable food on the Rosewood Unit, as observed during a survey. On the evening of 09/22/2025, a test tray containing lasagna with meat sauce, sliced carrots, green beans, and mashed potatoes was sent from the kitchen to the Rosewood Unit. The tray was followed by a surveyor and a dietary district manager, who observed the process. Upon arrival, the last dinner tray was served to a resident, and the food temperatures were measured: lasagna at 127°F, green beans at 117°F, carrots at 113°F, and potatoes at 112°F. The food was then sampled by two surveyors and the dietary district manager, who stated that the food could have been warmer and was not palatable, noting it should have been at least 130°F. The executive director, vice president of operations, and regional director of clinical services were informed of these findings, and no further information was provided before the survey exit.
Failure to Provide HS Snacks Results in Prolonged Fasting Periods
Penalty
Summary
Facility staff failed to provide HS (hours of sleep) snacks to residents on both the Dogwood and Rosewood units, resulting in a prolonged interval of over 14 hours between the evening meal and breakfast. The facility's meal delivery schedule indicated that dinner was served between 4:30 p.m. and 5:15 p.m., and breakfast was not served until 7:30 a.m. to 8:00 a.m. the following day. Resident council presidents from both units confirmed that residents were not offered snacks during the night shift and that the council had not agreed to allow up to 16 hours between meals. Staff interviews revealed that snacks were not consistently provided due to staffing shortages, and dietary staff reported that while snacks were prepared and delivered to the nurse's stations, nursing staff did not always distribute them to residents. Further documentation and communication between dietary and administrative staff highlighted ongoing concerns about the failure to pass out snacks, with photographic evidence and emails indicating that snacks remained undistributed. Despite the dietary department fulfilling its responsibility to supply snacks, nursing staff did not consistently ensure residents received them. Multiple staff members, including CNAs and nurse managers, either did not recall being informed about the issue or acknowledged that snack distribution was inconsistent. No additional information was provided by facility leadership prior to the survey exit.
Unsanitary Food Tray Drying Practices Observed in Kitchen
Penalty
Summary
Facility staff failed to serve food in a sanitary manner in the kitchen. On 09/22/2025, an observation revealed that two dietary staff members, including the acting dietary manager and the district manager for dietary, were hand drying 20 resident meal trays and placing them on the tray line. The kitchen staff then slid these trays down the tray line, placed meals on them, and loaded them into food carts for delivery to the unit floors. During an interview, the district manager for dietary confirmed that the trays should have been air dried to prevent contamination. The executive director, vice president of operations, and regional director of clinical services were informed of these findings, and no further information was provided prior to exit.
Lack of Updated Contract for Respiratory Equipment Provider
Penalty
Summary
Facility staff failed to provide evidence of an updated contract with an outside provider for respiratory equipment services, affecting seven residents who received these services. A review of contracts revealed that the agreement with the respiratory equipment provider was still in the name of the previous owner, a company that no longer exists, and no current contractual agreement was in place under the new ownership. The executive director confirmed that, following the change in ownership, the process of updating contracts with all vendors had been slow due to the volume of facilities acquired and the need for legal review and negotiation with vendors. No further information was provided prior to the survey exit.
Failure to Promote Resident Dignity During Feeding Assistance
Penalty
Summary
Facility staff failed to promote a resident's dignity during feeding assistance. A resident with severe cognitive impairment, vascular dementia, a history of CVA, and swallowing difficulties was observed being fed by a certified nursing assistant (CNA) who stood next to the bed while providing assistance. The resident was dependent on staff for eating, as documented in the care plan, and required support due to significant self-care deficits. The CNA confirmed during an interview that she stood while feeding the resident and acknowledged that this was not a dignified approach. The facility's policy on resident rights includes the right to be treated with respect and dignity, and to receive services with reasonable accommodation of resident needs and preferences. Despite this, the staff member did not follow practices that would uphold the resident's dignity during feeding. The deficiency was identified through observation, staff interview, and review of the clinical record, and facility leadership was made aware of the findings.
Failure to Honor Resident's Right to Retain Personal Belongings
Penalty
Summary
Facility staff failed to maintain a resident's right to be treated with respect and dignity, specifically the right to retain and display personal belongings. A resident, who was not cognitively impaired and had multiple medical diagnoses including diabetes, obesity, hypertension, sleep and mental health disorders, had handmade signs displayed on her door. On one occasion, the Director of Nursing (DON) removed these signs without the resident's permission, citing health department and infection control concerns. The removal was done abruptly, with the signs being ripped off the door, and without any prior discussion or consent from the resident. The resident expressed anger and distress over the removal of her personal items, stating that they were her belongings and that she was not asked for permission. Staff interviews confirmed that the resident was very upset by the incident and that the DON did not seek the resident's consent before removing the signs. Facility policy states that residents have the right to retain and use personal possessions unless doing so would infringe upon the rights or health and safety of others, but there was no documentation that the signs posed an immediate risk. The incident was also noted in an Ombudsman report, which highlighted the impact on the resident's mental well-being.
Failure to Maintain Confidentiality of Resident Clinical Records
Penalty
Summary
Facility staff failed to maintain the confidentiality of a resident's clinical record by printing and distributing a progress note without proper authorization. An LPN was asked by another LPN, through a CNA and with the involvement of a former staffing coordinator, to print a specific progress note related to backdated medication orders for a resident. The LPN expressed hesitation but proceeded to print and hand over the document, believing she had no alternative. The document was then given to the requesting LPN, who later admitted via text message to the director of nursing that she had destroyed the document after being questioned about its possession. Interviews with administrative staff revealed confusion regarding why the document was printed, as the requesting LPN should have had access to print it herself. The executive director and director of nursing both confirmed that the document was printed and distributed without proper oversight, and the facility's own policy states that residents have a right to secure and confidential personal and medical records. The incident involved multiple staff members and resulted in a breach of confidentiality for the resident's clinical information.
Failure to Ensure Safe and Informed Resident Discharge
Penalty
Summary
Facility staff failed to ensure that a resident's discharge needs were met, as evidenced by the lack of documentation that written discharge instructions were provided to the resident, failure to arrange home medications prior to discharge, and not supplying the resident with provider information that included standardized patient assessment data and quality measures for selecting a home health provider. The clinical record review showed that the resident was cognitively intact and was their own responsible party, with discharge planned to home with their spouse. Progress notes indicated ongoing discharge planning discussions with the resident and spouse, and referrals to home health and pharmacy were made, but there was no documentation of a discharge note or review of instructions and medications with the resident or family on the day of discharge. The discharge plan and instructions were electronically signed the day after discharge, and the nursing discharge summary was left blank. The social services discharge summary only briefly noted the discharge home and follow-up arrangements, but did not evidence that instructions were reviewed with the resident or family, nor that a copy was provided at discharge. Interviews with staff revealed inconsistent practices and uncertainty regarding the process for ensuring that prescriptions were signed and sent to the pharmacy prior to discharge, and that residents received their medications in a timely manner. Staff also indicated that while home health referrals were made, residents were not routinely given a selection of home health agencies or comparative data to make an informed choice, contrary to facility policy. Facility policy required that residents and their representatives be provided with information on post-acute care options, including quality and resource use data, and that all relevant discharge information be presented in an accessible format. However, the investigation found that this process was not followed for the resident in question. The lack of documentation and inconsistent staff practices led to a failure to ensure the resident was prepared for a safe discharge, with necessary instructions, medication arrangements, and provider choice information not properly provided or documented.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a baseline care plan within 48 hours of admission for one resident. The clinical record review showed that the resident was admitted with a PICC line, was always incontinent of bowel and bladder, had multiple wounds, a colostomy, and was taking insulin. Despite these complex care needs, there was no evidence in the clinical record that a baseline care plan was created within the required timeframe following admission. Interviews with staff confirmed that the baseline care plan is typically developed by the admitting nurse and should include essential information such as diet, mobility, behaviors, catheters, and colostomy care. However, staff were uncertain about including the PICC line in the baseline care plan. The administrator acknowledged that no baseline care plan was available for the resident in question. Facility policy requires a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident.
Failure to Follow Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to follow professional standards of practice in the administration and documentation of medications for two residents. For one resident, staff administered tramadol and oxycodone without current physician orders in place. The medications were given based on the presence of medication cards in the medication cart, and not on active orders in the electronic system. Subsequently, backdated orders were entered into the system several days later, with staff indicating that nursing management had claimed to have obtained physician approval, though the physician did not recall authorizing these orders. Facility policy required that physician orders be appropriately and timely documented and confirmed by the ordering physician, which was not followed in this instance. For another resident, staff failed to follow professional standards in the administration of Carvedilol and Entresto, both prescribed for heart failure and related conditions. On a specific date, the electronic medication administration record (eMAR) indicated that these medications were not administered because the resident was sleeping. There was no evidence of additional attempts to administer the medications later, nor was there documentation of physician notification regarding the missed doses. The physician orders did not include instructions to hold the medications if the resident was sleeping, and the nurse interviewed stated that important medications should be administered unless there was a specific order to hold them, and that the physician should be notified if medications are held. Both incidents were confirmed through staff interviews, clinical record reviews, and facility policy review. The failures included administering medications without proper authorization and not ensuring critical medications were administered or that the physician was notified when doses were missed. These actions did not meet professional standards of quality as required by facility policy and nursing best practices.
Failure to Obtain Physician Order and Maintain Sanitary Storage for Incentive Spirometer
Penalty
Summary
Facility staff failed to provide appropriate respiratory care and services for one resident by not obtaining a physician's order for the use of an incentive spirometer. The resident's clinical record did not contain an order for the device, and the admission minimum data set assessment was incomplete. The resident was alert and oriented at the time of admission, and a clinical admission assessment was documented, but there was no documentation supporting the use of the incentive spirometer as ordered by a physician. During observation, the incentive spirometer was found on the resident's nightstand with the mouthpiece uncovered, and the resident confirmed using the device without staff providing a cover. An LPN interviewed stated that a physician's order is required for incentive spirometer use, including frequency, and that the device should be stored in a plastic bag for infection control. The facility did not provide a policy regarding incentive spirometer use, and no further information was presented before the survey exit.
Unnecessary Medication Administration Without Physician Order
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications by administering tramadol and oxycodone without a current physician's order. After the resident returned from a hospital stay, the previous orders for these medications were discontinued. Despite this, a registered nurse administered both tramadol and oxycodone to the resident on a specific date, relying on the presence of medication cards in the medication cart rather than verifying active orders in the computer system or on the medication administration record (MAR). A review of the clinical record and MAR confirmed that there were no active orders for these medications at the time they were given, and the orders were only backdated in the system several days later. The nurse involved acknowledged during an interview that she made an error by not confirming the existence of current physician orders before administering the medications. Facility policy requires that medications be administered only as ordered by a physician, and that staff review the MAR to identify medications to be administered.
Administration of Controlled Medications Without Valid Physician Order
Penalty
Summary
Facility staff failed to comply with state regulations by administering tramadol and oxycodone to a resident without a valid physician's order. The resident had previously been prescribed these medications, but the orders were discontinued upon the resident's return from a hospital stay. Despite the absence of current orders in the system, a registered nurse administered both medications on the same day, relying on the presence of medication cards in the medication cart and assuming the medications were still prescribed. The nurse did not directly consult with the resident's physician before administering the drugs. Subsequently, the nurse entered backdated orders into the electronic system several days after the medications were given, based on information from nursing management that the physician had approved the orders. However, the physician later stated he did not recall being asked or approving the administration of these medications. Interviews with other staff members, including the staff development coordinator and the director of nursing, revealed a lack of direct involvement or recollection regarding the late entry of orders. The executive director was informed of the issue, and no further information was provided before the survey exit.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for three residents. For one resident, documentation showed assessments dated after the resident had already been discharged, with staff acknowledging that these entries should have been marked as late entries but were not, resulting in an inaccurate record. Facility policy requires documentation to be completed at the time of service or, if late, clearly marked as such, which was not followed in this instance. Another resident's medication administration record (MAR) indicated a Fentanyl patch was administered, but the narcotic sign-off sheets and nurse's notes revealed the medication was not available and not given, indicating an error in documentation. Additionally, for a third resident who experienced a change in condition and was transferred to the hospital, the clinical record lacked documentation of the interventions performed, such as administration of Narcan, oxygen, and chest compressions, despite the nurse confirming these actions were taken. These failures resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices for one resident who had a stage four pressure injury on the sacrum. The resident's clinical record included a physician's order for daily wound care, which required cleansing the wound, patting it dry, and applying medihoney and foam. The facility's policy and a CDC sign on the resident's door both indicated that enhanced barrier precautions, including the use of gloves and a gown, were required during high-contact care activities such as wound care for residents with wounds. However, there was no physician's order for enhanced barrier precautions in the resident's record. During an observation of wound care, an LPN performed the procedure without wearing a gown, despite the posted instructions and facility policy requiring this personal protective equipment. The LPN acknowledged during an interview that the sign on the door instructed staff to wear a gown during wound care, but she did not comply. Facility administrative staff were made aware of the incident, and the facility's policy clearly outlined the need for enhanced barrier precautions for residents with wounds.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to meet nurse staffing information posting requirements for all 31 days reviewed. Specifically, the postings did not include the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides directly responsible for resident care per shift. Instead, the postings only documented the total number and actual hours worked by licensed and unlicensed staff, without specifying the required categories. Additionally, on one occasion, the posted nurse staffing information was outdated, displaying a date several days prior to the observation. Interviews with facility staff revealed that the nurse staffing information postings were previously completed manually but had transitioned to being generated from an online scheduling system, which did not capture the required details. The staffing coordinator responsible for these postings had recently resigned, and the replacement from a related facility confirmed the current process and acknowledged the daily posting requirement. Facility policy also specified that the postings should include the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, but this was not followed during the review period.
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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