Ashland Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Virginia.
- Location
- 906 Thompson Street, Ashland, Virginia 23005
- CMS Provider Number
- 495362
- Inspections on file
- 28
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 49 (2 serious)
Citation history
Health deficiencies cited at Ashland Nursing And Rehabilitation during CMS and state inspections, most recent first.
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.
Facility Assessment Not Updated for Current Leadership: The facility’s assessment was not revised to reflect changes in key administrative and clinical leadership. It still listed a former administrator and Medical Director, and it did not include the current interim administrator or the current DON. The Executive Director stated he had not had time to update it.
Staff failed to maintain a clean, comfortable, and homelike environment and appropriate grooming on two nursing units, as evidenced by pervasive urine and feces odors in common areas and resident rooms, stained bed linens, dirty privacy curtains, damaged baseboards and furnishings, and clutter and trash on floors, including discarded wound dressings and gloves. Several residents were observed with wet pants, stained clothing, oily hair, and facial hair growth, and food particles were noted on clothing and wheelchairs. A bariatric resident reported that bariatric sheets and towels were not always available when linens needed changing, while housekeeping aides described cleaning 18–20 rooms per day, focusing mainly on floors and bathrooms and wiping tables only on request. A CNA reported that towels and bariatric sheets were sometimes insufficient at the start of shifts, requiring staff to obtain supplies from other units.
Facility staff failed to follow self-administration protocols when an LPN left two 500 mg Tylenol tablets at the bedside of a resident with alcoholic cirrhosis, ascites, and GERD, who had mild cognitive impairment, after the resident requested pain medication. Later observations found a medicine cup with multiple colored tablets still on the overbed table, but the two oblong white tablets were no longer present and the resident was not in the room. Record review confirmed there were no physician orders for the medications found at the bedside and no orders or interdisciplinary assessment authorizing self-administration, despite facility policy requiring such assessment and orders before residents may self-administer medications.
Staff failed to implement abuse and neglect prevention policies for a cognitively impaired, ambulatory resident with known wandering and exit-seeking behaviors, resulting in an elopement from an unsecured, unalarmed courtyard and multiple sexual contact incidents with other residents. Despite a physician order for a Wander-Gard and care plan focuses for elopement risk, behaviors, and 1:1 monitoring, the device was not consistently in place, interventions were not implemented or documented, and staff were unaware of the 1:1 requirement. The facility’s courtyard gate alarm was turned off with unaccounted-for keys, and an elopement and a later incident where the resident entered a female resident’s room without pants were not reported to the state agency. For a separate sexual incident between two residents, the facility produced only limited documentation, could not locate the initial facility-reported incident, had no confirmation of a 5-day follow-up being sent, and had no investigation notes or staff statements, despite a policy mirroring federal and state abuse/neglect reporting requirements.
The facility failed to provide required communication training for three CNAs whose employee records were reviewed. Record review showed the training was missing, and the DON verified the deficiency during the survey. The policy for the required training elements was requested but not provided prior to exit.
A CNA’s training record did not show the required resident rights education. During record review, the DON verified the missing training, and the policy for required training elements was not provided prior to exit.
Mandatory QAPI training was missing from one CNA’s employee record after surveyors reviewed staff training files and confirmed with the DON that the required training had not been completed. The facility also did not provide the policy for required training elements prior to exit.
Behavioral health training was not documented for four of ten employee records reviewed, including two CNAs, two OSMs, and dietary and housekeeping staff. The DON verified the missing training, and the policy for required training elements was not provided before exit.
Failure to post daily nurse staffing information at the start of the shift was observed when the receptionist desk posting still reflected the prior day. The Staffing Coordinator said she usually posts it around 8:00 a.m. and updates it before each shift, but she got involved with passing breakfast trays and forgot to post it. The ADON stated the scheduler should post it early in the morning, and the ED said there was no policy for the staff posting.
Facility staff did not hold or document resident council meetings for several months, leaving residents to organize meetings themselves and express grievances without formal support. During this time, concerns such as unmade beds, delayed medications, and staff-resident respect issues were repeatedly raised in meetings, but there was no evidence that these grievances were resolved or addressed according to facility policy.
The activities program was overseen by an individual who did not meet the required professional qualifications, as determined by surveyor review of staff credentials.
Facility staff did not update the facility-wide assessment after a change of ownership, continuing to use an outdated assessment that referenced previous leadership and staff competencies. The current executive director confirmed the assessment had not been revised to reflect new ownership or changes in contracts and staffing.
Following a change in ownership, facility staff did not provide updated contracts for mobile imaging, imaging equipment, and dialysis services, as all existing agreements were still under the previous owner's name. The executive director confirmed that new contracts had not yet been secured, and no policy for updating such agreements was provided.
Facility staff did not ensure the infection preventionist attended a required QAPI meeting, as shown by missing sign-in documentation. The infection preventionist had resigned, and the assistant DON covering the role was not present at the meeting, resulting in noncompliance with facility policy requiring infection preventionist participation in QAPI.
Staff did not maintain or provide infection surveillance logs for two consecutive months, and administrative and clinical leaders could not locate required documentation for infection tracking during that period. An LPN responsible for infection prevention confirmed that surveillance processes were not in place for the months in question, despite facility policy requiring ongoing monitoring.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards.
Facility staff did not follow required policies for investigating abuse allegations, as evidenced by incomplete documentation and missing interviews after multiple resident-to-resident altercations. In several cases, only clinical records or a single witness statement were present, and key investigative steps such as interviewing involved parties and witnesses were not documented, despite residents sustaining injuries and administrative staff acknowledging the incomplete investigations.
Facility staff did not conduct or document thorough investigations into multiple abuse allegations involving residents with cognitive impairments. In several cases, only basic clinical records and a single LPN witness statement were present, with no evidence of interviews with involved residents, staff, or other witnesses, despite significant injuries and repeated incidents. Administrative staff confirmed that required investigative documentation was missing.
Staff failed to develop and implement comprehensive care plans for multiple residents, resulting in unmet needs such as toileting assistance, structured activities, care planning for memory care and complex medical treatments, one-on-one behavioral monitoring, and personal hygiene support. Documentation and staff interviews confirmed that required interventions were not consistently provided or recorded, and in some cases, care plans did not address all relevant diagnoses or treatments.
Staff did not update or revise care plans for four residents after significant changes, including discontinuation of wanderguard devices, changes in safety check requirements, unaddressed activity preferences, and incidents of resident-to-resident altercations. Observations and staff interviews confirmed that care plans were not accurate or individualized as required.
Facility staff failed to provide and document required ADL care, including bathing, grooming, toileting, and personal hygiene, for four dependent residents. Documentation was incomplete or missing for multiple care opportunities, and observations revealed unmet hygiene needs, such as untrimmed facial hair and lack of evidence for toileting or bathing assistance. Staff interviews confirmed that care should have been provided and documented, but records did not support that these essential services were consistently delivered.
Facility staff did not provide or document required activities for multiple residents, including those with cognitive impairment and dementia, over several months. Due to the absence of an activities director and staffing challenges, activities such as music, group events, and outdoor time were not consistently offered or recorded, despite being identified as important in care plans and assessments. Staff and administrative interviews confirmed the lack of structured activities and documentation during this period.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Insufficient staffing in the kitchen resulted in delayed meal delivery, with the last lunch tray served to a resident significantly later than scheduled. Staff interviews confirmed that the kitchen was understaffed, and the account manager for dietary acknowledged the delays were unacceptable and not in line with facility policy.
Staff failed to serve palatable food at appropriate temperatures on one unit. A test tray with chicken stir-fry, chopped spinach, and potatoes was found to be served at temperatures below the required 140°F, with food described as lukewarm and not palatable. Dietary management confirmed the food was not at a safe or appetizing temperature, contrary to facility policy.
Lunch was served late to residents on one unit due to insufficient dietary staff, with the last food cart arriving much later than scheduled and the final tray served well after typical mealtime. Staff interviews confirmed the delay was caused by staffing shortages, and the dietary manager acknowledged the situation was not acceptable for residents.
Facility staff did not invite two residents and/or their representatives to participate in care plan meetings, including one cognitively intact resident and another with memory difficulties. Interviews and record reviews confirmed that the process for sending care plan invitations had lapsed after a staff change, resulting in no evidence of invitations or attendance for these residents' care planning.
Staff did not maintain a female resident's facial hair despite her need for substantial assistance with personal hygiene and no documentation of refusals or attempts to address the issue. Additionally, trash-filled food tray domes were left on dining tables during meals, contrary to facility policy and staff acknowledgment that this was undignified.
Facility staff did not inform a resident's responsible party when the resident displayed aggressive behaviors, refused medication, and was transferred to the ER for evaluation. Documentation confirmed the transfer and behavioral issues, but there was no evidence that the responsible party was notified, contrary to facility policy and staff expectations.
Staff did not maintain a clean and sanitary room for a resident with severe cognitive impairment, as evidenced by persistent food debris, dust, and a soiled fall mat. Additionally, strong, lingering urine odors were repeatedly observed in a memory care unit, despite established cleaning protocols and staff awareness of the issue.
Staff did not report an allegation of abuse involving a resident hitting another in the face within the required timeframe, and the investigation file lacked necessary documentation such as witness statements and interviews.
Facility staff did not provide required written notices of transfer and bed hold policies to two residents and/or their representatives during hospital transfers. In both cases, although forms were completed or available, there was no evidence that the notices were actually sent or received, as confirmed by interviews with the director of social services and the social worker.
A resident with severe cognitive impairment and a history of refusing care was observed with long, untrimmed toenails, and there was no documentation of recent foot care or refusals after the last podiatry visit. Staff interviews confirmed that care refusals should be documented, but the clinical record lacked evidence of toenail care or proper documentation, contrary to facility policy.
The facility did not provide adequate nursing staff each day to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Facility staff did not complete the required annual performance evaluation for a CNA, and could not provide documentation of this evaluation when requested by surveyors. Administrative staff cited a recent facility sale and lack of access to old personnel records as reasons for the missing documentation.
Facility staff did not assess or document the psychosocial status of a resident after the individual was physically abused by another resident. Although the resident received a physical assessment and medical follow-up, there was no evidence that required psychosocial interventions or monitoring were provided or recorded, as outlined in facility policy.
Staff did not maintain complete and accurate clinical records for two residents, including missing documentation of scheduled showers for a resident with severe cognitive impairment and failure to record an incident where one resident inappropriately touched another. Administrative staff confirmed these documentation lapses.
Facility staff did not provide evidence of communication between the hospice provider and the facility for a resident admitted to hospice care. Hospice visit notes were not promptly available in the medical record, and there was no established process to ensure all staff, including physicians, had access to hospice-related information, contrary to facility policy.
Staff failed to provide required communications training for a CNA, as administrative staff could not produce documentation due to a recent facility sale and lack of access to old records. The assistant director of clinical services, new to her role, was unable to explain the lapse in training, and the facility's policy requiring annual training was not met.
The facility did not provide required resident rights training to a registered nurse and an operations staff member. Administrative staff were unable to produce documentation of the training due to a recent change in facility ownership and lack of access to previous records. The assistant director of clinical services, new to her position, was not aware of the reasons for the missed trainings. Facility policy requires annual training on required topics, but no additional information or documentation was provided to the survey team.
A registered nurse did not receive required annual training on abuse, neglect, and exploitation prevention, and facility staff could not provide documentation of this training due to lack of access to old personnel records following a recent facility sale. Policy review confirmed that such training is required annually, but no evidence was available for this staff member.
The facility did not provide mandatory QAPI training to a registered nurse and a dietary staff member, as required by policy and regulations. Administrative staff cited a recent change in ownership and lack of access to old personnel records as reasons for the missing documentation, and no further information was provided to surveyors.
A registered nurse did not receive mandatory infection control training as required by facility policy and regulations. Administrative staff were unable to provide documentation of the training due to a recent facility sale and lack of access to old records. The deficiency was identified during a review of staff education records and interviews with administrative staff.
A registered nurse did not receive the required compliance and ethics training, as confirmed by a review of staff records and facility policy. Administrative staff were unable to provide documentation due to a recent facility sale and lack of access to previous records. The assistant director of clinical services, new to the position, acknowledged the gap in training and the importance of staff education for resident care.
The facility did not ensure that two CNAs received the required 12 hours of annual education, and administrative staff were unable to provide documentation of this training due to a recent change in facility ownership and lack of access to previous records.
The facility did not provide required behavioral health training to a registered nurse and a dietary staff member, as revealed by staff interviews and document review. Administrative staff cited a recent change in ownership and lack of access to old records as reasons for the missing documentation. The facility's policy requires annual training, but no evidence was provided to show compliance for these staff.
The facility failed to ensure the activities program was directed by a qualified professional, as the director of activities was not certified at the time of hire and only completed the necessary certification months later. The job description required a Bachelor's Degree, NCCAP certification, and experience in therapeutic recreation, which the director did not possess initially.
The facility failed to investigate and report an alleged abuse incident involving two residents who had a physical altercation. Despite initial reporting to the state agency, no follow-up investigation was conducted, and the required documentation was missing. The facility's policy mandates investigation by the DON or designee, but this was not followed due to an oversight during a staff transition.
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.
Facility Assessment Not Updated for Current Leadership
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that reflected current administrative leadership and medical oversight. Review of the Facility Assessment on 5/13/2026 showed it still listed the administrator who had left prior to November 2025, did not include the next administrator, and did not include the current interim administrator who started in February 2026. The current DON, who began in November 2025, was also not listed, and the Medical Director named in the assessment had ended his contract on April 1, 2026. The assessment was last updated or revised on August 27, 2025. During interview on 5/13/2026 at 4:50 p.m., the Executive Director stated the assessment had not been updated because he had not had time to do it.
Failure to Maintain Clean, Homelike Environment and Adequate Grooming
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and appropriate grooming for residents on Units W1 and W2. Upon entering the facility lobby, surveyors noted a strong pervasive odor resembling old dried urine. On Unit W1, observations during the initial tour included privacy curtains with dark smeared substances, baseboards buckling away from the wall, and bed linens with yellow-brown halos of stains. Foul odors of feces and urine were noted at various times of the day. Residents were observed with food particles on their clothes and in their wheelchairs, as well as wearing wet pants, stained clothing, and having oily hair. On Unit W2, multiple rooms were observed to be unclean and in disrepair. In one room, the baseboard near the HVAC unit was not attached to the wall and appeared to be crumbling, window blinds were bent, and paint on the wardrobe was scuffed; both residents in that room had hair under the chin and there was a very foul odor. Another room had a bedside table with a missing drawer, yellow-orange (rust-colored) stains and various trash on the floor under the sink, including a wound dressing, glove, and straw. A different room had bedside and overbed tables with liquid spills and dried substances and a very foul odor. One resident in a bariatric bed reported that bariatric sheets were not always available when linens needed changing and that towels sometimes ran out at the start of shifts, though she confirmed her linens had been changed that day and had extra towels and washcloths at bedside. Housekeeping aides reported they typically clean 18–20 rooms per day, focusing on floors and bathrooms and only wiping tables if residents request it. A CNA stated that sometimes there were not enough towels at the beginning of a shift and that staff would go to another unit to obtain more, and that bariatric sheets were available most of the time but occasionally not.
Medications Left at Bedside Without Self-Administration Assessment or Orders
Penalty
Summary
Facility staff failed to ensure it was clinically appropriate for a resident to self-administer medications when medications were left at the bedside without required assessment or physician orders. During an initial tour, surveyors observed a medicine cup containing seven colored tablets and two oblong white tablets on the overbed table of Resident #7, who was not in the room. Later the same day, during an evening tour, the medicine cup with the seven colored tablets remained on the overbed table, but the two oblong white tablets were no longer present, and the resident was again not in the room. Review of the clinical record showed that the resident had no active order for the medication found at the bedside and no order for self-administration of medications. Resident #7 had been admitted with diagnoses including alcoholic cirrhosis of the liver with ascites and gastro-esophageal reflux disease without esophagitis, and had a BIMS score of 13/15, indicating mild cognitive impairment. An interview with an LPN revealed that the resident had requested Tylenol after breakfast and was given two 500 mg Tylenol tablets at approximately 10:00 a.m.; the LPN stated the resident must have put them down instead of taking them as he said he would. The LPN also stated that medications should never be left at the bedside without a self-administration assessment and physician orders, and that no residents on the unit had such assessments or orders. Review of the facility’s Self-Administration of Medication and Treatments Policy showed that residents have the right to self-administer medications only if the interdisciplinary team has determined it is clinically appropriate and safe, which had not been done for this resident.
Failure to Supervise High-Risk Resident and Report Sexual and Elopement Incidents
Penalty
Summary
Facility staff failed to implement abuse, neglect, and theft prevention policies and procedures in relation to a resident with severe cognitive impairment and known wandering and exit-seeking behaviors, resulting in elopement and sexual contact incidents. One resident, diagnosed with Wernicke's encephalopathy, dementia, alcohol use disorder, and other conditions, had a BIMS score of 99 indicating severe cognitive impairment and was fully ambulatory. Despite multiple documented episodes of wandering into other residents' rooms, disrupting care, and seeking exits, staff did not consistently apply ordered safety measures such as a Wander-Gard device or supervision. The resident had a physician order for a Wander-Gard dated 11-13-25, but the device was not on the resident during surveyor observation, and documentation showed the resident had removed it on 3-8-26 without replacement. The same resident had a documented elopement on 12-15-25, when he went to the outside patio/courtyard and pushed open the gate, exiting to the parking lot before being redirected back inside by staff from another unit. This elopement was not reported to the state agency. The facility’s courtyard gate alarm was found by surveyors to be turned off, with the Maintenance Director acknowledging that the alarm had been shut off and that multiple unaccounted-for keys existed. The courtyard exit door lacked an activated alarm, and surveyors observed the gate standing open for approximately five minutes with no staff present and residents in the courtyard. An Elopement Evaluation completed on 2-16-26 documented that the resident’s wandering was not likely to affect the safety or well-being of self or others and not likely to affect the privacy of others, despite prior documented incidents of elopement and intrusion into other residents’ rooms during personal care. The resident was also involved in multiple sexual incidents. On 2-23-26, staff documented that the resident was found in another male resident’s room on his knees performing oral sex; the cognitively impaired resident later had no recollection of the event. On 3-5-26, the same resident was found sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; this third resident was not identified and the incident was not reported to the state agency. The care plan was updated over time to include behavior and elopement focuses, including a 1:1 monitoring intervention added on 3-9-26 for obsessive-compulsive behavior and a psychosocial problem related to sexual/physical contact with another resident, but multiple nursing staff and CNAs reported they were unaware of the 1:1 requirement, and supervision was not provided. Care plan interventions for behaviors and elopement were not documented as implemented, and no behaviors were recorded on the MAR. The facility failed to follow its abuse/neglect policy and regulatory reporting requirements for allegations and incidents of abuse and neglect. For the 2-23-26 sexual incident, the only documents produced were limited notes, a skin check, unsigned typed interview notes, and a purported final facility-reported incident (FRI) follow-up referencing an initial FRI that could not be located. The interim administrator could not produce the initial report, and there was no fax confirmation showing that the follow-up was successfully sent to the state agency; the state agency had no record of receiving it. No investigation notes or staff witness statements were found, and the facility’s abuse/neglect policy, which mirrored federal and state requirements for timely reporting and 5-day follow-up investigations, was not implemented. Additionally, the elopement on 12-15-25 and the 3-5-26 intrusion into a female resident’s room were never reported to the state agency. The report identifies these failures as neglect, defined as withholding required goods and services, including necessary supervision for a resident known to be a danger to self and others.
Failure to Provide Required Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide required communication training for three of ten employee records reviewed, including CNA #1, CNA #2, and CNA #3. During record review on 5/13/2026 at 6:00 p.m., the employee training records for these three CNAs were requested and reviewed, and none contained the required training in communication. On 5/14/2026 at approximately 3:45 p.m., the DON verified that the three CNAs did not have the required communication training. A request was made for the policy outlining the required training elements, but it was not provided prior to exit. The Executive Director, DON, and Regional Director of Operations were informed of the finding on 5/14/206 at 4:10 p.m.
Missing Required Resident Rights Training for CNA
Penalty
Summary
Staff members were not educated on resident rights and facility responsibilities as required, based on staff interview, facility document review, and employee record review. During review of employee training records for CNA #3, the required training in resident rights was not present. On 5/14/2026 at approximately 3:45 p.m., the DON verified that CNA #3 did not have the required resident rights training. A request for the policy outlining the required training elements was made but was not provided prior to exit, and the Executive Director, DON, and Regional Director of Operations were informed of the finding on 5/14/2026 at 4:10 p.m.
Missing Required QAPI Training for CNA
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not provided for one of ten employee records reviewed, CNA #3. During review of employee training records on 5/13/2026 at 6:00 p.m., CNA #3’s file was found to not include the required QAPI training. On 5/14/2026 at approximately 3:45 p.m., the DON verified that CNA #3 did not have the required QAPI training. A request for the facility policy outlining the required training elements was made but was not provided prior to exit, and the Executive Director, DON, and Regional Director of Operations were informed of the finding on 5/14/206 at 4:10 p.m.
Missing Behavioral Health Training for Multiple Employees
Penalty
Summary
Behavioral health training was not provided for four of ten employee records reviewed, including CNA #2, CNA #3, OSM #2, and OSM #3. During staff interview, facility document review, and employee record review, surveyors found no documented education regarding behavioral health for CNA #2, CNA #3, OSM #2, and OSM #3. On 5/14/2026, the Director of Nursing verified that these staff members did not have the required behavioral health training. A request for the policy outlining the required training elements was made but the policy was not provided prior to exit.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information at the beginning of the shift on one of three days observed. On 5/14/2026 at 9:03 a.m., surveyors observed the staffing posting at the receptionist desk and found it documented for 5/13/2026 instead of the current day. The Staffing Coordinator stated that she normally posts the daily staffing information when she arrives around 8:00 a.m., updates it before every shift, and had recently started asking the night nurse to post it in the morning to reflect overnight call offs. She stated that on the morning of 5/14/2026 she became involved with passing breakfast trays and forgot to post it. The ADON stated that the scheduler should post the staffing information early in the morning and that the night nurse has the schedule and should put it up front at the receptionist desk. The ED, DON, and Regional Director of Operations were informed, and the ED stated there was no policy for the staff posting.
Failure to Facilitate Resident Council Meetings and Resolve Grievances
Penalty
Summary
Facility staff failed to facilitate resident council meetings for three consecutive months, as evidenced by the absence of meeting minutes from early May through the time of the survey. During this period, there was no activities director, and residents, including one who was cognitively intact, reported that they had to organize meetings themselves to discuss concerns and grievances. The facility's own policy required monthly resident council meetings, facilitated and documented by staff, but this was not followed, potentially affecting all residents. Additionally, for two months, the facility did not provide evidence that grievances raised during resident council meetings were resolved. Multiple meeting minutes from November and December showed recurring and new concerns, such as unmade beds, delayed pain medication, lack of housekeeping, missing personal items, and staff-resident respect issues. There was no documentation in subsequent meeting minutes that these grievances were addressed or resolved, despite the facility's policy to make prompt efforts to resolve complaints and inform residents of progress. Interviews with administrative staff confirmed the lack of meeting minutes and the absence of documentation showing grievance resolution for the specified period. The executive director, who had recently started, acknowledged that there was no evidence of resolution for grievances from the months in question and described a process for tracking and resolving concerns that was not in place during the deficiency period.
Unqualified Professional Directing Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. Surveyors identified that the individual responsible for overseeing the activities program did not meet the required qualifications as specified by regulations. This deficiency was based on direct observation and review of staff credentials during the survey.
Failure to Update Facility Assessment After Change of Ownership
Penalty
Summary
Facility staff failed to review and revise the facility-wide assessment following a change of ownership that became effective on 6/1/2025. The most recent facility assessment available was dated 7/18/2024 and included information pertaining to the previous executive director, director of clinical services, and staff training/education and competencies under the former owner. During an interview, the current executive director confirmed that the assessment provided was from before the change of ownership and acknowledged that updates had not yet been made, as they were planning to address this in an upcoming QAPI meeting. No updated assessment reflecting the new ownership, leadership, or revised contracts was available at the time of the survey.
Failure to Secure Updated Contracts with Outside Service Providers After Ownership Change
Penalty
Summary
Facility staff failed to provide evidence of updated contracts with outside service providers following a change in facility ownership. During the survey, administrative staff were unable to produce current contractual agreements for mobile imaging services, mobile imaging equipment, and contract dialysis services. The contracts available were all in the name of the previous owner, a company that no longer exists due to bankruptcy and subsequent sale of the facility. The executive director acknowledged that the facility had not yet secured new contracts with these vendors under the new ownership. Additionally, the facility did not provide a policy related to updating contracts with outside providers. The lack of updated agreements potentially affects all residents, as required services may not be properly secured or documented. No further information or documentation was provided to the survey team prior to the exit interview.
Infection Preventionist Absent from Required QAPI Meeting
Penalty
Summary
Facility staff failed to ensure the attendance of the infection preventionist at one of five reviewed QAPI (Quality Assurance Performance Improvement) meetings, specifically the Q4 2024 meeting. Review of QAPI meeting sign-in sheets did not show the infection preventionist present at this meeting. Interviews with the director of clinical services revealed that the infection preventionist had resigned in November 2024, and although the assistant director of nursing was covering the role at the time, this individual was not present at the meeting. The executive director confirmed that QAPI meetings are held at least quarterly and are attended by an interdisciplinary team, which should include the infection preventionist as per facility policy. The facility's QAPI policy requires the infection preventionist to be a member of the Quality Assessment and Assurance Committee.
Failure to Maintain Infection Surveillance Documentation
Penalty
Summary
Facility staff failed to implement a complete infection prevention and control program for the months of November and December 2024. During this period, there was no evidence of an infection surveillance system in place to identify possible communicable diseases before they could spread within the facility. When asked, administrative and clinical leadership were unable to provide infection surveillance logs for the specified months, stating that both the director of clinical services and the current infection preventionist had only started their roles after the period in question and could not locate the required documentation. Interviews with the infection preventionist revealed that she began her role in mid-December 2025 and recalled a gastrointestinal issue affecting a few individuals, but no overarching trends or specific pathogens like Norovirus were identified. The infection preventionist described her current responsibilities for tracking infections and antibiotic usage, but this process was not in place or documented for the months under review. Facility policy requires ongoing surveillance for healthcare-associated infections, but no additional information or evidence of compliance for the deficient period was provided.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Abuse Investigation Policies and Procedures
Penalty
Summary
Facility staff failed to implement established policies and procedures for investigating allegations of abuse, neglect, and theft involving multiple residents. In several incidents involving residents with cognitive impairments and dementia, staff did not complete or document required investigative steps. For example, after a nurse witnessed one resident strike another, the facility's documentation lacked evidence of interviews with the residents involved, staff, or other potential witnesses, and did not include a summary of the investigation or supporting documentation. Similar deficiencies were noted in subsequent incidents involving the same resident and others, where only clinical records were present in the investigation files, and final reports to the state agency were missing from the facility's records. In another case, a resident sustained significant injuries, including a laceration, bloody nose, and orbital fracture, following an altercation with a roommate. The facility's documentation included only a single witness statement from an LPN and lacked evidence of interviews with the residents involved, other staff, or a comprehensive review of medical records. The executive director confirmed that the investigative file was incomplete and did not meet the facility's own standards for a thorough investigation. Throughout these incidents, the facility's failure to follow its own abuse investigation policy was evident. Required steps such as obtaining statements from all involved parties, conducting thorough assessments, and maintaining complete investigative files were not performed or documented. Administrative staff acknowledged these deficiencies during interviews, and no additional information or corrective documentation was provided prior to the survey exit.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
Facility staff failed to thoroughly investigate multiple allegations of abuse involving several residents with cognitive impairments. In one instance, a resident with vascular dementia and a low BIMS score was witnessed striking another resident in a memory care unit. The facility's documentation included a synopsis of the event and notification of the medical doctor and responsible parties, but lacked evidence of a comprehensive investigation. There were no documented interviews with the residents involved, staff, or other potential witnesses, nor were there detailed assessments or observations beyond basic skin checks. Similar deficiencies were noted in subsequent incidents involving the same resident, including an event where the resident was seen removing his hand from around another resident's neck. In each case, the investigation files contained only clinical records and lacked required investigative documentation such as witness statements and interview notes. Another incident involved a resident with severe cognitive impairment who sustained significant injuries, including a laceration to the lip, bloody nose, and swelling to the face, after an altercation with a roommate. The facility's investigation included a synopsis of the event and a single witness statement from an LPN, but did not include interviews with the residents involved, additional staff, or other residents. The documentation failed to provide a comprehensive account of the incident or demonstrate that a thorough investigation was conducted, as required by facility policy. Interviews with administrative staff confirmed that the investigative files were incomplete and did not meet the facility's own standards for abuse investigations. The facility's policy requires statements from all involved parties and witnesses, as well as a detailed summary and supporting documentation, none of which were present in the reviewed files. The lack of thorough investigation and documentation was acknowledged by facility leadership during the survey.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for six residents, resulting in unmet needs across multiple domains. For one resident with severe cognitive impairment and incontinence, documentation showed repeated failures to provide and record toileting assistance as required by the care plan over several months. Staff interviews confirmed that toileting assistance should have been provided and documented, but records did not support consistent implementation. Another resident, also with severe cognitive impairment, did not receive structured activities as outlined in their care plan. Staff and administrative interviews revealed that for months, there were no regular activities in the memory care unit due to staffing challenges, and the facility could not provide evidence of activity participation for the resident during that period. Additional deficiencies included the lack of a care plan addressing the needs of a resident on the memory care unit, despite documentation of severe cognitive impairment. For another resident with brain cancer and a seizure disorder, the care plan failed to address critical aspects such as radiation therapy, chemotherapy, anticonvulsant use, and the cancer diagnosis, even though these treatments and diagnoses were documented in the medical record. The regional MDS coordinator confirmed that these omissions meant the care plan was not comprehensive for the resident's needs. Further, the facility did not implement one-on-one monitoring for a resident with behavioral issues as required by the care plan, with no documentation to show monitoring occurred on multiple dates or that it was discontinued. In another case, a resident with quadriplegia and total dependence for personal hygiene had no documentation of care provided or refusal of care on a specific date, despite the care plan requiring total staff assistance. Staff interviews confirmed that care plans are intended to be individualized and updated as needed, but the required interventions were not consistently documented or implemented.
Failure to Update and Individualize Resident Care Plans After Changes in Status and Incidents
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following significant changes in their care needs and status. For two residents, the care plans continued to document the use of wanderguard devices and every 15-minute safety checks, despite the absence of current physician orders and the devices not being in use. Observations confirmed that these residents were not wearing wanderguards, and staff interviews acknowledged that the care plans were not accurate or up to date. The facility's own policy required care plans to be reviewed and revised based on changing needs and interventions, but this was not followed. Another resident's care plan was not updated to reflect the resident's preferences for activities, despite the most recent assessments indicating specific interests and needs. The care plan contained only general interventions and did not individualize activities according to the resident's stated preferences. Staff interviews confirmed that every resident should have an individualized activity care plan, and the current plan did not meet this standard. Additionally, the care plans for two residents were not reviewed or revised after incidents of resident-to-resident altercations. One resident was the victim of an assault, resulting in a skin tear and facial bruising, while another resident was the aggressor in two separate incidents. Despite documentation of these events in the clinical records and staff acknowledgment that care plans should be updated following such incidents, there was no evidence that the care plans were reviewed or revised to address the new risks or interventions needed.
Failure to Provide and Document ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide and document activities of daily living (ADL) care for four residents who were unable to perform these tasks independently. For one resident, records showed significant gaps in bathing and showering documentation over several months, with only a small fraction of opportunities for care being recorded and most entries left blank. When additional documentation was requested, only two shower sheets were produced for a three-month period, despite policy requiring regular review and documentation of bathing preferences and frequency. Another resident, assessed as severely impaired in decision-making and requiring substantial assistance with personal hygiene, was repeatedly observed with untrimmed facial hair over several days. The care plan indicated the need for daily grooming and assistance, and staff interviews confirmed that grooming, including shaving, should be performed daily or as needed. However, there was no documentation of care refusals or attempts to address the facial hair, and ADL records showed minimal entries for personal hygiene during the review period. A third resident, also severely impaired and requiring supervision for toileting, had multiple dates across three months where there was no evidence of toileting assistance being provided or documented on various shifts. The care plan specified the need for staff assistance with toileting, but ADL records showed numerous blank entries. For a fourth resident, who was totally dependent on staff for personal hygiene due to quadriplegia, there was no documentation of personal hygiene care or refusal on a specific date, despite the care plan requiring daily assistance. Staff interviews confirmed that care should be provided and refusals documented, but the absence of records made it impossible to determine if care was given.
Failure to Provide and Document Resident Activities
Penalty
Summary
Facility staff failed to provide activities to meet the needs and preferences of five residents over a period of several months. For one resident with no cognitive impairment, there was no evidence of activities being provided according to their stated preferences, which included listening to music, keeping up with the news, group activities, favorite pastimes, and going outside for fresh air. The facility lacked documentation of activities for this resident and others between February and June, and the executive director confirmed that there was no activities director during much of this time, resulting in gaps in activity provision and documentation. Several other residents, including those with severe cognitive impairment and dementia, also did not receive documented activities during the same period. These residents had care plans and MDS assessments indicating the importance of activities such as music, religious services, group events, going outside, and reading materials. Staff interviews revealed that, due to staffing challenges and the absence of an activities director, activities were not consistently offered, especially in the memory care unit. Some CNAs attempted to provide informal activities, but these were not regular or documented, and there was no structured program in place until a new activities director was hired at the end of June. The facility's own policy required group activities to be scheduled and documented to enhance residents' well-being and self-esteem, with participation recorded in the electronic health record and summaries provided at least quarterly. However, administrative and clinical staff acknowledged the lack of evidence for activity participation during the cited period. The deficiency was identified through resident and staff interviews, review of facility documents, and clinical records, all of which confirmed the absence of required activities and documentation for multiple residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Insufficient Dietary Staffing Led to Delayed Meal Service
Penalty
Summary
Facility staff failed to provide sufficient personnel in the kitchen to ensure timely meal service to residents. On one occasion, the last food cart for lunch arrived on a unit at 3:50 p.m., and the last lunch tray was served at 4:10 p.m., which was significantly later than the scheduled meal times. Staff interviews confirmed that the kitchen was understaffed on that day, resulting in delayed meal delivery. The account manager for dietary acknowledged that the observed delays were not acceptable and that residents should not have to wait for their meals. The facility's policy requires that at least three daily meals be provided at regular times comparable to normal community mealtimes. However, observations and staff interviews indicated that the kitchen did not have enough staff to meet this requirement, leading to delays in meal service. Administrative staff were made aware of these findings, and no additional information was provided prior to the survey exit.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
Facility staff failed to serve palatable food at a safe and appetizing temperature on one of three units, Unit One. On the specified date, a test tray containing chicken stir-fry, chopped spinach, and enhanced potatoes was sent from the kitchen to Unit One. The tray was followed by surveyors and a dietary district manager. Upon arrival, the last lunch tray was served to a resident, and the cover was removed from the test tray. Food temperatures were measured: chopped spinach at 118°F, stir-fry at 111°F, and potatoes at 115°F. These temperatures were observed by two surveyors and the dietary district manager, who described the food as lukewarm after tasting it. When asked if the food was palatable, the dietary district manager did not provide an answer. In a subsequent interview, the dietary account manager confirmed that food temperatures should have been 140°F or greater and acknowledged that food at the measured temperatures would not taste good because it was cold and the temperature had dropped too much. The facility's policy requires food to be prepared and served in a manner that conserves nutritive value, flavor, and appearance, and specifies that food should be palatable, attractive, and served at a safe and appetizing temperature. The deficiency was communicated to the executive director and director of clinical services, with no further information provided prior to exit.
Delayed Lunch Service Due to Dietary Staffing Shortage
Penalty
Summary
Facility staff failed to serve lunch in a timely manner on one of three units, specifically Unit One. On the observed date, the last food cart for lunch arrived on Unit One at 3:50 p.m., and the last lunch tray was served at 4:10 p.m. This was significantly later than the scheduled meal times, as the first lunch food carts are typically sent to the floor at 11:45 a.m. Staff interviews confirmed that there was insufficient dietary staff available on the day in question, which contributed to the delay in meal service. The account manager for dietary acknowledged that the observed delay was not acceptable for residents and that residents should not have to wait for their meals. The facility's policy requires that at least three daily meals be provided at regular times comparable to normal mealtimes in the community, and that meal and snack times be coordinated with residents and relevant administrative staff. Despite this policy, the observed delay in meal service on Unit One was attributed to staffing shortages in the kitchen, as confirmed by staff interviews. No additional information or explanation was provided by facility administration prior to the survey exit.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
Facility staff failed to invite residents and/or their representatives to participate in care plan meetings for two residents. For one resident, who was cognitively intact as indicated by a high BIMS score on the most recent MDS assessment, neither the resident nor their representative received invitations to care plan meetings throughout the year. Both the resident and their representative confirmed in interviews that they had not been invited to attend these meetings. Staff interviews revealed that the process for sending invitations had lapsed after the departure of the former MDS coordinator, with the last invitation letter sent several months prior. For another resident, who had documented short- and long-term memory difficulties, there was no evidence in the clinical record that the responsible party was invited to care plan meetings, nor was there documentation of their attendance. A note in the record referenced a meeting set up to address a room change, but this was not identified as a care plan meeting. Staff interviews confirmed that the system for generating and sending care plan invitations had not been maintained, resulting in a lack of invitations for residents and their representatives.
Failure to Promote Resident Dignity in Personal Hygiene and Dining Environment
Penalty
Summary
Facility staff failed to promote dignity for one resident by not maintaining trimmed facial hair on a female resident with severe cognitive impairment and significant ADL self-care deficits. Despite the resident requiring substantial to maximal assistance with personal hygiene and being assessed as sometimes resistant to care, there was no documentation in the clinical record or ADL logs of refusals or attempts to address the facial hair. Multiple observations over several days confirmed the presence of long, curled white hairs on the resident’s chin and upper lip, and staff interviews indicated that personal hygiene, including shaving, should be performed daily and refusals reported and documented, which was not done in this case. Additionally, observations in the dining area revealed that food tray domes containing trash were placed in the center of tables where residents were eating. This practice was observed on multiple occasions and was acknowledged by a nurse as not being a dignified manner for residents to eat. Facility policy requires that all non-edible items be removed from dining tables to maintain a relaxed and social dining environment, but this was not followed during the observed meal times. Both deficiencies were brought to the attention of facility administrative and clinical leadership. No further information or documentation was provided prior to the survey exit regarding these findings.
Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party of a significant change in condition when the resident exhibited aggressive behaviors, refused medication, and was subsequently transferred to the emergency room for further evaluation. Clinical record review showed documentation of the resident's behavioral changes and hospital transfer, but there was no evidence that the responsible party was informed of these events. Staff interviews confirmed that the expected protocol is to notify the representative when a resident is transferred to the hospital, and facility policy requires family notification of any resident changes. Despite these requirements, no documentation or evidence of notification was found for this incident.
Failure to Maintain Clean, Homelike Environment and Control Odors
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment for a resident with a history of stroke and severe cognitive impairment. Multiple observations over two days revealed that the resident's room contained unopened condiment packages, food wrappers, dust, and a fall mat that was sticky and covered with food debris. Despite the facility's policy requiring daily cleaning and immediate attention to visibly soiled surfaces, these conditions persisted across several observations. The director of housekeeping confirmed that the room and fall mat were not clean during a walkthrough. Additionally, staff failed to provide a homelike environment free of lingering urine odors on one of the facility's units. Repeated observations in the memory care unit detected strong, stale urine odors in specific hallways over two consecutive days. The director of housekeeping described the cleaning protocols, which included daily cleaning, weekly floor scrubbing, and deep cleaning of two rooms per day, but acknowledged that lingering urine odors were present and not homelike. The odors were attributed to bathrooms, and efforts were made to assign dedicated housekeeping staff to the unit. Interviews with staff confirmed awareness of the cleaning routines and the presence of odors, with the activities assistant noting that minimizing odors depended on both resident care and housekeeping efforts. The executive director and director of nursing were informed of the findings, and no additional information was provided before the survey exit.
Failure to Timely Report Alleged Abuse and Incomplete Investigation Documentation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner involving one resident who was witnessed hitting another resident in the face. The incident occurred on 12/27/24, but the report to the state agency was not made until 12/30/24, exceeding the facility's policy requirement to report such allegations within two hours if abuse or serious bodily injury is involved. Documentation in the facility's event synopsis and the final report to the state agency confirmed the delay in reporting. The incident resulted in one resident sustaining discoloration to the side of the face, and both the medical doctor and responsible party were updated. Upon review of the facility's investigation file, there was no evidence of a completed investigation, as the only documents present were clinical records for the residents involved. There were no witness statements, staff or resident interviews, or assessments of the residents involved or any other residents. Interviews with administrative staff confirmed awareness of the reporting requirements, but the deficiency was identified due to the lack of timely reporting and insufficient documentation of the investigation process.
Failure to Provide Written Transfer and Bed Hold Notices During Hospital Transfers
Penalty
Summary
Facility staff failed to provide required written notices of transfer and bed hold policies to residents and/or their representatives during hospital transfers for two residents. In the first instance, a resident was transferred to the emergency room due to medication refusal, aggressive behaviors, and psychosis. Although forms documenting the resident's and responsible party's names and the date were completed, there was no evidence that these notices were actually provided to the resident or their representative. The director of social services stated that notices are typically mailed and kept in her office, but could not provide proof that the notices were sent or received in this case. In the second instance, another resident was transferred to the hospital after exhibiting a high temperature and low blood pressure, with the transfer initiated at the request of the resident's spouse. The clinical record did not contain documentation that the required written notice and bed hold policy were sent to the responsible party. The social worker confirmed that while copies of the notices existed, there was no evidence they were actually sent. Facility policy requires notification of bed hold policies at admission and at the time of transfer, but documentation supporting compliance was not available for these two cases.
Failure to Provide Foot Care and Document Refusals
Penalty
Summary
Facility staff failed to provide appropriate foot care for one resident, resulting in long, untrimmed toenails that were observed to be uneven and approximately 1/8 inch from the nailbed. The resident, who was assessed as severely impaired in decision-making and required substantial to maximal assistance with personal hygiene and bathing, was seen walking barefoot in the hallway. The care plan documented that the resident had a self-care deficit related to dementia, lack of coordination, and hemiplegia, and also noted a history of refusing care, including foot care and podiatry services. However, there was no documentation in the nursing progress notes of refusals or attempts to trim the toenails after the last podiatry visit, which occurred several months prior to the observation. Staff interviews revealed that while the resident sometimes refused care, the expectation was that refusals should be documented and reported to the physician and responsible party. The facility's policies required daily grooming activities, including nail care, and documentation of care provided or refusals. Despite these requirements, the clinical record did not show evidence of toenail care or documentation of refusals after the last podiatry visit, indicating a lapse in following facility policy and in providing necessary foot care for the resident.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate daily nursing staff coverage and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
Facility staff failed to complete an annual performance evaluation for one of five certified nursing assistants (CNA) whose records were reviewed. Specifically, there was no evidence that the required annual performance evaluation for CNA #5 had been conducted within the past 12 months. When the survey team requested the most recent performance evaluation for this CNA, administrative staff members, including the executive director and the director of clinical services, indicated that they might not be able to provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not explain why the evaluation had not been completed in a timely manner.
Failure to Assess and Address Psychosocial Needs After Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to provide medically-related social services to a resident who experienced physical abuse from another resident. According to the clinical record, a nurse documented that the resident was found being hit in the face by another resident, resulting in a small skin tear on the nose, facial swelling, and bruising. The nurse assessed the resident's physical condition, notified the nurse practitioner, obtained an x-ray order, and informed the resident's power of attorney. However, there was no documentation that the resident's psychosocial status was assessed or that any psychosocial interventions were implemented following the incident. Interviews with the social services coordinator revealed that the facility's protocol requires social services staff to interview residents involved in such incidents, complete a psychosocial assessment, and monitor the resident's coping status weekly for at least four weeks, with all actions documented in the clinical record. Review of the resident's record did not show evidence that these steps were taken. The facility's policy also mandates that social services complete progress reviews with significant changes or as needed, but no such documentation was found for this incident.
Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for two residents. For one resident with a history of stroke and severe cognitive impairment, the facility's shower schedule and shower sheets indicated that showers were provided every Monday and Thursday. However, the activities of daily living (ADL) tracking sheets did not document that these showers occurred as scheduled. The director of clinical services confirmed that the shower sheets were kept in a separate binder and were not considered part of the clinical record, resulting in incomplete and inaccurate documentation for this resident. In a separate incident, staff failed to document in the clinical record an event where one resident touched another resident's breast. Although the incident was reported to the state agency and staff intervened immediately, there was no documentation of the event in the affected resident's clinical record. The director of clinical services acknowledged that this incident should have been documented. Both deficiencies were confirmed by administrative staff during interviews.
Failure to Ensure Communication and Documentation with Hospice Provider
Penalty
Summary
Facility staff failed to provide evidence of communication between the hospice company and the facility for one resident who had been admitted to hospice care. The physician order documented the resident's admission to hospice, and a request was made for records of communication between the facility and the hospice provider. Documentation from the hospice company, including visit notes, was only faxed to the facility on a later date, despite hospice visits occurring earlier. When questioned, the director of clinical services explained that received hospice information is given to the medical records department and uploaded into the electronic medical record system, but could not specify the expected timeframe for this information to be available in the record. Further investigation revealed there was no hospice communication book on the unit, and while nursing staff reported verbal communication with hospice staff, there was no system in place to ensure this information was accessible to all staff, including physicians. Facility policy requires coordination and communication with hospice representatives and the attending physician, as well as the collection of specific hospice documentation. However, the facility was unable to demonstrate that these requirements were met for the resident in question.
Failure to Provide Required Communications Training for CNA
Penalty
Summary
Facility staff failed to provide required communications training for one of ten certified nursing assistants (CNA #5) as evidenced by staff interviews and document review. When the education records for CNA #5 were requested, administrative staff indicated they might not be able to provide the information due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not account for why the required training had not been completed in the past. A review of the facility's in-service training policy indicated that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. Despite this policy, the facility was unable to provide documentation that CNA #5 had received the necessary communications training, and no further information was provided prior to the survey exit.
Failure to Provide Required Resident Rights Training to Staff
Penalty
Summary
Facility staff failed to provide required resident rights training to two staff members, specifically a registered nurse and an operations staff member. During a review of education records, administrative staff indicated that they could not provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to her role, confirmed she was unaware of why the required trainings had not been completed in the past. She acknowledged that tracking and maintaining staff training is necessary to meet residents' needs and that managers are responsible for ensuring staff are properly trained. A review of the facility's policy on in-service training revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also states that each center is responsible for ensuring compliance with federal, state, and local regulations regarding staff education. No further information or documentation regarding the missing training was provided prior to the survey team's exit.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to RN
Penalty
Summary
Facility staff failed to provide required training in the prevention of resident abuse, neglect, and exploitation for one of ten staff records reviewed, specifically for a registered nurse. During the survey, the education records for this nurse were requested, but administrative staff indicated they might not be able to provide the information due to a recent sale of the facility and lack of access to old personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not speak to why the required trainings were not completed in the past. A review of the facility's policy on in-service training revealed that employees are to be provided training on required topics annually, with additional training as needed based on regulatory requirements and facility assessments. However, for the registered nurse in question, there was no documentation or evidence provided to show that the required training on abuse, neglect, and exploitation prevention had been completed, as required by federal, state, and local regulations.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
Facility staff failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to two staff members, a registered nurse and a dietary staff member, as identified through staff interviews and review of facility documents. When education records for these staff members were requested, administrative staff indicated that the facility's recent change in ownership and lack of access to previous personnel records prevented them from providing the required documentation. The assistant director of clinical services, who was new to the role, was unable to explain why the required trainings had not been completed in the past. A review of the facility's policy on in-service training revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also states that each center is responsible for ensuring compliance with federal, state, and local training regulations. No further information or documentation regarding the missing QAPI training was provided to the survey team prior to their exit.
Failure to Provide Required Infection Control Training to RN
Penalty
Summary
Facility staff failed to provide required infection control training for one of ten staff members reviewed, specifically a registered nurse. During the survey, the education records for this nurse were requested, but facility administrative staff indicated they could not provide the information due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she was unaware of why the required trainings had not been completed in the past. A review of the facility's in-service training policy revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. Despite this policy, the facility was unable to demonstrate that the required infection control training had been provided to the registered nurse in question, and no further documentation was made available to the survey team prior to their exit.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
Facility staff failed to provide required compliance and ethics training for one of ten staff members reviewed, specifically a registered nurse. During the survey, the nurse's education records were requested, but administrative staff indicated they might not be able to provide the information due to a recent sale of the facility and lack of access to old personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not speak to why the required trainings were not completed in the past. She stated that she would be responsible for staff training moving forward and acknowledged the importance of training in meeting residents' needs. A review of the facility's policy on in-service training indicated that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also stated that each center is responsible for ensuring compliance with federal, state, and local regulations regarding staff training. No further information or documentation regarding the missing training was provided prior to the survey exit.
Failure to Provide Required Annual Education for CNAs
Penalty
Summary
The facility failed to provide at least 12 hours of annual education to two certified nurse aides (CNAs) over the past 12 months, as required. When surveyors requested the education records for these CNAs, administrative staff, including the executive director and director of clinical services, indicated that they might not be able to provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not account for the missing education hours in the past. No further information or documentation was provided to the survey team prior to the exit interview.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
Facility staff failed to provide required behavioral health training for two staff members, a registered nurse and a dietary staff member, as identified through staff interviews and review of facility documents. When education records for these staff were requested, administrative staff indicated that the facility's recent change in ownership and lack of access to previous personnel records prevented them from providing the necessary documentation. The assistant director of clinical services, who was new to the role, acknowledged that she could not account for why the required trainings had not been completed in the past. The facility's policy on in-service training specifies that employees are to receive training on required topics annually, with additional training as determined by the facility assessment and regulatory requirements. Despite this policy, the facility was unable to demonstrate that the required behavioral health training had been provided to the identified staff members. No further information or documentation was provided to address the deficiency prior to the survey exit.
Unqualified Activities Director
Penalty
Summary
The facility staff failed to ensure that the activities program was directed by a qualified professional, potentially affecting all residents in the facility. The director of activities, who was hired on October 12, 2023, did not meet the qualifications required for the position at the time of hire. The employee record review revealed that the director, previously employed as a CNA and supply/transportation coordinator, only completed an activity management certification class from January 15, 2024, through January 19, 2024, and was not certified prior to this period. The job description for the director of activities required a Bachelor's Degree in therapeutic recreation or equivalent training/experience, NCCAP certification, and a minimum of two years of experience in therapeutic recreation. The facility's executive director and director of nursing were informed of the concern, but they could not provide evidence that the director of activities was qualified from the time of hire until the completion of the certification class. The facility policy outlined various responsibilities for the Community Life Director, including the management and coordination of recreational activities, but the director did not meet the qualifications during the initial period of employment.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility staff failed to investigate an allegation of abuse and report the findings to the State Agency for two residents involved in a physical altercation. The incident occurred on 7/28/23 between two residents, one of whom was cognitively impaired and the other cognitively intact. The facility submitted an initial report to the state agency but did not follow through with an investigation or provide a follow-up report. Nurse's notes documented the altercation and the residents' conditions, but no further investigation was conducted. During the survey, it was discovered that the investigation was not completed, and no documentation was available. The facility's policy required the Director of Nursing or designee to investigate all reported events, but this process was not followed. The Administrator acknowledged the oversight, attributing it to a transition period when a former Director of Nursing left, and admitted that the reporting process was not adhered to. The facility's policy on abuse, neglect, exploitation, and misappropriation was reviewed, highlighting the requirement for thorough investigation and reporting of such incidents.
Latest citations in Virginia
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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