Birchwood Park Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Virginia Beach, Virginia.
- Location
- 340 Lynn Shores Drive, Virginia Beach, Virginia 23452
- CMS Provider Number
- 495150
- Inspections on file
- 16
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Birchwood Park Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple medical conditions and no cognitive impairment reported feeling embarrassed and uncomfortable after a CNA expressed frustration about frequent incontinence care, sprayed air freshener, and sang during care. The resident and a family member described the CNA's behavior as rude and insensitive, and facility documentation confirmed these concerns.
Staff did not follow required abuse reporting procedures after a resident with multiple medical conditions reported upsetting conduct by a CNA during care. Although the incident was brought to the attention of facility leadership and the resident was interviewed, the allegation was not reported to state agencies as required by policy, and no further interviews with other residents were conducted.
A resident with multiple medical conditions reported to a mental health provider that a CNA was verbally dismissive and rough during care, prompting a family member to contact the facility. Although the concern was communicated to facility staff, the allegation was not reported to authorities within the required two-hour timeframe, as staff did not believe abuse had occurred, contrary to facility policy.
A resident with multiple health conditions reported that a CNA was rude and expressed frustration during care, and a family member alleged rough handling. The facility did not interview other residents or report the incident to authorities, instead addressing the issue as a grievance and counseling the CNA, contrary to its abuse investigation policy.
A resident with a history of stroke, hemiparesis, and dysphagia requiring enteral feedings did not receive the necessary oral care as outlined in their care plan. Observations showed the resident had significant dry and whitish mucus in the mouth and on the lips, causing discomfort and difficulty communicating, despite being cognitively intact and dependent on staff for daily oral hygiene.
Facility staff did not maintain ongoing records of communication with the dialysis center for two residents with end stage renal disease. For one resident, communication notes were missing for two dialysis dates, and for another, notes were absent for an entire week, despite care plans requiring coordination and documentation. Staff interviews confirmed the missing records and inability to locate them in either the communication book or electronic medical records.
A resident with a history of diabetes was admitted to a facility without diabetes listed as a diagnosis. Despite the resident's indications of being diabetic, the facility failed to follow up on ordered lab work, including an HgbA1C. This oversight resulted in the resident's hospitalization with a blood glucose level over 900, highlighting a breakdown in communication and follow-up procedures within the facility.
Two residents in an LTC facility experienced harm due to inadequate fall precautions and supervision. One resident, with a history of falls and cognitive impairment, sustained a fractured hip after falling from a wheelchair, with care plans not updated post-fall. Another resident suffered burns from hot coffee due to insufficient supervision in a communal area. The facility failed to adhere to protocols for fall prevention and environmental safety.
A resident with chronic pain conditions experienced inadequate pain management upon admission to an LTC facility. Despite reporting significant pain, there was a delay in administering Hydromorphone, and the resident did not receive her routine Morphine due to a pharmacy backorder. The resident was also given only half the prescribed dose of Gabapentin. The facility's care plan included pain management goals, but the resident's pain was not effectively controlled, impacting her ability to participate in care.
A resident was involuntarily secluded in a locked memory care unit despite being cognitively intact and able to make his own decisions. The move was made for staff convenience without proper criteria or policy. The resident's living conditions were substandard, with a dirty and unsafe environment, missing personal items, and insufficient food. The facility lacked adequate social work support and care planning, resulting in psychosocial harm to the resident.
The facility staff failed to prevent and treat avoidable pressure ulcers in two residents, resulting in harm. One resident developed a stage 3 sacral pressure ulcer due to inadequate care, including lack of nutrition, hydration, and pressure relief measures. The resident's room was found in a dirty and unsafe condition, and the resident was neglected. Another resident developed four pressure ulcers due to the facility's failure to conduct weekly skin assessments and implement preventive interventions. The care plan was not updated timely, and necessary repositioning devices and schedules were not provided.
The facility failed to provide an adequate activities program for residents, particularly in the memory care unit, due to insufficient staffing and assumptions about resident behavior. A resident expressed dissatisfaction with the lack of activities and poor living conditions, while another was found in unsanitary conditions without basic amenities. Additionally, activity assessments for two residents were not conducted timely, and their preferences were not incorporated into their care plans, leading to substandard care.
The facility's activities program was directed by an unqualified professional, leading to substandard care. The current Activities Director (AD) lacked the necessary certification and experience in a healthcare setting, as required by the facility's job description. Despite having a degree in gerontology and over 700 hours of experience, the AD had not completed the certification process through the National Certification Council for Activity Professionals (NCCAP). The Human Resource Director confirmed that all ADs employed since August 2023 were unqualified.
A resident was involuntarily moved to a locked memory care unit without a licensed social worker's involvement, despite being cognitively intact and able to make his own decisions. The facility lacked a full-time social worker for several months, impacting care planning and discharge processes. The resident expressed dissatisfaction with the living conditions and lack of personal items, while staff interviews revealed no clear policy for such moves.
A facility failed to maintain a qualified social worker, impacting resident care. A resident, cognitively intact and able to make decisions, was moved against his will to a locked memory care unit without social work services for discharge planning. The facility lacked policies for such moves, and the resident's autonomy was ignored, leading to involuntary seclusion.
The facility failed to implement an effective infection prevention and control program, with significant environmental concerns noted in the memory care unit. A resident expressed dissatisfaction with unsanitary conditions, which were confirmed by surveyors. Additional deficiencies included lack of soap and towels for hand hygiene in resident rooms, affecting the care of two residents. The facility's staff acknowledged the issues, but no further information was provided during the survey exit meeting.
The facility failed to maintain a safe, clean, and homelike environment across all nursing units, including the memory care unit. Residents reported unsanitary conditions, such as dirty and foul-smelling shower rooms, broken room fixtures, and a pervasive smell of urine and feces. One resident had bug-infested sandwiches in their room, and another experienced water-stained ceiling tiles and dim lighting. Staffing issues in maintenance and environmental services contributed to these deficiencies.
The facility failed to complete PASARR assessments for four residents prior to or shortly after admission. One resident with major depressive disorder and PTSD was admitted without a PASARR, and a subsequent attempt by a new, underqualified social worker was incomplete. Another resident with schizoaffective disorder and bipolar disorder also lacked a PASARR, as did a resident with a subarachnoid hemorrhage and bipolar disorder. A fourth resident with multiple diagnoses, including bipolar disorder and vascular dementia, was admitted without a PASARR. The facility's leadership was informed, but no corrective actions were provided.
The facility failed to update care plans for two residents, one after multiple falls and another after discontinuation of hospice services. Despite policies requiring updates, the care plans were not revised to reflect changes in the residents' conditions, as confirmed by staff interviews and documentation reviews.
The facility staff failed to provide adequate ADL care to four dependent residents, resulting in significant deficiencies in personal hygiene and living conditions. Two residents were found dirty and unkempt, with one resident's room having a pervasive odor of urine and feces. Another resident received improper peri care, compromising infection control, while a fourth resident had poor oral hygiene despite requiring regular care. These issues were observed and reported to the facility's administration, but no corrective actions were provided at the time of the survey exit.
A resident with end-stage renal disease experienced a fall during dialysis transport, leading to back pain and hospital evaluation. The facility failed to maintain communication records with the dialysis center, as noted in the resident's care plan. The Unit Manager acknowledged the issue, but facility leadership did not express concerns.
The facility staff failed to ensure pharmacy recommendations were obtained and acted upon for several residents. A resident on multiple medications did not have pharmacist recommendations acted upon for two months, and the DON was unaware of the review process. Another resident on dialysis also had unaddressed recommendations. Additionally, three residents lacked complete drug regimen reviews in their records. The facility policy requiring monthly reviews was not followed, and the Administrator was informed of these deficiencies.
The facility staff failed to properly label and store medications for three residents and facility stock multi-use vial medications. Medications for a resident were found opened without an open date, making it impossible to determine if they were expired. Similarly, for two residents, bottles of liquid Ativan and Morphine were found without an open date, despite being labeled to be discarded after 90 days. Additionally, a bottle of liquid Augmentin was found open and available for use, even though it should have been completed and disposed of after 7 days. The facility also failed to ensure that narcotic medications no longer in use were properly locked away, accounted for, and disposed of in a timely manner.
The facility's Memory Unit was found lacking necessary resources, with broken window blinds compromising privacy, and essential supplies like soap and towels missing. Observations revealed discolored floors, strong urine odors, and improperly hung curtains. Interviews with the Administrator and staff indicated routine facility rounds, but no comments were made on the findings.
The facility did not maintain an effective training program for all staff, as not all required training was completed according to the review of training transcripts. This issue was discussed with the Administrator, DON, and Staff Development Coordinator, who were informed of the concerns.
The facility failed to ensure that all direct care staff completed mandatory Effective Communication training. A review of training transcripts showed incomplete documentation of this training. The Staff Development Coordinator claimed that records were up to date, but the deficiency was identified and reported to the facility's leadership.
The facility failed to ensure all staff completed mandatory Resident Rights Training. A review of training transcripts showed incomplete training, despite the SDC's assertion that records were up to date. The Administrator, DON, and SDC were informed of these concerns.
The facility staff did not complete the required training for the Quality Assurance and Performance Improvement (QAPI) program. A review of training transcripts showed that not all staff had completed the necessary education, and this issue was discussed with the Administrator, DON, and Staff Development Coordinator.
The facility staff did not ensure that all staff members completed the required training on Compliance and Ethics. A review of training transcripts showed incomplete training, and this issue was discussed with the Administrator, DON, and Staff Development Coordinator.
The facility failed to ensure all CNAs completed the mandatory twelve hours of education annually, which is essential for addressing CNAs' weaknesses and residents' special needs. Some training transcripts were lost during a transition between training systems, and despite an ongoing plan for compliance, the deficiency was not resolved.
The facility did not ensure all staff completed mandatory Behavioral Health Training. A review of training transcripts showed incomplete training, and the Staff Development Coordinator confirmed the records were believed to be current. The issue was discussed with the Administrator, DON, and SDC.
The facility staff failed to address repeated grievances from the Resident Council, including issues with linens, laundry, and cleanliness, as well as concerns about nursing staff behavior and lack of administrative follow-up. Turnover in activity staff and the social worker contributed to delays in addressing these concerns.
The facility failed to develop and implement comprehensive care plans for residents, leading to significant deficiencies in care. One resident experienced severe weight loss, dehydration, and pressure sores without appropriate interventions. Another resident developed pressure sores due to a lack of preventive measures in their care plan. Additional issues included a resident's refusal to have bedding, which was not addressed in their care plan, and a lack of specific interventions for a Candida infection. The care plans were not individualized, lacking specific interventions and failing to guide staff in providing appropriate care.
A resident did not receive several prescribed medications due to unavailability, despite protocols for ensuring medication access. Interviews with staff confirmed that medications should have been available, but lapses in communication and procedure led to missed doses.
The facility failed to provide transportation for two residents to their medical appointments, resulting in multiple missed appointments. One resident with a complex medical history missed three appointments due to transportation issues, while another resident with dementia and heart disease missed at least four cardiology appointments. Despite staff efforts, transportation was not adequately arranged, and the facility administrator was informed of these issues.
A resident with end-stage renal disease and other conditions left the facility against medical advice without receiving necessary discharge information. Despite being cognitively intact and informed of the implications, the resident insisted on leaving immediately. The facility did not provide current medication orders or the hospital's discharge summary, potentially affecting continuity of care.
A resident was found with medications left at the bedside without a self-administration assessment. The resident, who had no cognitive impairment, had medications scheduled for bedtime left from the morning. Facility staff confirmed no residents were assessed for self-administration, violating the facility's medication policy.
A resident, who was cognitively intact and his own responsible party, was involuntarily transferred to a locked memory care unit for staff convenience, despite his refusal and lack of a dementia diagnosis. The facility cited an unfounded elopement risk, and the resident expressed dissatisfaction with the unit's conditions. The absence of a social worker and lack of clear policy for transfers contributed to the violation of the resident's rights.
A resident with cognitive impairment was discouraged by facility staff from speaking with a state surveyor, violating residents' rights. The resident, who wished to leave the Memory Care unit for outdoor activities, was told by an unnamed staff member not to talk to surveyors as it could cause trouble for the facility. The facility's administration acknowledged awareness of the rule against discouraging resident communication with surveyors.
A resident experienced significant weight loss due to the facility's failure to complete and submit a timely Comprehensive Admission MDS assessment. The resident, with multiple medical conditions, lost over 15% of their body weight since admission. The delay in MDS submission and inaccuracies in the assessment led to deficiencies in care planning, as noted during a survey.
The facility failed to complete accurate and timely MDS assessments for two residents, leading to deficiencies in care planning. One resident experienced significant weight loss that was not documented correctly, while another resident's significant change assessment was not completed within the required timeframe after hospice services were discontinued.
The facility failed to provide adequate hospice care for two residents, resulting in significant deficiencies. One resident experienced severe weight loss, dehydration, and developed a stage 3 pressure sore due to inadequate care and poor communication between facility and hospice staff. Another resident's hospice care documentation was not included in the clinical record, leading to a lack of awareness of the care provided. The facility demonstrated a lack of coordination and communication, resulting in inadequate care for residents receiving hospice services.
A resident with severe cognitive impairment did not receive the influenza vaccine despite consent being obtained, due to an oversight by the facility staff. The facility's policy requires annual vaccination, but the resident had not been vaccinated by December, as confirmed by the Infection Preventionist.
A resident with severe cognitive impairment did not receive the COVID-19 vaccine despite consent being obtained. The facility's policy requires documentation of immunization or reasons for not administering it. The Infection Preventionist acknowledged the oversight, and no further information was provided by the facility's leadership.
A resident with Schizoaffective Disorder and moderate cognitive impairment was not provided with quarterly financial statements, a right they are entitled to. The facility, acting as the Representative Payee, sent statements to the resident's Guardian Services but did not inform the resident to request them directly from the business office. This led to the deficiency being identified during a survey.
The facility staff failed to notify the physician about missed medication doses and unprovided wound care for two residents. One resident did not receive several doses of prescribed medications, and the physician was not informed. Another resident's wound care was not administered as ordered, leading to a worsening condition and emergency hospital transfer. The deficiency highlights a breakdown in communication and documentation processes.
Facility staff failed to maintain confidentiality of medical records for two residents when Point of Care Kiosks were left open and unattended, displaying personal information. One resident had no cognitive impairment and multiple diagnoses, while the other had severe cognitive impairment and resided on a different unit. The incidents were observed by surveyors and reported to the facility's administration.
A resident sustained burns from a coffee spill while using a communal microwave, which was not reported to the state agency as required. The resident, who was cognitively intact but had a history of unsteadiness and impulsiveness, was using a walker when the incident occurred. The facility's DON confirmed the incident was not reported, violating the facility's abuse policy.
A facility failed to notify the State LTC Ombudsman of a resident's discharge to the hospital. The resident, with Peripheral Vascular Disease and severely impaired cognitive abilities, was discharged with an anticipated return. The Social Services Worker did not send notifications due to the absence of a Social Worker, which was their responsibility. This deficiency was confirmed during an interview and shared with the facility's administration.
The facility failed to provide ordered wound care for a resident with calciphylaxis, leading to worsening conditions and eventual death. Medications were improperly left at the bedside for another resident, contrary to policy. Additionally, neuro-checks were not conducted after an unwitnessed fall, and vital signs were not obtained before transferring a resident to the hospital.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
Facility staff failed to ensure that a resident was treated with respect and dignity during activities of daily living (ADL) incontinence care. The resident, who had no cognitive impairment and multiple medical diagnoses including a right femur fracture, joint replacement aftercare, diabetes, and chronic kidney disease, reported to mental health services that a CNA expressed frustration about having to change him frequently due to loose bowel movements. The resident stated that the CNA told him she could not keep coming in to change him, which made him feel uncomfortable. Additionally, a family member reported that the CNA or nurse was rough during care and slammed items down, further upsetting the resident. Upon investigation, the CNA admitted to spraying air freshener in the room and singing while providing care, but denied being rude or slamming items. The CNA did not perceive her actions as unprofessional or disrespectful, despite the resident's feelings of embarrassment and discomfort. Facility documentation, including a grievance form and counseling record, confirmed the resident and his daughter reported the CNA's behavior as rude and insensitive, specifically mentioning the use of air freshener and mumbling during care. The facility's policy defines verbal and mental abuse to include actions that humiliate or use disparaging terms, which were relevant to the resident's experience.
Failure to Report Alleged Abuse According to Policy
Penalty
Summary
Facility staff failed to implement the abuse reporting policy for one resident who reported concerns about the conduct of a CNA during care. The resident, who had no cognitive impairment and multiple medical diagnoses including a recent femur fracture, diabetes, and chronic kidney disease, reported to a mental health provider that a CNA expressed frustration about having to change him frequently and made statements indicating reluctance to provide care. The resident denied physical abuse or injury but reported the incident as upsetting. Additionally, a family member emailed the facility's social worker stating that the resident was upset and described a CNA or nurse as being rough and slamming items while providing care after a bowel movement. Upon receiving the family member's email, the social worker and unit manager interviewed the resident, who did not claim to be abused. However, the facility did not interview other residents cared for by the CNA in question. The administrator acknowledged that, according to both the State Operations Manual and facility policy, all allegations of abuse should be reported immediately, but no later than two hours after the allegation is made. In this case, the allegation was not reported to the required agencies because staff determined that abuse had not occurred, which was not in accordance with established reporting guidelines.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident within the required timeframe. The resident, who had multiple medical conditions including a right femur fracture, joint replacement aftercare, diabetes, and no cognitive impairment, reported to a mental health provider that a CNA expressed frustration about having to change him frequently due to loose stools. The resident stated that the CNA told him she could not keep coming in to change him, but denied any physical abuse or injuries. The allegation was communicated to the unit manager, but there was no documentation that it was reported to the appropriate authorities within two hours as required by facility policy and federal regulations. Further review revealed that a family member had emailed the social worker about the resident being upset and described a staff member being rough and slamming items while providing care. The social worker and unit manager interviewed the resident, who did not claim to be abused, and no other residents cared for by the CNA were interviewed. The administrator confirmed that the allegation was not reported to authorities because staff did not believe abuse had occurred, despite facility policy requiring immediate reporting of all allegations. The facility's policy clearly outlines the need to report all alleged violations to the administrator and state agencies within two hours if abuse is involved.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of abuse and neglect for one resident. The resident, who had multiple medical conditions including a recent femur fracture, diabetes, and chronic kidney disease, reported to a mental health provider that a CNA expressed frustration about having to change him frequently due to loose stools. The resident denied physical abuse or injury but described the CNA as having an attitude and being rude. Additionally, a family member reported that the CNA or nurse was rough while cleaning the resident and slammed items down. The social worker and unit manager interviewed the resident, who did not claim abuse but complained about the CNA spraying air freshener and mumbling. No other residents cared for by the CNA were interviewed. The administrator stated that the incident was not reported to authorities because staff did not believe abuse had occurred. Instead, a grievance form was completed, and the CNA was counseled for unprofessional behavior. The facility's policy defines verbal and mental abuse, but the investigation did not include interviews with other residents or reporting to external agencies. The documentation shows that the facility did not follow its own procedures for thoroughly investigating and reporting abuse allegations.
Failure to Provide Oral Care to Dependent Resident Receiving Enteral Feedings
Penalty
Summary
Facility staff failed to provide necessary oral care to a dependent resident who was receiving enteral feedings. The resident, who had a history of stroke with hemiparesis and dysphagia resulting in pulmonary aspiration, was assessed as cognitively intact and required assistance with activities of daily living, including oral hygiene. The resident's care plan specified an oral care routine to be performed multiple times daily, including brushing teeth, rinsing dentures, cleaning gums with a toothette, and rinsing the mouth. Despite these documented needs and interventions, observations revealed that the resident's oral cavity and lips were covered with dry, stringy, and whitish mucus on multiple occasions, making it difficult for the resident to open and close his mouth and causing discomfort. The resident attempted to communicate his needs but had difficulty due to his speech impairment and the poor condition of his oral cavity. Staff interviews and clinical record reviews confirmed that the required oral care was not consistently provided as outlined in the care plan.
Failure to Maintain Ongoing Dialysis Communication Records
Penalty
Summary
Facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for two residents requiring dialysis services. For one resident with end stage renal disease, there were no communication notes from the dialysis center for two specific dates, despite the resident attending dialysis on one of those days and missing the other due to a dermatology appointment. The resident's care plan included coordination with dialysis as needed but did not specify ongoing communication, coordination, or collaboration between the facility and the dialysis center. Staff interviews confirmed the absence of communication notes and the inability to locate them in the communication book or electronic records. For another resident with end stage renal disease receiving in-house dialysis, there were no communication notes from the dialysis center for the last week of February. The resident reported receiving dialysis services Monday through Friday and carrying the communication book to and from dialysis. The care plan required that the dialysis communication record be sent and returned with each appointment, but staff confirmed the absence of notes for the specified period, attributing it to the need for uploading into the electronic medical records. No further information or comments were provided by facility leadership during the final interview.
Failure to Follow Up on Lab Results Leads to Resident Harm
Penalty
Summary
The facility staff failed to ensure that a resident received appropriate follow-up on lab work, which resulted in harm. The resident, who had a history of diabetes, was admitted to the facility with several diagnoses, including end-stage renal disease and myocardial infarction. Despite the resident's repeated indications of being diabetic and insulin-dependent, there were discrepancies in the discharge orders from the hospital, and diabetes was not listed as a diagnosis. The Nurse Practitioner ordered labs, including an HgbA1C, but the results were not followed up on, leading to the resident's hospitalization with a blood glucose level over 900. The clinical record review revealed that the resident's discharge paperwork from the hospital did not list diabetes as a diagnosis, although the resident had been diabetic since 2008. The resident communicated to the facility staff about his diabetic condition and the medications he was taking. However, the facility failed to obtain and review the necessary lab results from the dialysis center, which were critical in managing the resident's diabetes. The lack of follow-up on the abnormal A1C lab results contributed to the resident's deteriorating condition. Interviews with the facility's Director of Nursing and the Nurse Practitioner highlighted a breakdown in communication and follow-up procedures. The DON stated that the nurses usually notify the physician or NP of abnormal lab results, but in this case, the results were not received from the dialysis center. The NP confirmed that they had access to the hospital's electronic health records but could not find the A1C lab results. This oversight led to the resident being sent to the ER unresponsive, where he was diagnosed with a hyperosmolar hyperglycemic state and did not return to the facility after his hospital stay.
Failure to Implement Fall Precautions and Supervision Leads to Resident Harm
Penalty
Summary
The facility staff failed to implement adequate fall precautions for a resident identified as a high fall risk, resulting in harm. Resident #78, who had a history of repeated falls and severe cognitive impairment, sustained a fractured hip after falling from her wheelchair. Despite being identified as a high fall risk upon admission, the resident experienced multiple falls over several months, with the care plan not being updated or revised after a significant fall with major injury. The facility's fall policy, which requires assessment, documentation, and care plan updates after a fall, was not consistently followed, as confirmed by the Unit Manager. In another incident, the facility staff failed to provide adequate supervision and implement interventions to reduce environmental hazards, resulting in a resident being burned. Resident #56, who had intact cognitive abilities but was noted for impulsiveness and unsteadiness, suffered burns after spilling hot coffee on herself while using a communal microwave. The microwave, located in a communal dining room, was removed after the incident, but the facility did not provide adequate supervision or assess the potential hazards of allowing residents to use it unsupervised. Both incidents highlight a failure to adhere to established protocols and provide necessary supervision and interventions to prevent accidents and injuries. The facility's lack of timely updates to care plans and inadequate supervision in communal areas contributed to the harm experienced by the residents. Interviews with staff and reviews of facility documentation revealed gaps in the implementation of safety measures and post-incident procedures.
Inadequate Pain Management for Resident
Penalty
Summary
The facility staff failed to manage pain effectively for a resident, resulting in harm. The resident, who was admitted after an acute care hospital stay, had a history of chronic pain conditions including migraines, fibromyalgia, and chronic back and neck pain. Upon admission, the resident reported significant pain and requested medication to prevent it from becoming severe. However, there was a delay of 2-3 hours before the resident received Hydromorphone, and the resident did not receive her routine Morphine the night of admission or the following day. The resident's pain management was further compromised as she was only given half the prescribed dose of Gabapentin and did not receive the Morphine tablets she was accustomed to, due to a backorder from the pharmacy. Instead, Morphine Concentrate was ordered to start two days after admission. The resident expressed that the initial doses of liquid Morphine did not provide the same relief as the tablets, and she experienced debilitating pain that affected her ability to participate in care or eat. The facility's care plan for the resident included goals for pain management and interventions such as medicating as ordered and obtaining pain ratings. However, the Medication Administration Record showed that the resident did not receive any pain medication upon arrival, and the Hydromorphone was only administered once during her stay. Interviews with facility staff, including the Unit Manager, acknowledged that the pain management could have been handled better, but no concerns were voiced by the facility's administration and corporate consultants regarding the findings.
Involuntary Seclusion and Substandard Living Conditions
Penalty
Summary
The facility staff involuntarily secluded a resident, identified as Resident #226, in a locked memory care unit despite the resident's refusal and lack of criteria for such a move. The resident, who was cognitively intact and able to make his own decisions, was moved against his will for staff convenience, as there was no policy or procedure guiding such a decision. The resident's request to stay in his current room and plan for discharge was ignored, and the move was justified by staff as an elopement risk, although the resident had never eloped and had only sat outside once after dialysis. The resident's living conditions in the memory care unit were substandard, with a dirty and unsafe environment, including a mildewed shower room, a cold room with a broken heating unit, and missing personal items. The resident's room lacked basic amenities such as a television, clock, or telephone, and the resident was unable to bathe in a clean environment. The resident's roommate was disruptive, calling out all night for water, and the resident reported insufficient food, keeping a jar of peanut butter and bread by his bed to compensate for missed meals. The facility lacked a social worker for a significant period, and the newly hired social worker was not adequately qualified. There was no evidence of care planning or discharge planning for the resident, and the facility failed to notify the physician of the resident's request to discharge. The facility's failure to provide adequate social work support and care planning resulted in the resident's involuntary seclusion and psychosocial harm.
Failure to Prevent and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility staff failed to prevent, assess, and treat avoidable pressure ulcers for two residents, resulting in harm. For one resident, the staff did not identify an avoidable sacral pressure ulcer until it became a stage 3 full-thickness ulcer with 80% slough. The resident also suffered from significant weight loss, malnutrition, and dehydration, which were not adequately addressed. The resident was not provided with timely ADL care, preventative skin care, or pressure reduction devices, and was not assisted out of bed during the entire two-week survey period. The resident's room was found to be in a dirty and unsafe condition, and the resident was observed to be in a state of neglect, with inadequate hydration and nutrition. The resident had a history of multiple hospitalizations for serious conditions, including a colonic hemorrhage and a severe urinary tract infection causing sepsis. Despite these conditions, the facility failed to implement necessary interventions to prevent further deterioration, such as providing adequate nutrition, hydration, and pressure relief measures. The facility's documentation was inconsistent and incomplete, with missing or incorrect entries in the Minimum Data Set assessments and a lack of communication between facility staff and hospice care providers. For the second resident, the facility staff failed to conduct weekly skin assessments and implement interventions to prevent the development of pressure injuries. This resulted in the resident developing four pressure ulcers. The care plan was not updated in a timely manner following the discovery of the pressure areas, and there was no evidence of repositioning devices, booties, air mattresses, or specific turning and repositioning schedules being implemented to aid in the healing of the pressure wounds. The facility's policy on pressure injury prevention and management was not followed, leading to the development of these avoidable pressure injuries.
Deficient Activities Program in Memory Care Unit
Penalty
Summary
The facility failed to maintain an activities program that met the needs and preferences of residents, particularly affecting the entire locked memory care unit and four individual residents. The survey revealed that from the commencement of the survey until its conclusion, the memory care unit lacked televisions and any form of activities, with some activity planning only occurring just before the survey exit. This lack of engagement was attributed to the facility having only one activity person for the entire 150-bed facility, and assumptions that residents would damage televisions if provided. Resident #226, who was cognitively intact and able to make his own decisions, expressed dissatisfaction with being placed in the memory care unit, citing issues such as lack of activities, poor living conditions, and inadequate personal care. His room, shared with Resident #117, was found to be in a state of disrepair, with broken furniture, unsanitary conditions, and a lack of basic amenities such as a television, clock, or personal items. Resident #117, who had dementia and other health issues, was observed to be in bed without adequate clothing or hydration, further highlighting the neglect in care and engagement. Additionally, the facility failed to conduct timely activity assessments for Residents #77 and #105, and their preferences were not incorporated into their person-centered care plans. Resident #77, who had moderate cognitive impairment, expressed a preference for music and other activities that were not reflected in her care plan. Similarly, Resident #105, with severe cognitive impairment, had activity interventions that were not aligned with his needs or abilities. These deficiencies in activity programming and care planning contributed to a substandard quality of care for the residents involved.
Unqualified Activities Director Leads to Substandard Care
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, resulting in substandard quality of care. During a recertification survey, it was found that the current Activities Director (AD) had been employed since July 2024 and had previous experience in an assisted living community, which is not classified as a healthcare setting. The AD expressed a desire to become an Activities Director Certified but was not yet certified. She had a degree in gerontology and over 700 hours of experience in an activities program but had not completed the necessary certification process through the National Certification Council for Activity Professionals (NCCAP). The facility's job description for the Activities Director required specific qualifications, including certification as a therapeutic recreation specialist or a Certified Activity Director, or relevant experience in a healthcare setting. However, the current AD and her assistants did not meet these qualifications. The Human Resource Director confirmed that all ADs employed from August 2023 to December 2024 were unqualified based on the facility's job description. Despite the AD's experience and efforts to obtain certification, the facility did not comply with the regulatory requirements for the qualifications of an Activities Director.
Failure to Employ Licensed Social Worker and Involuntary Seclusion of Resident
Penalty
Summary
The facility failed to employ a full-time licensed or certified social worker, impacting the care of all residents, including Resident #226. Resident #226, who was cognitively intact and his own responsible party, was moved against his will to a locked memory care unit without the involvement of a social worker to plan his care and discharge. The facility staff did not honor his request to stay in his current room or plan for his discharge back to the community or an assisted living facility. The move was justified by the staff as a precaution against elopement risk, despite the resident having no history of elopement and being able to make his own decisions. Resident #226, who had diagnoses including end-stage renal disease, stroke history, and diabetes, expressed dissatisfaction with the memory care unit, citing a lack of personal items, inadequate clothing, and poor living conditions. He reported that his requests for discharge planning were ignored, and he was involuntarily secluded in the memory care unit. The facility's lack of a social worker from June 28 to November 19, 2024, further compounded the issue, as the newly hired social worker was not familiar with the resident's case and did not document his desire for discharge. Interviews with facility staff revealed a lack of clear policy or procedural guidance for moving residents to the memory care unit. The Director of Nursing and Administrator could not provide a pathway for such decisions, and there was no evidence in the clinical record that the resident's physician was notified of the move or his discharge wishes. The facility's failure to provide adequate social work services and respect the resident's rights resulted in involuntary seclusion and a deficiency in care.
Failure to Maintain Qualified Social Worker and Resident Rights
Penalty
Summary
The facility failed to maintain a qualified full-time social worker in a 220-bed facility, resulting in a substandard level of care impacting all residents, including one specific resident in the survey sample. The deficiency was highlighted by the case of a resident who was moved against his will to a locked memory care unit, despite being cognitively intact and able to make his own decisions. The resident had requested to stay in his current room and plan for discharge, but his requests were ignored, and he was not provided with the services of a social worker to assist with care and discharge planning. The resident, who had no diagnosis of dementia, was moved to the memory care unit due to an alleged elopement risk, although he had never eloped and had only gone outside once to sit in the sun. The facility staff failed to honor the resident's autonomy and did not involve a social worker in the decision-making process. The resident expressed dissatisfaction with the conditions in the memory care unit, citing a lack of personal items, activities, and basic amenities, which contributed to his distress. The facility had been without a social worker from late June until mid-November, and the newly hired social worker was not adequately qualified according to state and federal regulations. The facility lacked policies or procedural guidance for moving residents to the memory care unit, and there was no evidence of physician involvement in the decision to move the resident. The deficiency was further compounded by the lack of social work services during the resident's stay, leading to the withholding of the resident's rights and involuntary seclusion.
Inadequate Infection Control and Environmental Concerns in Memory Care Unit
Penalty
Summary
The facility staff failed to implement an effective infection prevention and control program across all four nursing units, including the locked memory care unit. The survey revealed significant environmental concerns, such as dirty and disrepaired conditions, bodily fluids on surfaces, and the absence of soap and paper towels for handwashing in resident rooms. These deficiencies were observed in the direct care of four residents, including Resident #226 and Resident #117, who shared a room in the memory care unit. The unit was found to be unsanitary, with pervasive odors of urine and feces, and lacked basic amenities like televisions and personal items. Resident #226, who was cognitively intact and capable of making his own decisions, expressed dissatisfaction with the living conditions, citing issues such as wandering residents, lack of food, and unsanitary shower facilities. The surveyor's observations confirmed the resident's complaints, noting a dirty and foul-smelling shower room, broken and disintegrating furniture, and a lack of basic hygiene supplies. The facility's maintenance and environmental services departments were understaffed, contributing to the inadequate cleaning and maintenance of the units. Additional deficiencies were noted in the care of Resident #105 and Resident #87. Resident #105's room lacked soap and towels, preventing proper hand hygiene before and after meals. Similarly, Resident #87's care was compromised when a CNA was observed washing her hands without soap and using wet hands to don gloves before providing a bed bath. The facility's staff acknowledged the lack of soap and paper towels, which hindered their ability to maintain proper hygiene standards. Despite these findings, the facility's administrative staff did not provide any additional information or comments during the survey exit meeting.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across all four nursing units, including the locked memory care unit. This deficiency was evident in the conditions experienced by several residents. For instance, two residents in the memory care unit reported unsanitary conditions, including a dirty and foul-smelling shower room, broken and unsafe room fixtures, and a pervasive smell of urine and feces. The residents also lacked basic amenities such as a television, clock, or personal items, and one resident was observed without adequate clothing or bedding. Another resident on Unit 1 was found to have sandwiches infested with bugs, stored on a light fixture above the bed. The room was cluttered, and the resident was observed lying on an uncovered vinyl mattress without sheets or bedding. Despite the resident's preference for not having sheets due to heat, there was no documentation of this refusal, and the presence of bugs was acknowledged as unacceptable by the facility administrator. Additional observations included water-stained ceiling tiles, dim lighting, and unclean floors in another resident's room, as well as a lack of towels and washcloths due to laundry issues. The facility's environmental quality policy was not adhered to, as evidenced by the presence of soiled linens on floors, dirty shower rooms, and strong odors in hallways. The facility's staffing issues in maintenance and environmental services contributed to these deficiencies, with insufficient personnel to adequately clean and maintain the facility.
Failure to Complete PASARR Assessments for Residents
Penalty
Summary
The facility staff failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission or shortly thereafter for four residents. Resident #49 was admitted with diagnoses including major depressive disorder with psychotic symptoms, anxiety disorder, and PTSD. Despite being on psychotropic medications, no PASARR was completed prior to admission, and the subsequent attempt by a newly hired social worker was incomplete and contained errors. The facility lacked a social worker for several months, and the new social worker did not meet the required qualifications. Resident #24, who was admitted and later readmitted after a hospital stay, had diagnoses of schizoaffective disorder and bipolar disorder. The resident's cognitive abilities were assessed as intact, yet no PASARR assessment was completed. The Social Services Director acknowledged the oversight and stated that a PASARR would be completed. Similarly, Resident #47, admitted with a subarachnoid hemorrhage and bipolar disorder, was not screened through the PASARR process. The resident's cognitive abilities were severely impaired, and the necessary Level 1 screening was missing from the clinical record. Resident #80, admitted with multiple diagnoses including bipolar disorder and vascular dementia, also did not have a PASARR Level 1 completed prior to admission. The resident was on psychotropic medications, and the social worker admitted awareness of the requirement for PASARRs to be completed prior to admission. The Director of Nursing and Administrator were aware of the requirement but failed to ensure compliance. The deficiencies were communicated to the facility's leadership, but no additional information or corrective actions were provided at the time of the report.
Failure to Update Care Plans After Falls and Hospice Discontinuation
Penalty
Summary
The facility staff failed to review and revise the care plan for two residents, leading to deficiencies in their care. For one resident, the care plan was not updated after multiple falls, despite the facility's policy requiring such updates. The resident, who had a history of falls and cognitive impairment, experienced six falls over several months. The care plan was only revised after one of these falls, failing to include new interventions for the other incidents. This oversight was confirmed by a Unit Manager, who acknowledged that the care plan should have been updated after each fall. Another resident's care plan was not revised after hospice services were discontinued. The resident, who had severe cognitive impairment, was initially placed on hospice care, which was later discontinued due to an extended prognosis. Despite this change, the care plan continued to reference hospice care, indicating a failure to update the plan to reflect the resident's current status. This discrepancy was noted during a review of the care plan, which still included interventions related to hospice care. The facility's failure to update care plans as required by their policies was confirmed through interviews and documentation reviews. The facility's fall policy clearly outlines the steps to be taken after a fall, including updating the care plan, which was not consistently followed. Similarly, the care plan for the resident who discontinued hospice services was not revised to reflect the change in care needs, highlighting a lapse in the facility's adherence to care planning protocols.
Deficiencies in ADL Care and Hygiene in LTC Facility
Penalty
Summary
The facility staff failed to provide adequate Activities of Daily Living (ADL) care to four dependent residents, resulting in significant deficiencies in personal hygiene and living conditions. Resident #226, who was cognitively intact, was found dirty and unkempt, with food debris on his clothing and greasy hair. His room, shared with Resident #117, had a pervasive odor of urine and feces, and the shower room was in a deplorable state, discouraging its use. Despite being aware of these conditions, staff attributed the lack of care to residents' refusals and did not ensure alternative solutions were provided. Resident #117, who had dementia and was on hospice care, was found unclothed and unkempt, with soiled linens and a strong odor of urine. The resident was observed to be consistently in bed, asking for water, and exhibiting signs of dehydration with cracked and dry lips. Despite documentation indicating daily baths, the resident remained in a state of neglect throughout the survey period, highlighting a discrepancy between recorded care and actual care provided. Additionally, Resident #18, who was dependent on staff for ADL care, received improper peri care from a CNA, who used a soiled washcloth in the rinse water, compromising infection control. Resident #48, who required enteral feedings, was observed with poor oral hygiene, having a mouth full of dry mucus and dry lips, despite the care plan specifying regular oral care. These findings were shared with the facility's administration, but no additional information or corrective actions were provided at the time of the survey exit.
Lack of Communication Between Facility and Dialysis Center
Penalty
Summary
The facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for a resident with end-stage renal disease requiring dialysis. The resident, who was cognitively intact, reported experiencing back pain after being dropped by dialysis transport personnel during a transfer. The resident informed the facility nurse upon return, and was subsequently transferred to the hospital for evaluation. However, a review of the resident's dialysis communication book revealed no communication notes from either the dialysis center or the facility. The resident's person-centered care plan included a goal to prevent complications from dialysis but did not address the need for ongoing communication and coordination with the dialysis center. The Unit 4 Manager acknowledged the absence of communication notes and indicated that the facility was not consistently receiving forms back from the dialysis center. Despite the deficiency, the facility's leadership, including the Administrator and Director of Nursing, did not express concerns regarding the findings.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility staff failed to ensure that pharmacy recommendations were obtained and acted upon for five residents in the survey sample. For Resident #117, the pharmacist's recommendations were not obtained or acted upon in two of the preceding three months. The resident was on multiple medications, including anticoagulants and psychotropic medication, and had a history of kidney disease and congestive heart failure. The Director of Nursing (DON) was unaware of the percentage of residents reviewed monthly and how irregularities were communicated to staff. It was revealed that not all residents were reviewed monthly, and the physician had not been notified of recommendations, which were not printed from the system. Resident #226 also had pharmacist recommendations that were not acted upon in two of the preceding three months. The resident was receiving medications for conditions such as kidney disease and was on dialysis. Similar to Resident #117, the DON was unsure of the review process, and it was found that the physician had not been informed of the recommendations. The facility policy required monthly reviews to be documented and available for review, but this was not adhered to. Additionally, Residents #51, #33, and #78 did not have complete drug regimen reviews in their clinical records for various months. The DON was unable to provide a complete set of pharmacy reviews for these residents, indicating a lack of adherence to the facility's policy of monthly reviews. The Administrator was informed of these deficiencies, but no further information was provided to address the missing evaluations and documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility staff failed to properly label and store medications for three residents and facility stock multi-use vial medications. For Resident #8, two bottles of liquid Ativan were found opened without an open date, making it impossible to determine if they were expired. The facility policy requires labeling the bottle with the open date to ensure timely disposal. Similarly, for Resident #74, two bottles of liquid Ativan and one bottle of liquid Morphine were found without an open date, despite being labeled to be discarded after 90 days. The facility policy was not followed, as the medications were available for administration without proper labeling. For Resident #103, a bottle of liquid Augmentin was found open and available for use, even though it should have been completed and disposed of after 7 days. The label clearly stated the disposal timeframe, but the medication was still available for administration. Additionally, two house stock vials of Tubersol were incorrectly labeled and stored, open and available for use without an open date. The facility policy requires multi-use vials to be dated and discarded within 28 days unless specified otherwise by the manufacturer. The facility also failed to ensure that narcotic medications no longer in use were properly locked away, accounted for, and disposed of in a timely manner. During an inspection, a large number of medications, including controlled substances, were found unsecured in an unlocked cart. The Unit Manager and DON confirmed that this was not acceptable practice, as narcotic medications should be stored behind two locks. The cart contained several controlled substances without count sheets, indicating a lack of proper record-keeping and reconciliation as required by the facility's policy.
Resource Deficiency in Memory Unit
Penalty
Summary
The facility staff failed to ensure that necessary resources were available to meet the needs of residents in the Memory Unit. Observations made from December 10 to December 13, 2024, revealed that most windows in the unit had broken blinds, which were unsightly and compromised privacy by allowing residents and staff to be viewed. Additionally, there was a lack of essential supplies such as soap, paper towels, and window coverings, contributing to an environment that was neither clean nor homelike. The floors in multiple resident rooms were discolored, dirty, and had molding pulling away from the walls. Several rooms lacked blinds or had severely damaged window coverings, allowing direct visibility from the activity room into the residents' rooms. Further observations on December 12, 2024, indicated that residents in several rooms did not have access to soap and towels at their sinks, and there was a strong odor of urine upon entering the unit. Curtains in one room were improperly hung using zip ties instead of a curtain rod, and sinks in several rooms were severely warped. Additionally, a receptacle box was pulling away from the wall at the head of the bed in one room, and the heating unit receptacle box was damaged. During interviews with the Administrator and other staff, it was noted that facility rounds were routinely performed, but no comments were made regarding the findings when they were presented to the administrative staff.
Failure to Maintain Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members. A review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts revealed that not all facility staff had completed the required training. This deficiency was identified during a final interview with the Administrator, Director of Nursing, and the Staff Development Coordinator, who were made aware of the concerns. No additional information was provided by the facility to address these findings.
Failure to Complete Mandatory Effective Communication Training
Penalty
Summary
The facility failed to ensure that all direct care staff completed mandatory Effective Communication training. A review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts revealed that not all direct care staff had documented completion of this required training. During an interview, the Staff Development Coordinator (SDC) stated that training and education records were maintained by SNF Clinic and Healthcare Academy and asserted that the files were correct and up to date. However, the deficiency was identified, and the Administrator, Director of Nursing, and SDC were informed of the issue during an end-of-day meeting.
Deficiency in Staff Education on Resident Rights
Penalty
Summary
The facility failed to ensure that all staff members were educated on the rights of the residents and the responsibilities of the facility. A review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts revealed that not all staff had completed the mandatory Resident Rights Training. During an interview, the Staff Development Coordinator (SDC) stated that the training and education records were maintained by SNF Clinic and Healthcare Academy and were up to date. However, the survey findings indicated otherwise, as not all staff had completed the required training. The Administrator, Director of Nursing, and Staff Development Coordinator were informed of these concerns during an end-of-day meeting.
Incomplete QAPI Training for Facility Staff
Penalty
Summary
The facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement (QAPI) program. A review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts revealed that not all facility staff had completed the required training for QAPI. This deficiency was identified during a final interview with the Administrator, Director of Nursing, and the Staff Development Coordinator, who were made aware of the concerns.
Failure to Ensure Staff Compliance and Ethics Training
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on Compliance and Ethics. A review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts revealed that not all facility staff had completed the required training for Compliance and Ethics. This deficiency was identified during a final interview with the Administrator, Director of Nursing, and the Staff Development Coordinator, who were made aware of the concerns. No additional information was provided to address the deficiency.
Deficiency in CNA Mandatory Training Compliance
Penalty
Summary
The facility staff failed to ensure that all Certified Nurse's Aides (CNAs) completed the mandatory twelve hours of education each year. This education is crucial as it addresses each CNA's areas of weakness as determined in their performance reviews, the facility assessment, and the special needs of residents. A review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts revealed that not all CNAs had completed the required training. During an interview, the Staff Development Coordinator (SDC) acknowledged that while most CNAs had completed their training, some transcripts were lost during the transition from Healthcare Academy to SNF Clinic. Despite an ongoing plan to ensure compliance, the deficiency remained unaddressed at the time of the survey.
Incomplete Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that all staff members completed the mandatory Behavioral Health Training as required. This deficiency was identified through a review of the Staff Education, SNF Clinic, and Healthcare Academy training transcripts, which revealed that not all staff had completed the necessary training. An interview with the Staff Development Coordinator confirmed that the training records were maintained by SNF Clinic and Healthcare Academy and were believed to be up to date. However, the discrepancy in training completion was brought to the attention of the Administrator, Director of Nursing, and Staff Development Coordinator during an end-of-day meeting.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility staff failed to promptly address the grievances and recommendations of the Resident Council, as evidenced by repeated complaints documented in the Resident Council minutes. Issues such as the need for more linens, long turnaround times for laundry, and missing personal items were consistently raised over several months. Additionally, concerns about the cleanliness of bathrooms and the absence of clocks in common areas were noted. Despite these issues being brought up in meetings on multiple occasions, the facility did not take timely action to resolve them. Further concerns were raised about the behavior of the nursing staff, including making residents feel like they are in the way, not administering medications during the night shift, and using cell phones while on duty. There were also complaints about staff discussing residents in common areas where others could overhear. The Resident Council expressed dissatisfaction with the administration's lack of follow-up on grievances. An interview with a facility employee indicated that turnover in activity staff and the social worker contributed to delays in addressing these concerns. The administrator was informed of these issues during an end-of-day meeting, but no further information was provided.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement a comprehensive care plan for several residents, leading to significant deficiencies in care. For one resident, the staff did not address significant weight loss, dehydration, pressure sores, and the provision of ADL care. The resident experienced a colonic hemorrhage and a severe urinary tract infection, resulting in hospitalizations. Despite these events, the care plan did not include necessary interventions such as diet changes, supplements, or repositioning to prevent further deterioration. The resident was observed in unsanitary conditions, with inadequate hydration and nutrition, and no effective communication between facility and hospice staff. Another resident was admitted with multiple diagnoses and was dependent on staff for all aspects of ADL care. The care plan did not include interventions for pressure ulcer prevention until after the resident developed pressure sores. The DON acknowledged that the care plan should have included pressure ulcer prevention for non-ambulatory residents, but this was not done in this case. Additional deficiencies were noted for two other residents. One resident's care plan did not address their refusal to allow bedding on the bed, despite the resident's clear preference and the potential impact on their comfort and care. Another resident's care plan failed to specify the location of a Candida infection or provide specific interventions to address the severe itching and irritation experienced by the resident. The care plans appeared to be generic and not tailored to the individual needs of the residents, lacking specific interventions and failing to guide staff in providing appropriate care.
Medication Availability Deficiency for Resident
Penalty
Summary
The facility staff failed to ensure that medications were acquired and available for Resident #327, leading to several missed doses. Resident #327, who was admitted with multiple diagnoses including asthma, emphysema, seizure disorder, and chronic anxiety, did not receive prescribed medications such as Topiramate, Adderall XR, Lidocaine, and Savella at various times in August 2023. The clinical record review revealed that these medications were not available for administration as ordered by the physician, and there was no documentation of the facility taking appropriate steps to ensure their availability. Interviews with facility staff, including an LPN, the Director of Nursing, and the Regional Nurse Consultant, confirmed that the medications should have been available and that the pharmacy was expected to deliver medications twice daily. The staff acknowledged that the nurses were responsible for checking the in-house Stat box (Cubex) and notifying the pharmacy and physician if medications were unavailable. Despite these protocols, the medications were not administered as required, indicating a lapse in the facility's pharmaceutical services.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility staff failed to ensure transportation for two residents to their outside medical appointments, resulting in multiple missed appointments. Resident #378, who had a complex medical history including encephalopathy, type 2 diabetes, and a surgical amputation, missed three appointments with an orthotic and prosthetic service due to transportation issues. The appointments were rescheduled multiple times, but the resident was unable to attend any of them before being admitted to the hospital for encephalopathy and a urinary tract infection. Resident #381, diagnosed with unspecified dementia, hypertension, and atherosclerotic heart disease, missed at least four cardiology appointments. The progress notes indicate that transportation issues were a recurring problem, with appointments being canceled or rescheduled due to the unavailability of transportation. Despite efforts to confirm transportation and family involvement, the resident's appointments were not attended as planned. Interviews with facility staff, including an LPN and the DON, revealed that the responsibility for scheduling appointments and transportation had shifted from unit managers to the social worker. However, the staff's efforts to ensure transportation were insufficient, leading to the residents missing critical medical appointments. The facility administrator was informed of these issues, but no further information was provided regarding corrective actions.
Failure to Provide Discharge Information for Resident Leaving AMA
Penalty
Summary
The facility staff failed to provide a resident with necessary discharge information at the time of a planned discharge. Resident #278, who had diagnoses including end-stage renal disease with dialysis, diabetes, and infected left hip hardware, left the facility against medical advice. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). On the day before discharge, the resident expressed a desire to leave immediately, and despite being informed that leaving would be against medical advice, the resident and his sister understood and agreed to proceed. The nurse's notes revealed that the resident requested prescriptions and medications, but was informed that none would be provided if he left AMA. Consequently, the resident planned to use medications he already had at home. Social Services attempted to persuade the resident to stay for a planned discharge, but the resident insisted on leaving. The facility staff completed the AMA documentation, which the resident signed, and he left with transportation arranged by his family. The facility failed to ensure the resident received current medication orders and the hospital's discharge summary, potentially affecting continuity of care.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility staff failed to conduct a self-administration of medication assessment for a resident before leaving medications at the bedside. The resident, who had a BIMS score indicating no cognitive impairment, was observed with a medication cup containing two pills on the overbed table. The resident stated that the medications were from the morning and expressed a preference to take them at his own pace. However, the medications were identified as those scheduled for bedtime administration, not morning, indicating a lapse in proper medication management. Interviews with facility staff, including the Unit Manager and the nurse responsible for medication administration, revealed that no residents on the unit had been assessed or had orders for self-administration of medications. The facility's Medication Administration Policy requires that medications be administered by licensed nurses and observed for consumption, which was not adhered to in this instance. The Unit Manager and Administrator confirmed that medications should not be left at the bedside without a proper assessment, and the medications were subsequently removed from the resident's room.
Resident's Rights Violated in Involuntary Transfer to Memory Care Unit
Penalty
Summary
The facility staff failed to respect a resident's right to refuse a transfer within the nursing home, affecting one resident in a survey sample of 74. The resident, who was cognitively intact and his own responsible party, was moved against his will to a locked memory care unit for staff convenience. Despite the resident's clear refusal and lack of a dementia diagnosis, the staff cited an unfounded elopement risk as the reason for the transfer. The resident had never eloped and had only once sat outside after dialysis, which was misinterpreted as wandering behavior. The resident expressed dissatisfaction with the conditions in the memory care unit, describing it as dirty, lacking in activities, and unsuitable for his needs. He reported that his room was invaded by other residents, and he was deprived of basic amenities like regular meals and a clean shower. The facility's failure to provide adequate social work support further compounded the issue, as there was no social worker from June to November, and the newly hired social worker was unfamiliar with the resident's case. The resident's desire to plan for discharge was ignored, and there was no evidence of physician involvement in the decision to move him. Interviews with facility staff revealed a lack of clear policy or procedural guidance for transferring residents to the memory care unit. The Director of Nursing and Administrator could not provide a rationale for the decision, and the staff's justification for the transfer was based on the resident's occasional walking, which they equated with wandering. The facility's failure to honor the resident's rights and the absence of a social worker during a critical period led to the involuntary seclusion of the resident, which was only rectified after the surveyors' intervention.
Resident Discouraged from Communicating with Surveyor
Penalty
Summary
The facility staff prohibited and discouraged a resident from communicating with a state surveyor, which is a violation of residents' rights. The incident involved a resident who was admitted to the facility with diagnoses including end-stage renal disease requiring hemodialysis, dementia, and atrial fibrillation. The resident, who was cognitively impaired with a BIMS score of 11, expressed a desire to leave the Memory Care unit to enjoy outdoor activities. However, the care plan did not include interventions to facilitate outdoor access, focusing instead on encouraging participation in indoor activities. During an interview, the resident reported being told by an unnamed staff member that he should not speak to surveyors because he had already disclosed too much information, which could cause trouble for the facility. This interaction was confirmed during a final interview with the facility's administration and corporate nurse consultants, who acknowledged awareness of the rule that residents should not be discouraged from speaking with surveyors.
Delayed MDS Assessment and Significant Weight Loss
Penalty
Summary
The facility staff failed to complete and submit a Comprehensive 14-day full Admission MDS assessment for a resident in a timely manner. The resident, who was admitted with a history of congestive heart failure, dementia, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease, did not have their admission MDS assessment completed and submitted until over two months after admission. This delay was discovered during the completion of a subsequent significant change MDS assessment. The resident experienced a significant weight loss of 22.3 pounds, equating to more than 15% of their body weight, from the time of admission to the current survey. This weight loss was documented in the clinical record but was not accurately reflected in the MDS assessments. The facility's failure to submit timely and accurate MDS assessments led to deficiencies in care planning for the resident. The facility's administration and nursing leadership were informed of these issues during the survey process.
Failure to Complete Timely and Accurate MDS Assessments
Penalty
Summary
The facility staff failed to complete and submit a correct Significant Change Minimum Data Set (MDS) assessment for two residents, leading to deficiencies in care planning. For one resident, the staff did not accurately document significant weight loss in the MDS assessment. The resident was admitted with a weight of 145.3 pounds and experienced a weight loss of 22.3 pounds, equating to more than 15% weight loss over three months. This significant weight loss was not reflected in the MDS assessment, which incorrectly indicated no weight loss. Additionally, the resident's previous MDS assessment was submitted over two months late, further complicating the care planning process. For another resident, the facility staff failed to complete a significant change MDS assessment within the required 14 days after the discontinuation of hospice services. The resident, who had a major neurocognitive disorder with Lewy Bodies dementia, was initially receiving hospice care, which was later revoked due to an extended prognosis. The MDS Coordinator acknowledged that the interdisciplinary team missed the significant change assessment, and it was not completed within the specified timeframe. This oversight was identified during a survey, highlighting the facility's failure to adhere to CMS guidelines for timely MDS assessments.
Inadequate Hospice Care and Documentation in LTC Facility
Penalty
Summary
The facility staff failed to provide adequate hospice care services for two residents, leading to significant deficiencies in their care. For one resident, the facility did not conduct timely and accurate MDS assessments, provide timely ADL care, or develop a comprehensive care plan. The resident experienced severe weight loss, dehydration, and developed a stage 3 sacral pressure sore. The resident's room was found in unsanitary conditions, and the resident was observed to be in a state of neglect, with no personal items or means of communication in the room. The facility staff did not communicate effectively with hospice staff, and there was a lack of documentation and follow-up on the resident's care needs. Another resident's care was also compromised due to the facility's failure to include hospice nurses' and CNAs' notes in the clinical record. This resident was admitted with multiple diagnoses, including cognitive impairment and a history of falls. The facility did not ensure that hospice care documentation was accessible to the facility's physicians and nurses, leading to a lack of awareness of the care provided by hospice staff. The DON was unaware that hospice notes were not being scanned into the resident's chart, which hindered the facility's ability to coordinate care effectively. Overall, the facility demonstrated a lack of coordination and communication between its staff and hospice providers, resulting in inadequate care for residents receiving hospice services. The deficiencies included failure to monitor and address significant weight loss, inadequate documentation of care plans, and insufficient communication regarding hospice services. These failures contributed to the residents' deteriorating conditions and highlighted the need for improved oversight and collaboration in the provision of hospice care.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility staff failed to administer the influenza vaccine to one resident, despite having obtained consent from the responsible party. The resident, who was admitted to the facility in 2016, has a medical history that includes Alzheimer's Disease with early onset, hyperlipidemia, depression, dysphagia, and muscle weakness. The resident's cognitive abilities were severely impaired, as indicated by a score of 00 on the Brief Interview for Mental Status (BIMS) during the quarterly Minimum Data Set (MDS) assessment. The facility's policy, revised in October 2024, mandates that influenza vaccinations be offered annually from October 1st through March 31st unless contraindicated, already administered, or refused. Despite the policy and the signed consent form dated September 2024, the resident had not received the influenza vaccine by December 2024. The Infection Preventionist acknowledged the oversight, confirming that the vaccine should have been administered. During a final interview with the facility's leadership team, including the Regional President of Operations and the Director of Nursing, no additional information or concerns were presented regarding the failure to administer the vaccine.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility staff failed to administer the COVID-19 vaccine to one resident, despite having obtained consent from the responsible party. Resident #34, who was admitted to the facility in 2016, has a medical history that includes Alzheimer's Disease with early onset, hyperlipidemia, depression, dysphagia, and muscle weakness. The resident's cognitive abilities were severely impaired, as indicated by a score of 00 on the Brief Interview for Mental Status (BIMS) during the quarterly Minimum Data Set (MDS) assessment. The facility's policy requires documentation of immunization or reasons for not administering it, such as medical contraindications or refusal. A review of Resident #34's medical record showed that consent for the COVID-19 vaccine was signed by the responsible party in October 2024. However, the vaccine was not administered, which the Infection Preventionist acknowledged as an oversight. During a final interview with the facility's leadership team, no additional information or concerns were presented regarding this oversight.
Failure to Provide Resident with Quarterly Financial Statements
Penalty
Summary
The facility failed to ensure that a resident was provided with quarterly statements of their personal funds, which is a right afforded to them. The resident, who was diagnosed with Schizoaffective Disorder, Bipolar type, and had a moderate cognitive impairment, expressed during an interview that they were not receiving their money or the quarterly statements. The Business Office Manager (BOM) and the Regional BOM confirmed that the facility was the Representative Payee and that statements were sent to the resident's Guardian Services. However, they stated that the resident needed to request the statements directly from the business office, which had not been communicated effectively to the resident. The deficiency was identified during a survey when the resident reported the issue, and the BOM acknowledged that the resident had requested funds for the first time only recently. Despite the facility's process of sending statements to the Guardian Services, the resident was not informed or provided with the statements directly, leading to the deficiency. The facility staff, including the Administrator and Director of Nursing, were informed of these findings, but no additional information was provided to address the issue at the time of the survey.
Failure to Notify Physician of Medication and Wound Care Issues
Penalty
Summary
The facility staff failed to notify the physician about the unavailability and non-administration of medications for two residents, leading to a deficiency. For one resident, several doses of prescribed medications, including Lidocaine, Topiramate, and Adderall, were not administered as ordered due to unavailability. The staff did not document any notification to the physician regarding these missed doses, which is a critical lapse in communication and care. Interviews with the LPN, Director of Nursing, and Regional Nurse Consultant revealed that the expected protocol was to check the in-house medication supply, notify the pharmacy, and inform the physician if medications were unavailable. Another resident did not receive wound care as ordered by the physician, with documentation missing for six instances of wound care administration. The wound care was scheduled twice daily, but there were consecutive instances where it was not provided, and the physician was not notified. The resident's condition worsened, with the wound showing heavy sanguinous drainage, leading to an emergency transfer to the hospital, where the resident later expired. Interviews with the LPN and Director of Nursing confirmed that wound care should have been documented and provided as ordered. The facility's failure to ensure proper communication and documentation regarding medication administration and wound care led to significant deficiencies in resident care. The lack of notification to the physician about these critical issues indicates a breakdown in the facility's processes for managing resident health needs. The findings were communicated to the Facility Administrator, Regional Nurse Consultant, and Director of Nursing during the end-of-day debriefing.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility staff failed to maintain the confidentiality of medical records for two residents during a survey. For the first resident, the issue occurred when a Point of Care Kiosk, used by Certified Nursing Assistants (CNAs) to document Activities of Daily Living, was left open and unattended, displaying personal information. This incident was observed by surveyors as they entered the facility. The resident involved had a BIMS score indicating no cognitive impairment and was diagnosed with several conditions, including Chronic Obstructive Pulmonary Disease and Anxiety. The CNA responsible for leaving the screen open admitted to the oversight, explaining that she left the kiosk to respond to another resident's immediate need. In the second instance, another resident's information was left visible on a kiosk screen, also unattended, as surveyors were exiting the facility. This resident, who resided on a different unit, had a BIMS score indicating severe cognitive impairment and was diagnosed with conditions such as Dementia and Diabetes. The Director of Nursing acknowledged that staff should not leave kiosks open and unattended, but the facility did not provide information on who was responsible for the lapse. Both incidents were reported to the Facility Administrator and Director of Nursing during the survey debriefings.
Failure to Report Burn Incident
Penalty
Summary
The facility staff failed to report an accident hazard that resulted in bodily harm to the State Survey and Certification Agency. The incident involved a resident who sustained burns on her left forearm and right middle finger after spilling hot coffee on herself while using a communal microwave in the dining area. The resident, who had a history of unsteadiness on feet and impulsiveness, was cognitively intact as per her recent assessment. Despite the incident occurring in June, it was not reported to the appropriate authorities as required by the facility's abuse policy. The incident was discovered during a survey when another resident mentioned the removal of the communal microwave following the burn incident. The facility's Director of Nursing (DON) confirmed the incident but admitted that a Facility Synopsis of the event was not completed and sent to the State Survey and Certification Agency. The microwave was removed from the communal area after the incident to prevent further accidents, but the failure to report the incident remained unaddressed until the survey. Interviews with staff and residents revealed that the microwave was initially intended for staff use, but residents also used it. The resident involved in the incident was using her walker when the spill occurred, and first aid was provided immediately. However, the lack of timely reporting of the incident to the state agency constituted a deficiency in the facility's compliance with its abuse policy, which mandates reporting all alleged violations within specified timeframes.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a discharge for one resident. The resident, who had been admitted to the facility and later readmitted after a hospital stay, was diagnosed with Peripheral Vascular Disease and had severely impaired cognitive abilities, as indicated by a BIMS score of 7 out of 15. The resident was discharged to the hospital, with a discharge assessment indicating a return was anticipated. However, the Social Services Worker admitted that no Ombudsman notifications were sent due to the absence of a Social Worker at the time, which was the SSW's responsibility. This deficiency was confirmed during an interview with the SSW and shared with the facility's administration, but no additional information was provided by the facility staff before the survey exit.
Multiple Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility staff failed to provide wound care as ordered by the physician for a resident with calciphylaxis, a serious condition involving calcium buildup in small blood vessels. The resident required wound care twice daily, but documentation revealed that care was not provided on multiple occasions. Interviews with nursing staff confirmed that medications and treatments should be signed off at the time of administration, and any blanks in documentation indicated that the administration did not occur. The resident's condition worsened, leading to an emergency transfer to the hospital, where the resident ultimately expired. Another deficiency involved the improper administration of medication for a resident with cerebral infarction and vascular dementia. Medications were left at the bedside, which is against the facility's policy unless a resident has been assessed for self-administration. The resident stated that the medications were from the morning, but the nurse responsible for medication administration claimed that the medications were not part of the morning schedule. The facility's policy requires that medications be documented at the time of administration and not left at the bedside. Additionally, the facility failed to conduct neuro-checks for a resident with severe cognitive impairment following an unwitnessed fall, which is against the facility's fall prevention protocol. The protocol requires neurologic assessments to be conducted after any fall. Furthermore, the facility did not obtain vital signs for a resident prior to transferring them to the hospital, which is a professional standard of care. The resident had ongoing issues that were considered stable, but the lack of vital signs documentation at the time of transfer was noted as a deficiency.
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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