Canterbury Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 1776 Cambridge Drive, Richmond, Virginia 23238
- CMS Provider Number
- 495272
- Inspections on file
- 34
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Canterbury Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff failed to protect multiple cognitively impaired residents on a memory care unit from repeated abuse by an aggressive resident with dementia and behavioral disturbances. In separate incidents, one resident was pushed to the floor and sustained a head bump, another was found in bed with the aggressive resident while her brief was displaced and her buttocks exposed, a third was struck in the mouth and suffered a lip laceration after using a racial slur, and a fourth, who was on an anticoagulant for DVT, was struck in the eye during a struggle over a reacher and developed significant bruising and swelling before later deteriorating and being sent to the ED, with her family later reporting she died from a brain bleed. Documentation and interviews showed that the aggressive resident continued to wander the unit, enter female residents’ rooms, attempt to get into bed with them, and become physically aggressive when redirected, while staff and leadership were aware of both his escalating behaviors and the residents’ vulnerability.
Facility staff failed to adequately supervise a cognitively impaired, aggressive resident with documented wandering, sexual ideation, and intrusive behaviors, allowing him to freely enter other residents’ rooms and common areas. Over time, this resident pushed another resident to the floor causing a head bump, was found lying in bed with a cognitively impaired female whose brief was displaced and buttocks exposed, struck another resident in the mouth after being verbally provoked, and hit a resident on anticoagulation in the eye, leading to significant bruising, neurological decline, hospitalization, and subsequent death. Despite repeated incidents on the Memory Care Unit and care‑planned behavioral risks, supervision levels were reduced from 1:1 to Q15‑minute checks and then discontinued, while the resident continued to ambulate independently with direct access to other residents, contrary to the facility’s own safety and supervision policy.
A resident with quadriplegia, chronic respiratory failure, a tracheostomy, and existing Stage 3 and Stage 4 pressure injuries, fully dependent for ADLs and severely cognitively impaired, developed a new pressure injury on the left upper arm after a tourniquet was left in place following IV initiation for antibiotic therapy. Facility staff and an external IV team placed peripheral IVs in both arms, and a lab phlebotomist later drew blood from the left hand, but there was no documentation that the tourniquet used during these procedures was removed. Several days later, a CNA discovered the tourniquet still around the resident’s left upper arm during ADL care, and an RN observed swelling, redness, denuded skin, and blisters encircling the arm. The wound was documented as a new, in-house–acquired, device-related pressure injury, initially unstageable and later staged as Stage 3. Interviews revealed that routine bathing and gown changes that could have exposed the tourniquet earlier were not completed, and staff acknowledged that the wound was preventable and related to the prolonged presence of the tourniquet and lack of thorough skin assessment.
Facility staff did not ensure that several CNAs completed the required 12 hours of annual training. A review of five CNA training transcripts showed that three CNAs had significantly fewer than the required hours documented in the computerized education system. The staff development coordinator, who had recently assumed the role, reported she was still working on coordinating education schedules and auditing training records. Facility documents stated that annual education requirements were in place for all staff and that completed training, including hours, was to be documented by the staff development coordinator or designee.
Staff failed to follow a care plan intervention requiring a Breathcall adaptive call bell for a resident with quadriplegia, chronic respiratory failure, tracheostomy, tube feeding, and a sacral pressure ulcer, who was severely cognitively impaired and totally dependent for ADLs. Despite the care plan specifying a Breathcall arm instead of a traditional button call light due to lack of mobility, repeated observations showed only a standard handheld call bell clipped to the bed linens. Interviews with an LPN, CNA, director of specialty care, and DON described processes for selecting adaptive call bells and indicated such devices should follow residents when they change rooms, but the ordered adaptive device was not in place for this resident.
Staff failed to implement abuse-prevention and supervision policies for a cognitively impaired, behaviorally disturbed resident who repeatedly engaged in aggressive and sexually inappropriate conduct toward other severely cognitively impaired residents on a Memory Care Unit. In separate incidents, one resident was pushed to the floor and sustained a head bump after a slap-and-push altercation, another cognitively impaired female was found in bed with the aggressive male resident while her brief was displaced and her buttocks exposed, a male resident with dementia suffered a lip laceration after being struck, and a female resident on anticoagulant therapy developed significant bruising and swelling to her eye after reporting she was hit during a struggle over a reacher/grabber. Despite facility policies requiring individualized supervision, hazard mitigation, and protection from abuse, the aggressive resident continued to ambulate freely throughout the unit with direct access to other vulnerable residents, and staff and leadership acknowledged that such resident-to-resident altercations and non-consensual bed-sharing constitute abuse.
The facility failed to follow its abuse policy by not timely submitting the final 5‑day investigative summary of an altercation between two residents to the state survey agency and by not notifying the involved resident’s representative of the investigation outcome. After a resident reported being struck in the eye by another resident during a struggle over a reacher/grabber tool, staff separated the residents, documented bruising and swelling to the injured resident’s eye, and initiated required assessments and notifications. The initial incident report was faxed to required agencies, and the final 5‑day summary was successfully sent to adult protective services and the ombudsman, but multiple fax attempts to the state survey agency failed, with no documented re‑attempts on subsequent business days as required by policy. The injured resident was later transferred to the ED and did not return, and there was no documentation that the resident or the resident’s representative was informed of the investigation’s outcome.
Facility staff failed to accurately complete an MDS assessment for a resident with documented pressure injuries. The resident had physician orders and ongoing treatments for sacral and left ear wounds, and a care plan noting a pressure ulcer or risk related to impaired mobility, incontinence, and diabetes. On the quarterly MDS, Section M0100 indicated a pressure injury, but Sections M0210 and M0300 were left incomplete and did not record unhealed pressure injuries or their stages, despite the LPN MDS coordinator acknowledging that these wounds should have been documented based on the RAI Manual and the 7-day look-back period.
Staff did not fully implement comprehensive care plans for two residents. One resident with quadriplegia, chronic respiratory failure, and total dependence for ADLs had a care plan requiring a Breath Call adaptive call bell and daily skin inspection during care, but surveyors repeatedly observed only a standard handheld call bell in use, and documentation showed limited bathing and dressing over several days. Clinical notes later described discovery of a tourniquet left on the resident’s arm, with skin damage identified only when a CNA bathed the resident and removed the gown after prior days when only washups were given due to a lack of clean gowns. Another resident with severe cognitive impairment and behavioral issues had a care plan directing staff to dress him in multiple layers of his own clothing because he was cold natured, yet he was observed walking the unit in shorts and a long-sleeve shirt while rubbing his arms, and an LPN reported she was unaware of the layering requirement and relied on the resident to say when he was cold.
A dependent, cognitively impaired resident with quadriplegia, chronic respiratory failure, and existing pressure ulcers did not receive adequate ADL care, including bathing and gown changes, over several days. Although documentation reflected completed baths and dressing, a CNA reported only providing a washup and not removing the gown due to perceived lack of clean gowns. During this period, IV access was placed in both arms for IV ABT, and a tourniquet applied to one arm by an IV team was not removed. The tourniquet was only discovered when a CNA later washed the resident, revealing damaged, blistered skin and a new in-house–acquired pressure injury, indicating that required daily hygiene and skin inspection per the care plan were not consistently performed.
Staff failed to maintain complete and accurate clinical records for two residents, including missing documentation of midline and peripheral IV insertion details for one resident receiving IV antibiotics and inaccurate eMAR entries for another resident when an LPN signed off morning and afternoon medications that she later stated she likely had not administered. Additional inaccuracies included a trauma-informed care assessment note stating a resident was doing okay with no issues despite concurrent clinical documentation and interviews indicating the resident was unresponsive with abnormal vital signs and being transferred to the ED, and neurological assessment forms marked with symbols the LPN used without understanding the legend. The DON reported there was no formal policy on maintaining a complete and accurate medical record, although accurate and timely documentation was expected from all disciplines.
Facility staff failed to ensure that a CNA completed required communication training, as revealed through staff interviews and document review. The facility’s assessment identified effective communication as an annual education topic for all staff, and policy required regular in-service education on effective communication with residents and families for direct care staff. However, there was no documentation that the CNA had completed this training, and the staff development coordinator acknowledged that, although an annual competency calendar existed and an effort to catch up on missed education was in progress, the communication training for this CNA was not completed or documented at the time of review.
Surveyors found that required Quality Assurance and Performance Improvement (QAPI) training was not completed by a CNA, a dietary staff member, and a housekeeping staff member, despite facility policy and the facility assessment requiring all staff, including contracted personnel and volunteers, to receive annual education on QAPI basics and the elements and goals of the QAPI program. The SDC reported that education was assigned via an annual competency calendar and that she was working on catching up missed education and arranging training for contracted staff, but could not provide documentation that these three employees had completed the required QAPI training.
Facility staff did not ensure that required annual compliance and ethics training was completed for two CNAs. The staff development coordinator reported that staff education was assigned via an annual competency calendar and that staff had the full year to complete required modules, but she could not produce documentation showing that these CNAs had completed the compliance and ethics training. Facility documents, including the facility assessment and an in-service training policy, specified that all staff must receive annual education on corporate compliance, ethics, and the compliance and ethics program standards, policies, and procedures.
Surveyors found that required behavioral health training was not completed for a CNA and a dietary staff member, despite a facility assessment and policy mandating annual education for all staff on topics such as managing challenging behaviors, aggressive behaviors, and trauma-informed care. The staff development coordinator reported use of an annual competency calendar and acknowledged ongoing efforts to address missed education and extend training to contracted staff, but could not provide documentation that these two employees had completed the required behavioral health training.
A resident with hypotension related to ESRD had a comprehensive care plan directing staff to administer Midodrine as ordered and to monitor vital signs as ordered and as clinically indicated, but staff did not implement the care-planned intervention to give Midodrine per the physician’s orders. An LPN acknowledged that the care plan is meant to guide staff in meeting residents’ individual needs, and facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident.
Staff failed to clarify PRN orders and consistently monitor blood pressure for a resident receiving Midodrine via PEG tube for orthostatic hypotension and Clonidine for HTN, both ordered every eight hours with specific SBP parameters. Clinical record review showed no evidence that blood pressure was taken every eight hours to determine the need for these PRN medications. An LPN stated that blood pressure should be checked before administering such medications, and a regional clinical leader acknowledged that PRN Midodrine had been cited previously and that PRN Clonidine orders were unusual and required clarification.
Staff failed to follow physician-ordered blood pressure parameters for Midodrine administration for a resident with hypotension related to ESRD and dialysis dependence. The order required Midodrine 10 mg via PEG tube every 8 hours only when SBP was under 100 mmHg, but the MAR showed the medication was given multiple times when SBP readings were above 100 mmHg. An LPN confirmed that the medication should have been held based on the documented blood pressures, despite the care plan and facility policy requiring adherence to ordered parameters and monitoring of vital signs.
Staff failed to monitor and document blood sugar checks as ordered for a resident with diabetes, and did not initiate or document required neurological checks after falls resulting in head injuries for two other residents, despite facility policy and physician orders. Interviews and record reviews confirmed these omissions, with administrative staff acknowledging the lack of evidence for the required care.
A resident admitted with diabetes, respiratory failure, and a tracheostomy did not have diabetes or blood sugar monitoring addressed in their baseline care plan upon admission. Although physician orders for blood sugar checks were present, the initial care plan focused only on discharge planning and equipment needs, omitting necessary interventions for diabetes until several days later. Staff confirmed that diabetes management should have been included from the start.
Multiple residents did not receive wound care treatments as recommended by the wound nurse practitioner, with delays and omissions in implementing physician orders and eTAR documentation. Staff were unaware of required treatments, and residents dependent on staff for turning and repositioning were not consistently assisted, leading to worsening pressure injuries. Recommended changes in wound care and infection management were not followed, resulting in harm and deterioration of residents' conditions.
Staff failed to maintain a clean and homelike environment, as strong urine odors persisted in multiple units and hallways despite regular cleaning, and privacy curtains in several rooms were found to be dirty or improperly maintained. Additionally, a resident was left with a bloody pillowcase in contact with his body for an extended period, with both nursing and housekeeping staff acknowledging this did not meet cleanliness standards.
Facility staff did not follow required procedures for reporting and investigating abuse, neglect, and injuries of unknown origin for several residents. In multiple cases, injuries were not reported to the state agency within the mandated timeframe, and documentation of final investigative reports was missing or incomplete. Staff interviews confirmed knowledge of reporting policies, but these were not consistently implemented.
Facility staff did not follow individualized care plans and physician or practitioner recommendations for several residents, resulting in missed or delayed wound care treatments, lack of required repositioning for pressure injury prevention, improper infection control precautions for a resident with shingles, incomplete tracheostomy care documentation, and failure to provide required medication education. These deficiencies were identified through observations, record reviews, and staff interviews.
Facility staff did not provide or document tracheostomy care as ordered for two residents, with multiple missed care instances noted on both day and night shifts. Despite physician orders and facility policy requiring regular tracheostomy care, the absence of documentation on respiratory administration records indicated that care was not consistently given. Nursing staff confirmed that proper care should be recorded, and administrative staff were informed of these deficiencies.
A resident with ESRD requiring hemodialysis did not have complete dialysis communication forms filled out on multiple treatment days, despite physician orders and facility policy mandating this documentation. Review of records showed several instances where pre-dialysis or dialysis communication was missing, and staff confirmed the expected process was not consistently followed.
A resident with end-stage renal disease and on dialysis did not receive Midodrine as ordered prior to dialysis sessions, despite blood pressure readings within the prescribed parameters. Facility staff, including an LPN and physician, confirmed the medication should have been administered, but records showed repeated omissions. The care plan and facility policy required medication administration as ordered, but this was not followed.
Two residents did not receive dignified care when staff failed to answer a call bell promptly for one cognitively intact resident, resulting in a 13-minute wait, and when a sign in the dining room required another resident to retrieve her meal from outside the dining area if arriving late. Both incidents were contrary to facility policies on dignity and timely response.
Facility staff did not inform a cognitively intact resident about new orders for Percocet and Xanax, nor did they provide information on the risks, benefits, or alternatives before administering these medications. Despite care plan requirements and facility policy mandating resident education and involvement in care decisions, there was no evidence that the resident was notified or educated prior to receiving the medications.
A resident's personal clothing and belongings were not relocated to their current room after a room change, leaving items such as clothing and water bottles in a vacant room. Staff confirmed the items belonged to the resident and acknowledged they should have been moved. The resident, who was moderately cognitively impaired, noticed the missing items and expressed a desire to have them returned. This failure violated facility policy regarding respect for resident property.
Two residents were assessed by a nurse practitioner in the dining room while other residents were present, rather than in a private setting as required by facility policy. An LPN confirmed that assessments should be conducted privately except in emergencies, and the nurse practitioner stated that public assessments sometimes occur for timing reasons. Facility leadership was informed of these privacy breaches.
A resident with anxiety and intact cognitive status received Xanax multiple times without evidence that staff attempted or documented alternative interventions prior to administration. Staff interviews confirmed that no alternate interventions were tried before using the psychotropic medication as a chemical restraint.
Facility staff did not report injuries of unknown origin for three residents with severe cognitive impairment within the required timeframe. In each case, bruises were discovered without a known cause, and although internal notifications were made, reporting to the state agency was delayed beyond the facility's policy of two hours. Staff and administrative interviews confirmed the reporting failures and the lack of adherence to established procedures.
Facility staff did not submit required follow-up investigative reports to the state agency for two residents after incidents involving an allegation of neglect and a bruise of unknown origin. Despite staff awareness of reporting procedures and initial incident reporting, documentation confirming submission of the final investigative reports within the required timeframe was not found.
Facility staff did not document required neurological checks after an unwitnessed fall involving a resident at moderate fall risk who was on anticoagulant therapy. Although initial assessments and notifications were made, there was no evidence of ongoing neuro monitoring as required by facility policy, and staff interviews confirmed the lack of documentation.
A resident with paraplegia and an indwelling urinary catheter was repeatedly observed with the catheter collection bag lying on the floor while in bed. Both an LPN and a CNA confirmed this practice was improper due to infection risk, and facility policy required catheter bags to be kept off the floor.
Staff failed to document attempts at non-pharmacological pain interventions before administering prn Percocet to a cognitively intact resident. Despite facility policy and standard nursing procedures requiring such interventions and their documentation, records showed that pain medication was given without evidence that alternatives were tried first.
A resident who was cognitively intact repeatedly refused morning medications before dialysis, believing they would be removed during the procedure. Nursing staff documented the refusals and informed the physician, who acknowledged awareness but did not document any discussion or provide further education to the resident. Facility policy requires physician supervision and documentation of such events, which was not completed in this case.
A resident with a history of pulmonary embolism was prescribed Apixaban and required monitoring for anticoagulant complications as per physician orders and care plan. However, staff did not document any monitoring for adverse effects or complications in the eMAR for an extended period, despite facility policy and staff statements that such monitoring should occur every shift.
Staff failed to adhere to infection control protocols for three residents, including improper glove use and hand hygiene during tracheostomy care, not replacing a blood-soiled pillowcase for a dependent resident, and not implementing required contact precautions for a resident with shingles. Interviews confirmed staff awareness of the lapses, and facility policies and CDC guidelines were not followed.
Facility staff failed to provide adequate ADL care, specifically turning and positioning, for four dependent residents with various medical conditions. Documentation was missing for several dates and shifts, despite care plans requiring repositioning every two hours. Interviews with CNAs confirmed the expected practice, but it was not consistently followed. Administrative staff were informed, but no further information was provided before surveyors' exit.
The facility staff failed to implement comprehensive care plans for three residents, resulting in missed treatments and medication errors. A resident with impaired skin integrity did not receive prescribed treatments, while another received medication despite contraindications and missed doses due to pharmacy issues. A third resident's treatments for pressure ulcers and GERD were not administered as ordered, despite available medications. Interviews confirmed the importance of following care plans, but deficiencies were noted.
Two residents in a facility did not receive medications and treatments as per physician orders, leading to deficiencies. One resident did not receive wound care and medications due to lack of documentation and unavailability, while another received medication against prescribed parameters and had discrepancies in medication administration. These issues highlight significant deficiencies in medication management and adherence to physician orders.
The facility staff failed to provide adequate pressure ulcer care and documentation for three residents. A resident did not receive prescribed treatments for deep tissue injuries, with missing documentation on several dates. Another resident's wound care was compromised by improper glove use, violating infection control protocols. Additionally, there was a lack of documentation for a third resident's pressure injury treatments on a specific date, contrary to physician orders.
A resident did not receive prescribed medications as scheduled, and the facility staff failed to notify the physician and responsible party. Despite the availability of medications in the emergency backup system, they were not administered, and the facility's policy on handling unavailable medications was not followed.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident in an LTC facility. The incident involved inappropriate sexual behavior observed by a CNA, leading to immediate separation and reporting to authorities. Both residents had cognitive impairments, and the male resident was placed under 1:1 supervision.
A resident's clinical record was incomplete due to the failure to document the holding of Metoprolol Tartrate and the lack of notification to the physician or responsible party. The LPN stated that the facility's protocol requires documentation and notification when a medication is unavailable, but this was not followed. The nurse practitioner was informed via text, but this was not recorded in the clinical record, violating the facility's documentation policy.
The facility failed to maintain kitchen utensils in a sanitary manner, with several items found dirty or damaged during an observation. The dietary manager acknowledged the issue and took immediate action to clean and discard the affected utensils. The facility's sanitation policy requires all utensils to be clean and in good repair.
A facility failed to maintain accurate clinical records for three residents, leading to documentation errors. One resident's record inaccurately documented urinary drainage bag changes after catheter removal. Another resident's advanced directives were inconsistently recorded, with conflicting 'Full Code' and 'DNR' statuses. A third resident's dental consult efforts were not documented, despite family refusal for an outside consult. These deficiencies highlight issues in record-keeping and communication among staff.
The facility failed to implement comprehensive care plans for four residents, resulting in deficiencies in urinary catheter care, dialysis care, and respiratory therapy. Documentation was missing for critical care interventions, indicating that the care plans were not fully executed. Interviews with staff confirmed these lapses in care plan adherence.
Failure to Protect Cognitively Impaired Residents From Repeated Abuse by an Aggressive Resident
Penalty
Summary
Facility staff failed to protect multiple cognitively impaired residents on the Memory Care Unit from abuse by another resident, identified as Resident #14 (R14). Over a period beginning on 3/20/24, R14 was involved in repeated resident-to-resident altercations with residents who had dementia and severe cognitive impairment. On 3/20/24, Resident #17 (R17), who had Lewy body dementia, frontotemporal neurocognitive disorder, and severe cognitive impairment, was involved in an unwitnessed altercation with R14. Staff heard a scream and a hard fall and then found R17 on the floor near a food cart and R14 standing nearby. Both residents reported that R17 slapped R14 and that R14 then pushed R17 to the floor. R17 was found to have a bump on the top/back of her head, and neuro checks were initiated. On 12/18/24, staff again failed to prevent an abusive situation when R14 was found in bed with Resident #16 (R16), a female resident with dementia, psychotic disorder with delusions and hallucinations, and who was unable to complete a cognitive assessment. Staff had already redirected R14 from attempting to enter R16’s room earlier that evening and had laid him down in his own bed. Later, staff observed R14 fully clothed lying on top of the covers in R16’s bed while R16’s entire body, including her head, was covered. When the covers were pulled back, R16’s brief was deviated to the right with her buttocks exposed. Neither resident could recall the incident, but the documentation shows that R14 had been repeatedly attempting to enter R16’s room and that he was ultimately found in her bed with her brief displaced and buttocks exposed. On 1/22/25, Resident #15 (R15), who had Alzheimer’s dementia with agitation and severe cognitive impairment, wandered into R14’s room and called him a racial slur. Witnesses reported that R14 then hit R15, who was later observed with a bleeding mouth and a small cut to the lower lip, documented as a new laceration. On 12/30/25, Resident #2 (R2), who had dementia, PTSD, psychosis, chronic pain, and was on the anticoagulant Eliquis for DVT, was involved in a physical altercation with R14 in her room. Another resident alerted staff that they were fighting. Staff found R2 and R14 pushing and pulling on R2’s reacher/grabber tool. R2 stated that R14 came into her room, she tried to get him to leave, and he hit her in the left eye. Staff documented immediate swelling and bruising to R2’s left eye and initiated neuro checks. The next morning, R2 was noted to have her left eye swollen shut with purplish-reddish bruising, decreased responsiveness, refusal to eat, and then rapidly worsening vital signs including very high blood pressure, tachycardia, and hypoxia. She became unresponsive and was transferred to the hospital, where her responsible party later reported being told that R2 had suffered a significant brain bleed related to being hit in the eye while on a blood thinner and that she subsequently died. Throughout this period, R14 remained on the Memory Care Unit with ongoing access to other residents despite escalating aggressive and sexually inappropriate behaviors. Progress notes and psychiatric evaluation documented that R14 entered female residents’ rooms, attempted to get into bed with them while clothed and in a brief, and became physically aggressive when redirected, including making grabbing motions and attempting to hit staff. A psychiatric nurse practitioner documented that R14 had significant behavioral disturbances with aggression, poor impulse control, and sexually inappropriate behavior, and that his behaviors placed him and others at risk. Interviews with staff, including LPNs, the DON, social services, and other department heads, confirmed awareness that residents on blood thinners who sustain head trauma are at high risk for serious bleeding, that resident-to-resident physical and sexual incidents constitute abuse, and that residents have the right to be free from abuse and to feel safe. Despite this, R14 continued to ambulate freely on the unit and have direct access to other residents, and the facility’s practices resulted in multiple abusive incidents, including the altercation with R2 that led to significant injury and hospitalization.
Failure to Supervise Aggressive Resident Leads to Multiple Altercations and Harm
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision of a resident with known aggressive and sexually inappropriate behaviors, which led to multiple resident‑to‑resident altercations and harm. Resident #14 (R14), who had vascular dementia with psychotic disturbance, anxiety, insomnia, restlessness, agitation, and severe cognitive impairment on MDS, was repeatedly allowed to move freely throughout the Memory Care Unit despite a documented history of wandering into other residents’ rooms, aggression, and sexual ideation. The facility’s own incident synopses and staff statements show that R14 entered other residents’ rooms or was involved in altercations on multiple occasions, while care plans and supervision levels did not consistently reflect or control these risks. On 3/20/24, Resident #17 (R17), who had Lewy body dementia with agitation, frontotemporal neurocognitive disorder, and severe cognitive impairment, was involved in a physical altercation with R14. Staff reported hearing a scream and a hard fall and then found R17 on the floor near a food cart with R14 standing nearby. Both residents stated that R17 slapped R14 and that R14 pushed R17 to the floor. R17 was found to have a bump on the top/back of her head. Although R14’s care plan was revised to address a psychosocial well‑being problem related to an alleged physical abuse incident, the care plan did not reflect his potential for aggressive behaviors, despite his severe cognitive impairment and prior behaviors. On 12/18/24, Resident #16 (R16), who had dementia with agitation, major depressive disorder, psychotic disorder with delusions and hallucinations, and was unable to complete a cognitive assessment, was found in bed fully covered with blankets while R14 was lying fully clothed on top of the covers in the same bed. A CNA had previously redirected R14 from attempting to go into R16’s room and had laid him down in his own bed, but later another CNA overheard a nurse telling R14 to exit R16’s bed and then observed R16’s brief undone with her buttocks exposed. The facility’s final synopsis documented that neither resident could recall the incident and that no injuries were noted, but the event occurred in the context of R14’s known behaviors of sexual ideations, roaming into rooms, taking others’ belongings, and defecating on the floor, which were already care‑planned. The facility was aware of R14’s history of entering other residents’ rooms and had previously used 1:1 supervision and Q15‑minute checks, but he was transitioned off 1:1 and later off Q15‑minute checks. On 1/22/25, Resident #15 (R15), who had Alzheimer’s dementia with agitation, major depressive disorder, anxiety, and severe cognitive impairment, wandered into R14’s room and called him a racial slur, after which R14 hit R15 in the mouth. Staff observed R15 exiting R14’s room holding a bloody rag to his mouth and stating that the other resident had hit him. A progress note documented a small cut to the lower lip and an interim skin check identified a new laceration. At the time of this incident, R14 was on Q15‑minute checks due to prior behaviors, and his care plan included general behavioral interventions such as monitoring behaviors, assisting with coping, and intervening to protect others, but he continued to have direct access to other residents and their rooms. On 12/30/25, Resident #2 (R2), who had dementia without behavioral disturbance, PTSD, psychosis, depression, chronic pain, and was on Eliquis for prevention of recurrent DVT, was involved in an altercation with R14 that resulted in significant injury. Staff were alerted by another resident that R2 and R14 were fighting. When staff entered, they observed R14 standing in front of R2, both struggling over R2’s reacher/grabber tool. R2 stated that R14 had come into her room, she tried to ask him to leave, and he hit her in her left eye. A nurse documented swelling and bruising around R2’s left eye, and an interim skin check identified a new bruise. R2 was initially kept in the facility with neuro checks and Q15‑minute safety checks. By the next morning, staff noted that R2’s left eye was swollen shut with purplish‑reddish bruising, she was less responsive, and then became unresponsive with critically abnormal vital signs and oxygen saturation, leading to her transfer to the emergency department. Her responsible party later reported that the hospital physician said R2 had suffered a significant brain bleed from being hit in the eye while on a blood thinner and that she died on 1/1/26. Additional documentation shows that all of these incidents occurred on the Memory Care Unit and were perpetrated by R14. A nurse progress note dated 1/3/26 recorded R14 being observed in a female resident’s room attempting to get into bed with her while clothed and wearing a brief, and that he became physically aggressive, making grabbing motions and attempting to hit staff when redirected. A psychiatric nurse practitioner note dated 1/5/26 described escalating behavioral disturbances, including aggression, poor impulse control, and sexually inappropriate behavior, and stated that R14 posed risks to staff and peers due to aggressive and sexually inappropriate behaviors. Despite this, a nurse progress note on 1/5/26 documented that R14 was no longer on 1:1 supervision per physician order, and he remained a current resident permitted to ambulate freely on the unit with direct access to other residents. The facility’s own safety and supervision policy required individualized, resident‑centered analysis of accident hazards and adequate supervision, but the pattern of repeated incidents involving R14 and multiple cognitively impaired residents demonstrates that adequate supervision and an accident‑hazard‑free environment were not maintained.
Tourniquet Left in Place Causes Device-Related Pressure Injury
Penalty
Summary
Facility staff failed to provide necessary care and services to prevent a pressure injury when a tourniquet was left in place on a resident’s left upper arm for an extended period, resulting in an unstageable pressure injury that later evolved to Stage 3. The resident had significant medical conditions including quadriplegia, chronic respiratory failure, a tracheostomy, tube feeding, and existing Stage 3 and Stage 4 pressure injuries. The resident was severely cognitively impaired, dependent on staff for all ADLs, and already care planned for pressure ulcer risk and existing wounds, including a sacral wound and a left arm antecubital wound. On one date in March, the resident received orders for a midline catheter and IM medications due to ongoing clinical concerns, and a few days later, orders were in place for IV antibiotics. Facility documentation shows that a peripheral IV was inserted in the right arm by facility staff and that an external pharmacy IV team attempted a midline but instead placed a second peripheral IV in the left arm. The resident also had blood drawn from the left hand by a lab phlebotomist, who reported placing a tourniquet below the IV site. Progress notes documented that the resident continued on IV antibiotics with no noted IV site complications, and there was no documentation of skin issues at the left upper arm until several days later. On a later date in March, a CNA discovered a tourniquet still in place on the resident’s left upper arm while providing ADL care. The CNA reported the finding to an RN, who observed that the tourniquet remained around the arm and that there was a #20 gauge IV in the forearm dated several days earlier. Staff described the left arm as more swollen than the right, reddened, denuded, and blistered, with a wound encircling the circumference of the upper arm and a large blister on the posterior aspect. Clinical documentation identified this as a new, in-house–acquired pressure injury at the left antecubital/upper arm area, initially described as a medical device–associated contusion with blistering and later assessed by the wound NP as an unstageable pressure injury, then as a Stage 3 pressure injury on subsequent assessment. Interviews indicated that staff believed the wound was caused by a tourniquet left in place after attempts to start an IV for antibiotics, and that routine bathing and gown changes that might have revealed the tourniquet earlier did not occur, contributing to the prolonged presence of the device and development of the pressure injury. Additional staff interviews further clarified the sequence of inactions that led to the deficiency. The wound nurse reported being notified only after the pressure injury was discovered and stated that he did not know when the tourniquet had been applied, only that it was related to IV initiation. A CNA who had cared for the resident over the weekend prior to discovery stated she had only provided a wash-up and did not remove the resident’s gown because there were no clean gowns available; she acknowledged that if she had removed the gown, she might have seen the tourniquet earlier. The DON confirmed that the wound was considered preventable and that, had staff been bathing and changing the resident’s gown as expected, the tourniquet should have been identified and removed before it caused skin damage. These combined failures in monitoring the IV site, ensuring removal of the tourniquet after use, and performing thorough skin and gown assessments led directly to the development of the device-related pressure injury on the resident’s left upper arm.
Failure to Ensure Required Annual CNA Training Hours
Penalty
Summary
Facility staff failed to ensure that certified nursing assistants (CNAs) received the required 12 hours of annual training. On 4/9/2026 at 8:15 AM, a review of five CNA training transcripts showed that three of the five CNAs did not meet this requirement. CNA #8, hired on 5/1/2023, had completed a total of 7.18 hours of training. CNA #9, hired on 7/6/2022, had completed only 0.25 hours of training. CNA #10, hired on 9/23/2022, had completed 4.18 hours of training. The facility required CNAs to obtain 12 hours of annual training each year using computerized education, which tracked hours and allowed completion through December 31 of each year. During an interview on 4/9/2026 at 9:57 AM, the staff development coordinator, who had been in the role since 12/15/2025, stated she was working to coordinate education schedules and competency calendars and was conducting audits, which were not yet complete. The facility assessment dated 2/26/2026 documented that annual education requirements were in place for all staff to ensure ongoing education and competency. The facility policy "In-Service Training, All Staff" dated 2001 stated that completed training is documented by the staff development coordinator or designee and includes the hours of training completed. On 4/9/2026 at approximately 11:12 AM, the administrator, DON, vice president of operations, regional director of clinical services, assistant DON, and clinical consultant were informed of the concern, and no further information was provided prior to exit.
Failure to Provide Care-Planned Adaptive Call Bell for Dependent Resident
Penalty
Summary
Facility staff failed to reasonably accommodate a resident’s physical limitations by not providing the adaptive call bell specified in the resident’s care plan. The resident had diagnoses including quadriplegia, chronic respiratory failure, and a sacral pressure ulcer, and the most recent MDS documented severe impairment in decision-making and total dependence on staff for all ADLs, as well as the need for oxygen, tracheostomy care, tube feeding, pressure injury care, and suctioning. The comprehensive care plan, initiated on 07/10/2025, identified an ADL self-care performance deficit related to multiple conditions and directed staff to ensure a Breathcall arm was within reach and to provide reminders to use it, noting that the Breathcall arm was to be used instead of a traditional button call light due to the resident’s lack of mobility. On multiple observations over two days, the resident was seen lying in bed with only a standard handheld call bell with a finger-press button clipped to the bed linens near the chest, and no Breathcall device was present. Interviews with an LPN, the director of specialty care, a CNA, and the DON revealed that staff relied on clinical judgment and therapy recommendations to determine appropriate call bell types, and that adaptive call bells were to follow residents when they changed rooms. The director of specialty care was unsure what type of call bell the resident had used in a previous room and indicated the resident had recently switched rooms. The facility’s ADL policy stated that interventions to improve or maintain function were to be in accordance with assessed needs and preferences, but the resident’s care-planned intervention for a Breathcall arm was not implemented as observed.
Failure to Implement Abuse-Prevention Policies for Aggressive Resident on Memory Care Unit
Penalty
Summary
Facility staff failed to implement abuse-prevention policies and provide adequate supervision and protection from abuse, neglect, and theft for multiple cognitively impaired residents on the Memory Care Unit, particularly in relation to one resident with escalating aggressive and sexually inappropriate behaviors. The facility’s written policies require identification of hazards, individualized supervision based on assessed needs, and staff competency in recognizing and reporting accident hazards and abuse. Despite these policies, the same resident (Resident #14), who had severe cognitive impairment and behavioral disturbances, was repeatedly involved in resident-to-resident altercations that resulted in physical harm and potential sexual abuse of other residents with severe cognitive impairment. In one incident, a resident with Lewy body dementia, frontotemporal neurocognitive disorder, and severe cognitive impairment (Resident #17) was involved in a physical altercation with Resident #14. Staff heard a scream and a hard fall and then found the cognitively impaired resident on the floor near a food cart, with the other resident standing nearby. Both residents reported that the cognitively impaired resident slapped Resident #14 and that Resident #14 then pushed her to the floor. The injured resident was later documented to have a bump on the back of her head. This event occurred despite the facility’s policy that resident supervision and accident prevention are facility-wide priorities and that supervision should be adjusted based on individual risk and environmental hazards. In another incident, a severely cognitively impaired female resident (Resident #16), who could not complete a cognitive assessment, was found in bed fully covered with blankets while Resident #14 was lying on top of the covers, fully clothed, in the same bed. A CNA later observed that the female resident’s brief was deviated to the side with her buttocks exposed. Neither resident could recall the incident. The facility’s policies state that residents have the right to be free from abuse and that staff must identify and mitigate hazards, including through adequate supervision and individualized interventions, yet a male resident with known behavioral issues was able to enter and remain in a vulnerable female resident’s bed. A further incident involved a male resident with Alzheimer’s dementia and severe cognitive impairment (Resident #15), who wandered into Resident #14’s room and used a racial slur, after which Resident #14 struck him. Staff later observed the injured resident exiting the room with a bloody rag to his mouth, stating that he had been hit, and documentation confirmed a new laceration to his lower lip. In another serious event, a female resident with dementia, PTSD, psychosis, chronic pain, and on long-term anticoagulant therapy for deep vein thrombosis (Resident #2) was found in a struggle with Resident #14 over a reacher/grabber tool. She reported that he had hit her in the left eye, and staff documented swelling and bruising to that eye. Her condition subsequently deteriorated, with abnormal vital signs and decreased responsiveness, and she was transferred to the hospital, where her responsible party later reported being told that she had suffered a significant brain bleed related to being hit while on a blood thinner. These repeated incidents, all involving the same resident aggressor on the Memory Care Unit, occurred despite facility policies requiring a systems approach to safety, close supervision based on individual risk, and protection of residents’ rights to be free from abuse. Post-incident documentation for Resident #14 showed that, after the altercation resulting in the eye injury, he was again observed in a female resident’s room attempting to get into bed with her while clothed and wearing a brief, and he became physically aggressive when redirected, making grabbing motions and attempting to hit staff. A psychiatric nurse practitioner documented that staff reported increasing aggressive and sexually inappropriate behaviors, including entering a female resident’s room and attempting to get into bed with her, and that these behaviors placed him and others at risk. Despite this, he was noted as no longer being on one-to-one supervision per physician order, and surveyors later observed him ambulating freely throughout the Memory Care Unit hallways and common areas with direct access to other residents. The facility’s own leadership and social services staff acknowledged in interviews that resident-to-resident physical altercations and a male resident in bed with a cognitively impaired female resident who could not consent would constitute abuse, and that residents have the right to be free from abuse and to feel safe, yet the same resident continued to have unrestricted access to other vulnerable residents on the unit.
Failure to Timely Submit Final Abuse Investigation and Notify Resident Representative
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy for timely submission of the final 5‑day investigative summary to the state survey agency following an altercation between two residents. An incident occurred in which one resident reported being struck in the left eye by another resident during a struggle over a reacher/grabber tool. Staff separated the residents, completed head‑to‑toe skin and pain assessments, and documented swelling and bruising to the alleged victim’s left eye, while the alleged aggressor had no noted injuries. The incident was initially reported by fax to the state survey agency, adult protective services, and the ombudsman on the same day as the event. Subsequently, the facility prepared the final 5‑day investigative summary and successfully faxed it to adult protective services and the ombudsman. However, fax confirmation sheets showed that attempts to submit the same final 5‑day investigative summary to the state survey agency on two separate dates failed. There was no evidence that the facility attempted to re‑submit the final investigative summary on the intervening business days following each failed transmission. The state survey agency ultimately confirmed receipt of the final 5‑day investigative summary several days after the second failed attempt, beyond the facility policy’s requirement for submission within five business days of the incident. The facility’s written policy on abuse, neglect, exploitation, or misappropriation required that all allegations of abuse be reported to appropriate agencies and that a follow‑up investigation be provided within five business days of the incident. The policy also required that the resident and/or resident representative be notified of the outcome of the investigation immediately upon its conclusion. The clinical record showed that the injured resident was transferred to the emergency department the day after the incident and did not return to the facility. There was no evidence in the clinical record or facility synopsis file that the resident or the resident representative was notified of the outcome of the investigation into the altercation, further demonstrating noncompliance with the facility’s abuse reporting policy.
Incomplete MDS Coding for Existing Pressure Injuries
Penalty
Summary
Facility staff failed to ensure an accurate MDS assessment for one resident by not fully documenting existing pressure injuries on a quarterly MDS with an ARD of 2/12/2026. The resident had physician orders, initiated on 01/29/2026, for daily and PRN wound care to the sacrum and left ear, and the electronic treatment administration record showed that these treatments were carried out throughout February 2026. The comprehensive care plan, initiated on 10/21/2025, documented that the resident had a pressure ulcer or was at risk for pressure ulcer development related to impaired mobility, incontinence, and diabetes. Despite this documentation, the quarterly MDS assessment was incomplete in Section M. Section M0100 indicated the presence of a pressure injury, but Sections M0210 and M0300 did not document whether the resident had unhealed pressure injuries or the number of unhealed pressure injuries at each stage. During an interview, the LPN MDS coordinator stated she used the RAI Manual as a guide, acknowledged that the look-back period for Section M was seven days, and reported that she relied on wound care documentation, nursing notes, and evaluations to determine current pressure injuries. She further stated that the resident’s quarterly MDS with the ARD of 2/12/2026 should have had the pressure injuries documented and should not have been left incomplete.
Failure to Implement Care Plan Interventions for Adaptive Call Bell, ADL Care, and Clothing Needs
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for two residents, resulting in care that did not follow identified needs and documented interventions. For one resident with quadriplegia, chronic respiratory failure, tracheostomy, tube feeding, and severe cognitive impairment, the comprehensive care plan identified an ADL self-care performance deficit related to multiple conditions and specified use of a Breath Call adaptive call bell instead of a traditional button call light due to lack of mobility. Surveyor observations on multiple occasions showed the resident in bed with a standard handheld call bell clipped to the blanket and no Breath Call device in place. The director of specialty care and the DON both stated that the care plan is intended to guide individualized care and that adaptive call bells should follow the resident when rooms are changed, yet census records showed a room change prior to the observations and the adaptive device was not in use. The same resident’s care plan also included interventions for daily skin inspection during care and documented that the resident was dependent on staff for bathing. ADL documentation for the month showed baths and upper body dressing only over a limited four-day period, despite expectations from the director of specialty care and CNAs that residents receive daily bathing and gown changes. Clinical records showed orders for a midline catheter and peripheral IV for IV antibiotics, with IV therapy initiated. Progress notes later documented a new in-house–acquired pressure injury in the left antecubital area. A subsequent nursing note described that an RN was alerted by a CNA during bathing that a tourniquet had been left on the resident’s left upper arm, with damaged, discolored, and blistered skin underneath. Interview with the director of specialty care revealed that the CNA who bathed the resident on the weekend had only provided a washup and had not removed the gown due to a lack of clean gowns, which prevented earlier detection of the tourniquet and associated skin damage. For a second resident with vascular dementia with psychotic disturbance, anxiety, rheumatoid arthritis, anemia, insomnia, restlessness, agitation, and major depressive disorder, the comprehensive care plan addressed behavioral issues and specifically directed staff to layer the resident in multiple layers of his own clothes due to his cold nature. Observations showed this resident ambulating independently on the memory care unit wearing only shorts and a long-sleeve shirt, rubbing his arms and mumbling. When questioned, an LPN stated she was not aware that the care plan required multiple layers of clothing and reported that the resident usually verbalized when he was cold. The memory care unit manager stated that the purpose of the care plan was to provide staff with guidelines on resident needs and how to address them, and that care plans are updated with changes in condition or behaviors, yet the observed clothing and staff statements demonstrated that the existing care plan intervention for layering clothing was not being implemented.
Failure to Provide ADL Care and Skin Inspection Leading to Undetected Tourniquet Injury
Penalty
Summary
Facility staff failed to provide adequate ADL care, specifically bathing and dressing, to a dependent resident over several days, which contributed to a tourniquet remaining on the resident’s arm and causing skin damage. The resident had quadriplegia, chronic respiratory failure, sacral pressure ulcers, severe cognitive impairment, and was dependent on staff for all ADLs per the most recent MDS, which also documented the need for extensive medical care including oxygen, tracheostomy care, tube feeding, and suctioning. The resident’s care plan identified an ADL self-care performance deficit related to multiple conditions and required staff to provide daily skin inspections during care and to report abnormal findings. From 3/19/2026 through 3/22/2026, facility ADL documentation showed that staff recorded completion of baths and upper body dressing on day and evening shifts, including a scheduled shower/bath on 3/19/2026. However, interviews with CNAs revealed that on at least part of this period, only partial hygiene (“washup”) was provided and the resident’s gown was not removed or changed due to perceived lack of clean gowns. One CNA reported that over the weekend she did not remove the resident’s gown because it was not soiled and she believed there were no replacement gowns available, despite the facility’s expectation that CNAs bathe residents daily and change gowns daily. Another CNA stated that when linens ran out, staff had to obtain them from laundry or another floor. Clinical records showed that on 3/16/2026 and 3/18/2026, the resident was evaluated for worsening condition and received orders for a midline and peripheral IV for IV antibiotics. The eMAR documented IV antibiotic administration beginning 3/18/2026, and the director of specialty care later confirmed that facility staff placed a peripheral IV in the right arm while a pharmacy IV team placed another peripheral line in the left arm. On 3/23/2026, a CNA discovered a tourniquet still in place on the resident’s left upper arm while washing the resident, at which time the RN noted damaged, discolored, and blistered skin under the tourniquet. Subsequent documentation identified a new in-house–acquired pressure injury in the left antecubital area. The DON and other staff acknowledged that if staff had been bathing the resident and changing the gown as expected, the tourniquet should have been seen and removed earlier.
Incomplete and Inaccurate Clinical Documentation for IV Therapy, Medications, and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents, including missing documentation of IV line placement and inaccurate medication administration records. For one resident, orders on the eMAR showed a midline insertion and a peripheral IV for IV antibiotics, and progress notes referenced ongoing IV antibiotic therapy and an IV site without signs of infection. However, the clinical record contained no documentation of the midline insertion procedure, the site of the midline placement, the resident’s tolerance of the procedure, or the details and site of the peripheral IV insertion. Interviews with the director of specialty care, RN staff, and the DON confirmed that a facility nurse placed a peripheral IV in the right arm and a pharmacy team placed another line in the left arm, and that documentation of these procedures and verification from the pharmacy were not present in the record. For the second resident, staff failed to maintain accurate documentation of medication administration and assessments. The eMAR showed that an LPN documented administration of all scheduled morning and early afternoon medications, but in interview the LPN stated she did not think she had given the medications because the resident was in poor condition and likely unable to swallow, and then acknowledged she must have signed them off by mistake. This discrepancy showed that medication administration was documented as completed when it may not have occurred, contrary to standards requiring documentation immediately after actual administration. Additional documentation inaccuracies for the second resident involved trauma-informed care and neurological assessments. A social services assistant completed a trauma-informed care assessment and referenced a progress note stating the resident was doing okay with no issues or behaviors, even though nurse and physician notes and interviews indicated the resident was unresponsive, had abnormal vital signs, labored breathing, and was in the process of being transferred to the emergency department at that time. The neurological assessment record for this resident contained “X” marks in areas such as pupils, extremities, speech, and response to pain and environment, which the LPN interpreted as indicating completion of those assessment areas, but she reported having no training on the legend/code printed on the form. The DON stated there was no facility policy regarding a complete and accurate medical record, though her expectation was that all disciplines document accurate and timely information.
Failure to Ensure Required Communication Training for Direct Care Staff
Penalty
Summary
Facility staff failed to ensure completion and documentation of required communication training for a certified nursing assistant (CNA #9), constituting a deficiency in the facility’s staff education program. CNA #9 was hired on 7/6/2022, and during staff interview and document review on 4/9/2026, the facility was unable to provide any evidence that this CNA had completed the required communication training, despite the facility assessment listing “Communicating Effectively” as an annual education topic for all staff and the in-service training policy requiring all staff to participate in regular in-service education, including effective communication with residents and families for direct care staff. The staff development coordinator, who began working at the facility in December 2025, reported that there was an annual competency calendar assigning education throughout the year with a completion deadline of December 31, and acknowledged that an ongoing performance improvement plan to catch up on missed education was not yet completed, leaving CNA #9 without documented communication training at the time of the survey. On the date of the survey, leadership including the administrator, DON, vice president of operations, regional director of clinical services, assistant DON, and clinical consultant were informed of the concern, and no additional information or documentation demonstrating completion of communication training for CNA #9 was provided prior to survey exit.
Failure to Ensure Required QAPI Training for All Staff
Penalty
Summary
Facility staff failed to ensure completion of required Quality Assurance and Performance Improvement (QAPI) training for multiple employees. During a survey, review of staff records showed that a CNA, a dietary staff member, and a housekeeping staff member had no documented evidence of having completed QAPI training. The facility’s own assessment, reviewed in late February 2026, specified that all staff annual education topics included “QAPI Basics,” and the written policy on in‑service training for all staff, dated 2001, required all new and existing personnel, contracted service providers, and volunteers to participate in regular in‑service education, including training on the elements and goals of the facility’s QAPI program. In an interview, the staff development coordinator (SDC) reported that she began working at the facility in December 2025 and that there was an annual competency calendar assigning education throughout the year, with staff having until the end of the year to complete their assignments. She stated she had an ongoing performance improvement plan to catch up on missed education, including efforts to obtain education for contracted staff such as therapy and dietary personnel, but this work was not yet completed. When surveyors requested evidence of QAPI training completion for the identified CNA, dietary staff member, and housekeeping staff member, none was provided. The administrator, DON, and other regional and clinical leaders were informed of the concern, and no additional information was submitted before survey exit.
Failure to Ensure Completion of Required Compliance and Ethics Training
Penalty
Summary
Facility staff failed to ensure completion of required compliance and ethics training for two of eight employees reviewed, specifically CNA #9 and CNA #10. During an interview, the staff development coordinator reported that she began working at the facility in December 2025 and that there was an annual competency calendar assigning education throughout the year, with staff given until December 31 each year to complete required assignments. She also stated she had an ongoing performance improvement plan to address missed education that was not yet completed. Upon request, the staff development coordinator was unable to provide any evidence that CNA #9 and CNA #10 had completed the required compliance and ethics training. The facility assessment dated 2/26/2026 documented that all staff annual education course topics included corporate compliance and ethics, and the facility’s “In-Service Training, All Staff” policy dated 2001 stated that all staff are required to participate in regular in-service education, including required training on the compliance and ethics program standards, policies, and procedures, to be conducted annually when the organization operates five or more facilities. On 4/9/2026 at approximately 11:12 AM, the administrator, DON, vice president of operations, regional director of clinical services, assistant DON, and clinical consultant were informed of the concern, and no additional information was provided before survey exit.
Failure to Ensure Required Behavioral Health Training for All Staff
Penalty
Summary
Facility staff failed to ensure required behavioral health training was completed for two of eight reviewed employees, specifically a CNA and a dietary staff member. During staff interview and document review, surveyors requested evidence that these two staff members had completed behavioral health training, but no documentation was provided. The facility assessment dated 2/26/2026 identified required annual education topics for all staff, including "Tips on Managing Challenging Behaviors," "Managing Aggressive Behaviors," and "Understanding Trauma-Informed Care," indicating that behavioral health-related education was expected for all personnel. The facility’s “In-Service Training, All Staff” policy, dated 2001, stated that all staff, including new and existing personnel, contracted service providers, and volunteers, were required to participate in regular in-service education, with behavioral health listed as a required training topic. The staff development coordinator reported that she had been in her role since December 2025 and that an annual competency calendar assigned education to staff throughout the year, with completion expected by the end of the year. She also stated she was working to obtain education for contracted staff, including therapy and dietary staff, and that a performance improvement plan to catch up on missed education was in progress but not completed. Despite these processes, there was no evidence that the CNA and the dietary staff member had completed the required behavioral health training.
Failure to Implement Care Plan for Midodrine Administration
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plan for one of six sampled residents, Resident #5, related to the administration of the medication Midodrine for hypotension associated with end stage renal disease (ESRD). The comprehensive care plan dated 11/3/2025 identified a focus of hypotension related to ESRD and included interventions to give medications as ordered and to monitor vital signs as ordered and as clinically indicated. Surveyors determined that staff did not follow the care-planned intervention to administer Midodrine per the physician’s orders. In an interview, LPN #4 stated that the care plan is intended to guide staff on how to care for residents and their individual needs. The facility’s written policy on comprehensive, person-centered care plans states that a comprehensive care plan with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs is to be developed and implemented for each resident. Administrative staff, including the administrator, director of nursing, and regional director of operations, were informed of these findings during the survey, and no additional information was provided by the facility prior to survey exit.
Failure to Clarify PRN Blood Pressure Medication Orders and Monitor Blood Pressure
Penalty
Summary
Facility staff failed to clarify and appropriately implement physician orders for as-needed blood pressure medications for one resident. The resident had a physician order for Midodrine 10 mg via PEG tube every eight hours as needed for orthostatic hypotension, to be given when systolic blood pressure (SBP) was under 100 mmHg, and a separate order for Clonidine to be given by mouth every eight hours as needed for hypertension, to be given when SBP was over 170 mmHg. Review of the clinical record did not show that the resident’s blood pressure was being taken every eight hours to determine whether either of these PRN medications was needed. During an interview, an LPN stated that when a medication requires a blood pressure check, the nurse should take the blood pressure and then administer or hold the medication according to the physician’s order. In another interview, the regional director of clinical services reported that the facility had previously been cited regarding Midodrine orders and had addressed this with physicians by changing such orders from PRN to scheduled doses with hold parameters, and also stated that it was unusual to have a PRN order for Clonidine and that these orders needed clarification. Administrative staff, including the administrator, DON, and regional director of operations, were informed of these findings, and no additional information was provided before survey exit.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Facility staff failed to administer Midodrine according to physician orders for one resident with hypotension related to end stage renal disease and dependence on dialysis. The physician’s order, dated 11/4/2025, specified Midodrine 10 mg via PEG tube every 8 hours to be given only when the resident’s systolic blood pressure (SBP) was under 100 mmHg. The comprehensive care plan documented the resident’s hypotension and directed staff to give medications as ordered and monitor vital signs as ordered and as clinically indicated. The facility’s medication administration policy required staff to validate physician-ordered parameters prior to medication administration. Despite these orders and policies, the January 2026 MAR showed that Midodrine was administered on multiple occasions when the resident’s SBP was above 100 mmHg. Specifically, the drug was given when blood pressures were recorded as 126/80, 122/76, 126/86, 148/80, 125/78, and 117/83. During an interview, an LPN stated that when a medication has blood pressure parameters, the nurse should take the blood pressure and then administer or hold the medication based on the physician’s order, and acknowledged that the Midodrine should not have been administered under the documented blood pressure readings. Administrative staff were informed of these findings, and no additional information was provided prior to survey exit.
Failure to Monitor Blood Sugar and Perform Post-Fall Neuro Checks
Penalty
Summary
Facility staff failed to provide care and services to promote the highest level of wellbeing for three residents by not following physician orders and facility policies. For one resident with diabetes, acute/chronic respiratory failure, and a tracheostomy, staff did not perform or document blood sugar checks as ordered before meals and at bedtime on multiple occasions. The resident was cognitively intact and dependent for most activities of daily living. Staff interviews confirmed that if blood sugar checks are not documented, there is no evidence they were performed, and review of the facility's policy indicated that a physician's order must be verified for such procedures. Two other residents, both with significant medical histories including cerebrovascular accident, atrial fibrillation, NSTEMI, diabetes, CHF, subdural hemorrhage, and tracheostomy, experienced falls resulting in head injuries and bleeding. In both cases, the facility failed to initiate and document neurological checks post-fall as required by facility policy and standard clinical practice. Staff interviews revealed that neuro checks should be started immediately after a fall, especially when the resident is on anticoagulants or has sustained a head injury, and should be documented on a paper flowsheet. However, administrative staff confirmed that there was no evidence of neuro checks being performed for either resident after their respective falls. Facility documentation and staff interviews consistently indicated that the required monitoring and documentation were not completed for these residents. The facility's own policies on obtaining fingerstick glucose levels and managing falls and fall risks were not followed, and there was no evidence provided to show that the necessary assessments and interventions were carried out as ordered or per policy.
Failure to Include Diabetes Management in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop a baseline care plan addressing diabetes and blood sugar monitoring for a newly admitted resident diagnosed with diabetes, acute/chronic respiratory failure, and a tracheostomy. Upon admission, the resident was assessed as not cognitively impaired and was dependent on staff for mobility, transfers, dressing, hygiene, toileting, and eating setup. The baseline care plan created at admission focused only on discharge planning and equipment needs, without including any interventions or monitoring related to the resident's diabetes or blood sugar levels. A physician's order for blood sugar checks before meals and at bedtime was present, but there was no evidence that the baseline care plan incorporated these orders or addressed diabetes management until several days after admission. Staff interviews confirmed that diabetes should have been included in the baseline care plan, and documentation review supported the omission. The deficiency was acknowledged by administrative staff, with no additional information provided prior to survey exit.
Failure to Implement Wound Care Recommendations and Repositioning Protocols
Penalty
Summary
Facility staff failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident, staff did not implement wound nurse practitioner recommendations for treatment of a right heel and a right anterior lower leg pressure injury. The wound nurse practitioner recommended specific treatments, such as skin prep for the right heel and various wound dressings for the lower leg injury, but these were not entered into the physician orders or the electronic treatment administration record (eTAR) in a timely manner. Observations confirmed that staff were unaware of any treatment in place for the right heel, and documentation showed a delay in implementing recommended treatments for the lower leg wound. Another resident experienced a worsening pressure injury due to the facility's failure to change treatment as recommended by the wound nurse practitioner. The resident was totally dependent on staff for turning and positioning, yet the recommended wound care was not implemented for an extended period. Documentation revealed that the prescribed frequency of wound care was not followed, and the wound increased in size during this time. Additionally, staff failed to turn and reposition the resident as required, with observations and interviews confirming that the resident was left in the same position for several hours and did not receive the necessary assistance overnight. A third resident with a stage 4 sacral pressure ulcer did not receive the wound nurse practitioner's recommended changes in wound care, including the use of medical grade honey fiber and dual antibiotic coverage for a suspected infection. The facility continued with an outdated treatment regimen, and documentation showed that turning and positioning tasks were not performed on multiple nights. The resident's wound worsened, with increased depth and slough, and the recommended interventions were not implemented prior to the resident's discharge to the hospital.
Failure to Maintain Clean, Homelike Environment and Address Odors
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across multiple nursing units and common areas. Persistent strong urine odors were observed in two of three nursing units and one of three common hallways over several days, despite ongoing cleaning efforts by housekeeping staff. The director of housekeeping acknowledged the difficulty in controlling odors, particularly in areas with residents requiring frequent changing and in units with poor ventilation. The presence of these odors was confirmed by both staff and surveyors during multiple observations. In addition to odor issues, staff failed to maintain privacy curtains in a clean and sanitary condition for several residents. Observations revealed privacy curtains hanging off their tracks and touching the floor, as well as curtains with visible brown stains and debris. These conditions persisted over multiple days and were not addressed until brought to the attention of the director of environmental services during the survey. The facility's policy requires a clean, sanitary, and orderly environment, including the maintenance of privacy curtains, but these standards were not met for the affected residents. Furthermore, staff failed to provide a clean environment for a resident who was left with a bloody pillowcase in contact with his body for at least two days. The resident, who was totally dependent on staff for turning and positioning and was cognitively intact, reported that no staff member offered to change the soiled pillowcase overnight. Both an LPN and a CNA interviewed during the survey agreed that this was not a clean or homelike environment for the resident. These deficiencies were observed and confirmed by surveyors and facility leadership during the survey process.
Failure to Timely Report and Investigate Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to implement policies and procedures for reporting and investigating abuse, neglect, and injuries of unknown origin (IUO) for multiple residents. In several cases, staff did not report IUOs to the state agency within the required timeframe, and documentation of final investigative reports was missing or incomplete. For example, one resident with severe cognitive impairment was found with a large bruise on her hand, and although staff notified the physician and responsible party, the injury was not reported to the state agency as an IUO until several days later. Staff interviews confirmed that the policy required reporting within two hours, but this was not followed. Another resident was discovered with significant bruising and was unable to recall any injury or trauma. The incident was not reported to the state agency until several days after discovery, and staff statements indicated a lack of immediate notification to management as required by policy. Additionally, for a resident with an allegation of neglect, there was no evidence that the final investigative report was sent to the state agency within the required five-day period. Staff interviews confirmed knowledge of the reporting requirements but acknowledged the failure to submit the necessary documentation. A further case involved a resident with severe cognitive impairment who was found with an old bruise of unknown origin. The incident was not reported to the state agency within the required two-hour window, and documentation of the report was incomplete. Staff interviews consistently indicated awareness of the facility's abuse and IUO reporting policies, including the need for immediate reporting and investigation, but these procedures were not consistently followed for the residents involved.
Failure to Implement Comprehensive Care Plans and Physician Orders
Penalty
Summary
Facility staff failed to implement comprehensive care plans for multiple residents, resulting in deficiencies related to wound care, pressure injury prevention, infection control, medication education, and tracheostomy care. For one resident with severe cognitive impairment and immobility, staff did not follow wound nurse practitioner recommendations for treating a right heel and right anterior lower leg pressure injury. Orders for recommended treatments, such as skin prep and specific wound dressings, were not entered or implemented in a timely manner, and documentation in the electronic treatment administration record (eTAR) did not reflect the recommended care until weeks after the initial assessment. Interviews with staff revealed a breakdown in communication and order entry processes between the wound nurse practitioner, facility wound nurse, and primary care physician. Another resident with multiple pressure injuries on the buttocks was not turned or repositioned according to the care plan, which required assistance every two hours. Observations showed the resident remained in the same position for extended periods, and the resident reported not being repositioned overnight. The care plan specifically noted the need for monitoring, reminders, and assistance with turning and positioning, but these interventions were not consistently provided. Additional deficiencies included failure to implement contact precautions for a resident with shingles, as staff wore gloves but not gowns and posted the incorrect precaution signage. For a resident with a tracheostomy, required care was not documented as completed on several shifts, as evidenced by blank entries in the respiratory administration record. Another resident receiving anti-anxiety medication did not receive documented education about the risks, benefits, and side effects of the medication, as required by the care plan. In each case, the facility's failure to follow individualized care plans and physician or practitioner recommendations led to lapses in care delivery and documentation.
Failure to Provide and Document Tracheostomy Care for Two Residents
Penalty
Summary
Facility staff failed to provide required tracheostomy care for two residents, as evidenced by missing documentation on the respiratory administration records. For one resident, a physician's order specified tracheostomy care every shift and as needed, but the clinical record showed that care was not documented on several night shifts in January and February. The facility's policy required tracheostomy care at least once daily for established tracheostomies and at least every eight hours for unhealed tracheostomies. Interviews with nursing staff confirmed that tracheostomy care includes cleaning around the stoma, changing gauze, and changing the inner cannula, and that completion of care is evidenced by signing the respiratory administration record. A second resident also had a physician's order for tracheostomy care every shift and as needed, but the clinical record revealed multiple instances in March and April where care was not documented during both day and night shifts. The absence of signatures on the respiratory administration record indicated that tracheostomy care was not provided as ordered. Facility administrative staff were made aware of these concerns during the survey process. No additional information was provided prior to the survey exit.
Failure to Complete Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to provide complete dialysis communication for a resident with end stage renal disease (ESRD) who required hemodialysis and had a left arm AV fistula. According to the clinical record and physician orders, staff were required to complete a dialysis communication form and record vital signs prior to transporting the resident to dialysis on each treatment day. However, review of the Hemodialysis Communication Records revealed multiple instances across November, December, and January where pre-dialysis or dialysis communication forms were not completed as required. The resident's care plan documented the ongoing need for hemodialysis, and staff interviews confirmed the process for completing and transmitting dialysis communication forms. Despite this, there were several dates where no documentation was present, indicating a failure to follow established protocols and facility policy, which required routine communication of relevant information to the dialysis center on treatment days.
Failure to Administer Ordered Medication Prior to Dialysis
Penalty
Summary
Facility staff failed to prevent significant medication errors for one resident who was receiving dialysis. According to physician orders, the resident was to receive Midodrine as needed for hypotension prior to dialysis, provided their systolic blood pressure was below 140. Review of clinical records, hemodialysis communication records, and electronic medication administration records (eMARs) showed that on multiple occasions, the resident's blood pressure was within the parameters for administration, but there was no documentation that the medication was given before dialysis. The care plan for the resident included instructions to administer medications as ordered and to monitor for side effects and effectiveness, but these interventions were not followed as documented. Interviews with facility staff, including an LPN and the medical doctor, confirmed that the expectation was for Midodrine to be administered on dialysis days when the resident's blood pressure was below 140. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not adhered to in this case. The deficiency was brought to the attention of the administrator, director of nursing, and regional clinical nurse, with no further information provided prior to the survey exit.
Failure to Provide Dignity and Timely Response to Resident Needs
Penalty
Summary
Facility staff failed to provide dignity for two residents. For one resident, staff did not answer the call bell in a timely manner. The resident, who was cognitively intact according to the most recent MDS assessment, was observed waiting 13 minutes for staff to respond to her call bell, despite seven staff members being present in the hallway. The resident reported that response times varied and that she had waited up to an hour for assistance. Facility policy required call bells to be answered as soon as possible, and a CNA confirmed that the expected response time was within two minutes. For another resident, staff failed to provide dignity and respect in the dining room. A sign was posted at the entrance of the dining room stating that any residents arriving after a certain time must get their tray from their room or hallway. The resident, also cognitively intact per the most recent MDS, expressed dislike for the sign but felt compelled to follow the rule. Interviews with dietary and activities staff revealed uncertainty about who posted the sign. Facility policy required residents to be treated with dignity and respect at all times.
Failure to Inform Resident of New Medication Orders and Associated Risks
Penalty
Summary
Facility staff failed to notify a cognitively intact resident of new physician orders for the administration of Percocet and Xanax, including the associated risks, benefits, and alternatives. The resident, who had diagnoses including cancer of the larynx and anxiety, was admitted with a PEG tube and was capable of making daily decisions as indicated by a high BIMS score. Despite physician orders for these controlled medications and documented administration on multiple occasions, there was no evidence that the resident was informed in advance about the medications or their potential effects. The resident's care plan included an intervention to educate the resident and their family or caregivers about the risks, benefits, and side effects of medications being given. However, interviews with facility staff confirmed that no documentation or evidence existed to show that this education or notification occurred prior to the administration of Percocet and Xanax. The facility's policy requires residents to be informed and participate in care planning and treatment, but this was not followed in this instance.
Failure to Ensure Resident Access to Personal Possessions After Room Change
Penalty
Summary
Facility staff failed to ensure that a resident's personal clothing and possessions were properly relocated and accessible following a room change. During an observation, it was found that the resident's clothing, including pajama pants, sweatshirts, and water bottles, remained in a vacant room that the resident had never occupied, rather than being moved to the resident's current room. Staff interviews confirmed that the clothing belonged to the resident and acknowledged that all personal items should have been transferred to the new room. Additionally, other items such as a pressure-reducing boot and linens of unclear status were found in the room, with some items not labeled with a resident's name. The resident, who was moderately cognitively impaired according to a recent BIMS assessment, expressed awareness that his clothing was missing and stated that he wanted his clothes in his current room. Facility policy requires staff to treat residents with respect and dignity and to protect residents from misappropriation of property. The failure to ensure the resident's personal possessions were accessible and properly managed resulted in a deficiency related to resident rights and respect for personal property.
Failure to Provide Privacy During Resident Assessments
Penalty
Summary
Facility staff failed to maintain privacy for two residents during medical assessments. The nurse practitioner was observed assessing one resident's chest, back, and abdomen with a stethoscope in the dining room while other residents were present. Similarly, another resident was assessed in the same public setting, with the nurse practitioner palpating the resident's neck and listening to their chest and back in the dining room. These assessments were conducted in the presence of other residents, rather than in a private setting as required by facility policy. Interviews with an LPN confirmed that resident assessments are typically performed in private settings and that conducting such assessments in the dining room would only be appropriate in an emergency. The nurse practitioner acknowledged that while assessments are usually done in residents' rooms, they are sometimes performed in public areas for timing reasons. Facility leadership was made aware of these incidents, and the facility's policy was reviewed, which mandates the protection of resident privacy during treatment procedures.
Failure to Attempt Alternatives Before Administering Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident was free from chemical restraint by not documenting or attempting alternative interventions prior to administering Xanax (Alprazolam), a psychotropic medication. The resident in question was admitted with a diagnosis that included anxiety and was assessed as cognitively intact, scoring 14 out of 15 on the Brief Interview for Mental Status (BIMS). The physician's order allowed for Xanax to be given as needed for anxiety via PEG-tube for 14 days, and the medication administration record showed that the resident received Xanax on multiple occasions. During interviews, administrative and clinical staff confirmed that there was no evidence of attempts at alternative interventions before administering the medication. This lack of documented or attempted non-pharmacological interventions prior to the use of a controlled drug constituted a failure to prevent the unnecessary use of psychotropic medications and the use of a chemical restraint.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to timely report injuries of unknown origin (IUO) for three residents, as required by facility policy and state regulations. In one case, a resident with severe cognitive impairment was found with a large bruise on her left hand while in the dining room. Although the injury was observed and reported internally to the medical doctor, responsible party, and unit manager, the incident was not reported to the state agency until three days later. Staff interviews confirmed that the injury was unwitnessed, the resident was unable to provide a statement due to dementia, and the facility's policy required reporting IUOs within two hours of discovery. Another resident, also with severe cognitive impairment, was discovered with a large bruise on the left upper extremity after being transferred between units. The resident had no recall of injury or trauma, and staff statements indicated no witnessed incident. The IUO was not reported to the state agency until several days after discovery, despite staff and administrative interviews confirming that such incidents should be reported immediately and within two hours if the cause is unknown. A third resident was found with a bruise of unknown origin on the upper left side of the forehead. The injury appeared to be in the healing stage, and no staff could confirm any fall or incident that could have caused it. The incident was not reported to the state agency within the required two-hour timeframe. Facility policy clearly defined immediate reporting requirements for suspected abuse, neglect, or IUO, but these were not followed in these cases, as confirmed by staff and administrative interviews and documentation review.
Failure to Submit Follow-Up Investigative Reports to State Agency
Penalty
Summary
Facility staff failed to submit required follow-up investigative reports to the state agency for two residents following incidents involving allegations of neglect and injury of unknown origin. For one resident, who was cognitively intact according to the most recent MDS assessment, an incident report documented an allegation of neglect. However, review of facility records, including fax confirmation sheets and the incident file, did not show evidence that the final investigative report was sent to the state agency within the required timeframe. Interviews with facility staff, including the unit manager and administrator, confirmed the absence of documentation showing submission of the follow-up report as required by facility policy. For another resident, who was severely cognitively impaired and had a diagnosis including Alzheimer's disease, an incident report documented a bruise of unknown origin. Although initial reporting to the state agency was evidenced by fax confirmation, there was no documentation confirming that the follow-up investigative report was sent within five business days as required. Staff interviews indicated an understanding of the reporting requirements, but review of the fax confirmation sheets and incident documentation failed to provide evidence that the follow-up report was submitted to the state agency.
Failure to Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
Facility staff failed to follow professional standards of practice for monitoring a resident after an unwitnessed fall. Specifically, for one resident who was assessed as being at moderate risk for falls and was taking anticoagulant medication, there was no documented evidence of neurological checks being completed after the resident was found on the floor. The facility's own policy required observation and documentation of neuro checks for approximately 48 hours following an unwitnessed fall, but the clinical record did not contain this documentation. The resident's progress notes indicated that after being found on the floor, an initial assessment was performed, and the responsible party and nurse practitioner were notified. The notes referenced that a neurological assessment was in place, but there was no further evidence of ongoing neuro checks in the medical record between the time of the fall and the resident's departure for a medical appointment the following day. Interviews with staff confirmed that neuro checks should have been performed and documented, but no such documentation could be produced. The facility's fall investigation also failed to provide evidence of completed neuro checks, despite indicating that they had been initiated. The care plan for the resident identified a risk for falls due to multiple medical conditions, including impaired mobility, respiratory failure, and infection. Administrative and clinical staff were unable to provide any additional documentation of neuro checks when asked, confirming the deficiency in following professional standards for post-fall monitoring.
Catheter Collection Bag Not Maintained Off Floor
Penalty
Summary
Facility staff failed to maintain proper positioning of an indwelling urinary catheter collection bag for a resident diagnosed with paraplegia and obstructive uropathy, who was totally dependent on staff for turning and positioning. On multiple occasions, the resident was observed sitting up in bed with the catheter collection bag lying completely on the floor. These observations occurred on two consecutive days, despite the resident having a physician's order to maintain a straight drain catheter and being cognitively intact for making daily decisions. Interviews with both an LPN and a CNA confirmed that catheter bags should not be in contact with the floor due to infection risks. Review of the facility's urinary catheter care policy also specified that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated complications, including urinary tract infections. The deficiency was communicated to facility administrative and clinical leadership, and no additional information was provided prior to exit.
Failure to Document Non-Pharmacological Pain Interventions Prior to PRN Medication Administration
Penalty
Summary
Facility staff failed to implement a complete pain management program for one resident who was cognitively intact and had a physician's order for prn (as needed) Percocet for pain. The clinical record and electronic medication administration record (eMAR) showed that the resident received Percocet on multiple occasions, but there was no documentation that non-pharmacological interventions were attempted prior to administering the medication on at least two of those dates. Progress notes and the eMAR lacked evidence of such interventions, despite facility policy requiring evaluation and documentation of non-pharmacological pain management methods before administering prn pain medication. During staff interviews, an LPN confirmed that the standard procedure is to assess the resident, attempt non-pharmacological interventions, and only administer prn pain medication if those interventions are ineffective. The LPN also acknowledged that there was no documentation of non-pharmacological interventions for the resident on the specified dates. The facility's policy further supports the requirement to monitor and document the effectiveness of non-pharmacological interventions as part of pain management.
Failure to Address and Document Resident's Medication Refusal Prior to Dialysis
Penalty
Summary
Facility staff failed to ensure that a resident was under appropriate physician care regarding the refusal of prescribed medications prior to dialysis. The resident, who was cognitively intact and able to make daily decisions, consistently refused to take morning medications on dialysis days, believing that the medications would be flushed out during the dialysis process. This refusal was documented multiple times in the medication administration record and nurses' notes, with staff indicating that the physician was aware of the refusals but did not provide new orders or address the issue in the clinical record. Interviews with staff and the physician confirmed that the physician was aware of the resident's ongoing refusal and had discussed the risks with the resident, but failed to document these conversations or provide further education or consultation as recommended by facility policy. The resident reported that no staff, including the physician, had addressed his concerns or refusal of medications. Facility policy requires physicians to supervise medical care, participate in assessment and care planning, and provide consultation or treatment as needed, but these actions were not documented or carried out in this case.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
Facility staff failed to provide evidence of monitoring anticoagulant medication use for one resident from 2/1/25 to 2/11/25. The resident, who had a history of pulmonary embolism and was on anticoagulant therapy with Apixaban as ordered by the physician, was readmitted to the facility and assessed as taking anticoagulant medication on the most recent MDS. The physician's orders and the resident's care plan both indicated the need for monitoring for signs and symptoms of anticoagulant complications, including bleeding, bruising, and changes in vital signs. Despite these orders and care plan interventions, the electronic medication administration record (eMAR) showed that while Apixaban was administered as prescribed, documentation of anticoagulant monitoring did not begin until the night shift on 2/12/25. There was no evidence of monitoring for adverse effects or complications related to anticoagulant use from 2/1/25 to 2/11/25. Staff interviews confirmed that monitoring should occur every shift and be documented in the eMAR, but this was not done during the specified period. Facility policies also required clinical and laboratory monitoring for residents on anticoagulants.
Failure to Follow Infection Control Practices for Multiple Residents
Penalty
Summary
Facility staff failed to follow infection control practices for three residents. For one resident with a tracheostomy, a respiratory therapist was observed performing tracheostomy care without adhering to proper glove and hand hygiene protocols. The staff member donned clean gloves, touched potentially contaminated surfaces, and then proceeded to open sterile supplies and don sterile gloves over the soiled gloves. The staff member continued to provide care, including cleaning the stoma and replacing the inner cannula, without changing gloves or performing hand hygiene as required by facility policy and CDC guidelines. Another resident, who was totally dependent on staff for turning and positioning and had a diagnosis of paraplegia, was observed multiple times with a pillowcase containing a moderate amount of blood in contact with his leg. Despite these observations, staff did not offer to change the soiled pillowcase, and the resident reported that no staff member had offered to change it overnight. Interviews with nursing staff confirmed that a bloody pillowcase should not remain in contact with a resident due to infection control concerns. For a third resident with a physician's order for contact precautions due to shingles, staff failed to implement the required transmission-based precautions. During a transfer using a mechanical lift, staff wore gloves but did not wear gowns as required for contact precautions, and the signage on the resident's door indicated enhanced barrier precautions instead of contact precautions. Staff involved in the transfer stated they were unaware of the need for isolation precautions and did not wear gowns during the care activity.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care, specifically turning and positioning, for four dependent residents. These residents, identified as R2, R3, R4, and R5, were all admitted with various medical conditions that rendered them dependent on staff assistance for bed mobility, transfers, bathing, dressing, toileting, and eating. The comprehensive care plans for these residents included specific interventions for turning and repositioning every two hours to prevent skin breakdown and other complications. Documentation reviews revealed that the ADL care, particularly bed mobility and turning/positioning, was not consistently recorded for these residents on several dates and shifts. For instance, R2's documentation was missing on multiple evening and night shifts, while R3, R4, and R5 also had similar documentation gaps on various shifts. Interviews with CNAs confirmed that the expected practice was to turn residents every two hours and document it in the ADL form, yet this was not consistently done. The facility's administrative staff, including the administrator, director of nursing, regional director of operations, and regional nurse consultant, were informed of these findings. However, no further information or corrective actions were provided before the exit of the surveyors. The lack of documentation and adherence to care plans indicates a failure in providing necessary care for dependent residents, potentially impacting their health and well-being.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for three residents, leading to deficiencies in care. For Resident #7, the staff did not administer treatments as ordered for impaired skin integrity. The treatment administration record (TAR) showed multiple blanks for the prescribed treatments on specific dates, indicating that the treatments were not given. This was confirmed during an interview with an LPN, who acknowledged the importance of following the care plan. Resident #4's care plan was not followed regarding the administration of medications for altered cardiovascular status, seizure medication, and pain management. The medication administration record (MAR) showed that Midodrine was administered despite blood pressure readings outside the prescribed parameters. Additionally, Gabapentin and Oxycodone were not administered as ordered, with documentation indicating issues with pharmacy orders and lack of proper documentation in the nurse's notes. For Resident #3, the facility staff failed to administer medications and treatments as ordered for pressure ulcers, GERD, and antibiotic therapy. The TAR and MAR showed blanks and indications that medications were not administered, with notes suggesting delays in pharmacy orders. The emergency medication backup system had the necessary medications available, yet they were not utilized. Interviews with staff confirmed the care plan's purpose and the need for adherence, but the deficiencies persisted.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility staff failed to administer medications and treatments according to physician orders for two residents, leading to deficiencies in care. For Resident #3, the staff did not administer the prescribed treatments for an abdominal surgical wound and calluses on the right great toe and right lateral foot. The treatment administration record (TAR) lacked documentation for the day shift on January 20, 2025, indicating the treatments were not administered. Additionally, the staff failed to provide Vancomycin and Sucralfate as ordered, with the medication administration record (MAR) showing a code indicating the drugs were not administered. The nurse's notes revealed that the medications were ordered from the pharmacy but were not available in the emergency medication backup system, and there was no documentation of contacting the physician for further instructions. For Resident #4, the facility staff administered Midodrine despite the resident's blood pressure being outside the prescribed parameters on three occasions. The MAR documented the administration of the medication, but the nurse's notes did not provide any explanation for administering the medication against the physician's orders. Furthermore, the staff failed to administer Gabapentin as ordered, with the MAR indicating the medication was on hold, and the nurse's notes lacked documentation explaining the hold. The narcotic count sheet showed discrepancies in the available doses, suggesting the medication was not administered as prescribed. Additionally, the staff did not administer Oxycodone as ordered for Resident #4, with the MAR indicating the medication was not administered on two occasions. The nurse's notes documented issues with the pharmacy not receiving the prescription, but there were available tablets in the narcotic drawer that could have been used to administer the correct dose. These failures in medication administration and documentation highlight significant deficiencies in the facility's adherence to physician orders and medication management policies.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility staff failed to provide adequate care and services for the treatment of pressure injuries for three residents. For Resident #7, the staff did not apply physician-prescribed treatments, including Betadine and [NAME] Prep, to treat deep tissue injuries on both heels. The treatment administration record (TAR) lacked documentation for several dates, indicating missed treatments. The wound care nurse practitioner acknowledged that missing treatments could negatively affect the healing process, although it was unclear if this occurred for Resident #7. For Resident #9, the facility staff did not adhere to proper infection control practices during wound care. An LPN was observed performing wound care without changing gloves after removing a soiled dressing and before cleaning the wound. This action was contrary to the facility's wound treatment policy, which requires changing gloves and performing hand hygiene between these steps. The LPN admitted to the oversight during an interview. Resident #3's care was also deficient, as there was no documentation of the administration of treatments for pressure injuries on a specific date. The physician orders required daily cleansing and application of various treatments to the resident's wounds, but the TAR did not reflect this for the day shift on the specified date. The facility's comprehensive care plan emphasized the importance of administering treatments as ordered, but this was not evidenced in the records.
Failure to Notify Physician of Unadministered Medications
Penalty
Summary
The facility staff failed to notify the physician and responsible party when medications were not administered to a resident, identified as Resident #4, as per the physician's orders. The resident was readmitted on January 4, 2025, with orders for Sucralfate and Vancomycin to be administered via PEG-tube twice daily. However, the Medication Administration Record (MAR) indicated that these medications were not administered at the scheduled times, marked with a code '22' for 'Drug/Treatment Not Administered.' Despite the availability of these medications in the facility's emergency backup system, they were not administered, and the physician was not notified of the unavailability. An interview with an LPN revealed that the facility has a backup pharmacy system and a policy for handling unavailable medications, which includes notifying the physician and obtaining new orders if necessary. However, the LPN confirmed that the nurse should document the reason for not administering the medication and notify the physician and responsible party, which was not done in this case. The facility's policy on unavailable medications was not followed, leading to a deficiency in care for Resident #4.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to protect a resident from sexual abuse by another resident. The incident involved a female resident with severe cognitive impairment, as indicated by a BIMS score of zero, who was found in a compromising situation with a male resident. The male resident, who also had cognitive impairments, was observed by a CNA engaging in inappropriate sexual behavior with the female resident. The female resident was found undressed from the waist down, and the male resident was seen coming out of the bathroom fully clothed. The incident was immediately reported to the unit manager, and the responsible parties, including the medical doctor and hospice, were informed. A police report was filed, and the female resident was sent to the emergency room for a possible sexual assault evaluation. The male resident was placed under 1:1 supervision following the incident. Both residents were noted to have cognitive impairments, with the male resident having a history of sexual ideation and the female resident having a history of seeking male attention. The facility's investigation revealed that the male resident had no prior offenses on the Virginia State Police Sex Offenders screening, although there was no evidence of a screening being conducted at the time of his admission. Staff interviews indicated that the male resident was generally independent in his activities of daily living and had made comments about being attractive to women. The facility's synopsis of the event noted that neither resident had any recollection of the incident, and no injuries were observed on the female resident.
Failure to Document Medication Administration and Notification
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, specifically regarding the documentation of medication administration. The physician's order required Metoprolol Tartrate to be administered twice daily via PEG-tube for essential hypertension. However, on a scheduled dose, the medication was marked as 'Hold' without any documented notification to the doctor or responsible party explaining why the medication was not administered. Additionally, there were no documented parameters for holding the medication, which is a critical aspect of medication management. An interview with an LPN revealed that if a medication is unavailable, the nurse should document the reason in the clinical record and notify the doctor and responsible party. Despite this protocol, the nurse practitioner confirmed that she was informed via text about the medication being held, but this communication was not documented in the resident's clinical record. The facility's policy on charting and documentation requires notification of family, physician, or other staff when indicated, which was not adhered to in this instance.
Deficiency in Kitchen Utensil Sanitation
Penalty
Summary
The facility staff failed to maintain food preparation utensils in good repair and in a sanitary manner in the kitchen. During an observation, a metal shelving unit was found to contain serving and food preparation utensils that were not clean. Specifically, a metal serving spoon, a metal slotted spoon, and an ice cream scoop were observed with visible debris. Additionally, a plastic spatula was found with a broken tip, and a brush was noted to be charred, oily, and with stiffened bristles. The dietary manager acknowledged that these utensils should have been clean and ready for use, and proceeded to wash the dirty utensils and discard the damaged ones. The facility's sanitation policy, dated November 2022, requires that all utensils, counters, shelves, and equipment be kept clean, maintained in good repair, and free from defects that may affect their use or proper cleaning. The administrator, director of nursing, regional director of operations, and regional nurse consultant were informed of these findings. No further information was provided before the exit of the surveyors.
Deficiencies in Resident Record-Keeping and Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for three residents, leading to deficiencies in documentation and care. For one resident, the facility continued to document the changing of a urinary drainage bag on shower days even after the Foley catheter was discontinued. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the error in the Treatment Administration Record (TAR), which inaccurately recorded the treatment as completed on several dates after the catheter was removed. Another resident's medical record contained conflicting information regarding advanced directives. The physician orders indicated a 'Full Code' status, while other documents, including a social services assessment, incorrectly noted the resident as having no advanced directives and being 'Do Not Resuscitate' (DNR). Interviews with social services staff revealed that the error might have been due to incorrect documentation, as the staff member admitted to possibly clicking the wrong box. For the third resident, the facility failed to document efforts to arrange a dental consult for a toothache. Although a nurse practitioner had noted the need for a dental evaluation, the clinical record did not reflect any follow-up actions. Interviews with staff revealed that the resident's family had refused an outside dental consult, preferring the facility's visiting dentist. However, this refusal and the subsequent arrangements were not documented in the resident's medical record, highlighting a gap in communication and record-keeping.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to implement comprehensive care plans for four residents, leading to deficiencies in their care. Resident #429, who was admitted with respiratory failure and a urinary catheter, did not receive consistent documentation of urinary catheter care as required by the care plan. The treatment administration record (TAR) showed missing documentation for catheter maintenance and urinary output on multiple shifts in February and March 2024. Interviews with staff confirmed that the care plan was not implemented as intended. Resident #128, who required dialysis due to end-stage renal disease, also experienced lapses in care plan implementation. The care plan specified dialysis on certain days and emergency care for the dialysis site, but there was no documentation of bleeding checks on specific dates, and communication sheets were missing for two dialysis sessions. This lack of documentation indicates that the care plan was not fully executed, as confirmed by staff interviews. Similarly, Resident #479 and Resident #84 experienced failures in the implementation of their care plans. Resident #479, who had a urinary catheter, did not receive documented catheter care on several occasions, as evidenced by blank spaces in the TAR. Resident #84, who had a tracheostomy, had numerous instances of missing documentation for respiratory therapy care, including trach care, oral care, and humidified air administration. Interviews with staff revealed that if care was not documented, it was not considered completed, highlighting a significant gap in care plan adherence.
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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