Forest Hill Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 4403 Forest Hill Avenue, Richmond, Virginia 23225
- CMS Provider Number
- 495327
- Inspections on file
- 20
- Latest survey
- February 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Forest Hill Health & Rehabilitation during CMS and state inspections, most recent first.
Several residents with known substance abuse histories continued to use illicit drugs and alcohol, returning to the facility under the influence and, in some cases, requiring emergency care for overdose or withdrawal. Staff failed to implement ongoing monitoring or effective interventions, and care plans were not promptly updated to address these behaviors. Incidents included the creation of weapons from facility materials and repeated intoxication, with staff responses limited to documentation, education, and brief monitoring.
Facility staff did not act on repeated incidents of residents using illicit drugs and alcohol, bringing these substances into the building, or creating weapons from dining room cutlery. Multiple residents with substance abuse histories experienced overdoses, altered mental status, and engaged in unsafe behaviors, while the facility failed to implement effective interventions or update care plans to address these ongoing issues.
Surveyors found extensive pest infestations, unsanitary conditions, and lack of a homelike environment throughout the facility. Multiple residents were observed in soiled clothing, with pervasive odors, dirty and cluttered rooms, broken window blinds, and unpainted wall patches. Staff and residents reported ongoing pest problems and dissatisfaction with room conditions, while common areas had leaking water, debris, and missing privacy features. Maintenance staffing was inconsistent, and facility leadership did not provide further information during the survey.
Staff failed to maintain an effective pest control program, resulting in ongoing infestations of insects and pests in resident rooms and throughout the facility. Observations included insect traps densely covered with bugs, visible pests in multiple areas, and confirmation from both residents and staff that pest control services were limited to hallways and not resident rooms. Despite monthly pest control visits, the infestation persisted, with staff and residents reporting frequent sightings of cockroaches, flies, and bed bugs.
Staff did not apply an OT-recommended orthotic device for a resident with right hemiparesis and contracture risk, despite physician orders and therapy recommendations. Observations showed the resident was not wearing the splint, and no documentation of application or tolerance was found in the record.
Facility staff did not obtain or document dental services for two residents with intact cognitive abilities, despite both expressing dental concerns and having care plans or assessments indicating the need for dental follow-up. Social services staff were unaware of the residents' dental needs, and there was no evidence that recommended dental interventions were pursued.
Several residents with various medical conditions, including visual impairment and cognitive disorders, experienced ongoing issues with inaccurate or non-functioning clocks in their rooms. Despite being alert and able to communicate, these residents were left without proper orientation to time, as staff repeatedly failed to notice or correct the clocks during daily care and service rounds. Nursing staff and leadership acknowledged the importance of accurate clocks for resident orientation, but no action was taken to address the issue during the survey.
Staff did not ensure the protection of residents' belongings, as unlabeled clothing was routinely placed in a communal area for residents to search through, rather than being returned to the rightful owners. Family members were not consistently involved in locating missing items, and multiple grievances about missing clothing and personal property were documented. The process allowed residents to claim unmarked or donated clothing, which was then labeled for them, contributing to the misappropriation of property.
Facility staff did not timely review or update care plans for several residents after repeated incidents involving substance abuse, intoxication, and safety concerns, including weapon-making and the need for 1:1 supervision. Care plans lacked updated goals and interventions to address ongoing behaviors, and staff acknowledged delays in care plan revisions despite documented incidents and changes in resident condition.
The facility did not ensure that several CNAs completed the required 12 hours of annual in-service training, as confirmed by record review and staff interviews. The absence of a full-time HR Manager contributed to this deficiency.
A resident with multiple medical and psychiatric conditions was repeatedly left in bed wearing only a hospital gown, with greasy hair, body odor, and dirty nails, and was not regularly assisted with dressing, grooming, or participation in activities, despite having personal clothing available and expressing preferences for such care.
A resident with multiple chronic conditions was found with a bottle of Polyethylene Glycol at the bedside without a documented self-administration assessment or physician order. Staff confirmed that no residents on the unit had such assessments or orders, and facility policy requires an interdisciplinary team determination for self-administration. The medication was being administered as ordered, but the presence of the bottle at the bedside without proper authorization led to the deficiency.
Staff failed to properly complete and deliver required ABNs for two residents, omitting key information such as coverage end dates, estimated costs, and appeal instructions. The forms were incomplete, unsigned, and lacked documentation of proper notification to the residents or their representatives. Periods without a qualified social worker contributed to these deficiencies.
Staff failed to provide adequate privacy for three residents during ADL care, including dressing and incontinence care. In each case, privacy curtains were missing or incomplete, and residents were exposed to roommates or staff entering the room. Staff acknowledged the importance of privacy and the limitations caused by missing curtains.
Facility staff did not provide written notification to the State LTC Ombudsman when a resident with a history of stroke and moderate cognitive impairment was transferred to the hospital for a GI bleed. The omission was confirmed through record review and staff interviews.
Facility staff did not complete required PASARR screenings prior to admission for four residents with mental health or intellectual disability diagnoses. For each affected resident, no PASARR documentation was found in the clinical record, despite the presence of relevant diagnoses and ongoing psychotropic medication use. Staff interviews and policy review confirmed that PASARR screenings were not conducted as required before admission.
Facility staff did not ensure that a resident with multiple complex medical conditions received all prescribed topical medications and treatments as ordered, due to repeated unavailability of the medications and inconsistent adherence to the facility's medication policy by nursing staff and the DON.
A resident with glaucoma, who is wheelchair-bound and requires assistance with most care, reported worsening vision and a need for glasses. Although an optometrist appointment was initially scheduled and refused, staff did not reschedule it, and the resident was not receiving prescribed eye drops or follow-up ophthalmology care.
A resident with severe cognitive impairment and multiple comorbidities, who was fully dependent on staff and at high risk for skin breakdown, developed avoidable pressure ulcers on the lower extremities that were not identified or treated for several months. Facility documentation and care plans failed to address these wounds, and regular skin assessments and physician orders for wound care were not implemented until a specialized wound care evaluation was conducted.
A resident with diabetes and other chronic conditions did not receive proper foot and nail care, as evidenced by long, discolored toenails and dry skin. Despite being scheduled for podiatry visits, there was no documentation of recent foot care, and staff were unsure when the resident was last seen by a podiatrist.
A resident experienced significant unplanned weight loss and reported dissatisfaction with the food, stating it was often burnt, bland, and not tailored to his preferences. Despite documented weight loss, incomplete nutritional assessments, and lack of direct engagement from the dietary department, the resident's food preferences were not addressed, and the Registered Dietician did not personally assess or intervene regarding the resident's nutrition.
Facility staff failed to ensure two residents were free from significant medication errors. One resident did not receive prescribed medications for hypertension, hypothyroidism, and anxiety on multiple occasions, despite alternative dosages being available. Another resident, admitted for chronic pain and a recent fracture, did not receive Methadone for four days due to delays in pharmacy coordination and communication with a Methadone clinic, leading the resident to leave the facility against medical advice. Required procedures for handling unavailable medications were not consistently followed.
A resident, assessed as cognitively intact and capable of managing their own finances, had a payment plan in place with the business office. Despite this, the facility's business office manager applied to become the resident's Social Security payee without the resident's consent, even though a physician confirmed the resident's ability to manage funds. The resident was not notified or consulted about this action.
Facility staff did not ensure that two residents, one with moderate cognitive impairment and another with intact cognition, were given the opportunity to formulate advance directives. Both were coded as full code in their records, but interviews and documentation review confirmed that neither had been offered or completed advance directive forms, and staff could not locate the necessary documentation or resources.
Facility staff failed to protect a resident from sexual abuse and harassment by another resident, discouraged the victim from contacting police, and did not report the incident to authorities as required. Staff did not conduct a comprehensive investigation, omitted key witness interviews, and failed to follow abuse reporting policies, resulting in delayed and incomplete documentation of the event.
A resident with a history of traumatic brain injury and no cognitive impairment was repeatedly exposed to drug use, sexual harassment, and an alleged sexual assault by a roommate known for substance abuse. Despite staff awareness and documentation of ongoing incidents, the facility failed to implement effective interventions, did not promptly report the abuse to authorities, and did not conduct a comprehensive investigation, resulting in inadequate protection for the resident.
Facility staff failed to follow abuse prevention policies, resulting in unreported and inadequately investigated incidents of sexual harassment, possession of a weapon by a resident with suicidal ideation, and rough handling during care. In each case, staff did not report the incidents to the state agency within required timeframes, did not conduct comprehensive investigations, and failed to protect residents as outlined in facility policy.
Staff failed to promptly report and investigate multiple allegations of abuse, neglect, and self-harm involving several residents, including incidents of sexual assault, possession of a weapon with suicidal intent, and physical abuse during care. In each case, required notifications to authorities and comprehensive investigations were not completed within mandated timeframes, and facility policies on abuse prevention and reporting were not followed.
Facility staff did not fully investigate or report a sexual abuse allegation between two residents, despite multiple reports and direct staff observations. The aggressor, with a history of substance abuse, was documented returning to the facility under the influence, and staff were aware of ongoing inappropriate behavior. Required actions such as timely reporting to authorities, comprehensive investigation, and protection of the victim were not taken, and the facility's abuse policy was not followed.
Facility staff failed to accurately code the discharge status of a resident who left AMA, incorrectly documenting the resident as discharged to a hospital in the MDS assessment despite clinical records indicating otherwise.
Three residents did not receive proper ADL care, including lack of lotion application after bathing, inadequate foot and nail care for a diabetic resident, and insufficient hygiene and grooming for a resident with multiple chronic conditions. Staff failed to follow care plans and provide necessary assistance, as confirmed by observations, interviews, and documentation review.
A resident with occasional urinary incontinence and intact cognitive function was repeatedly observed with urine-soaked clothing and left unattended by staff, despite a care plan outlining specific incontinence care interventions. The resident managed his own hygiene and obtained supplies without staff assistance during multiple episodes.
Staff failed to ensure that two residents received their prescribed medications and topical treatments as ordered, with multiple doses documented as unavailable or awaiting pharmacy delivery. Despite facility policy and available inventory, staff did not consistently check in-house supplies or follow procedures for notifying physicians and obtaining alternative orders, resulting in missed administration of both routine medications and treatments.
A resident with moderately impaired cognition and a history of nutritional deficiencies did not have her cultural food preferences honored, as her desire for Ghanaian meals such as red beans and rice was not documented or accommodated until the time of survey. The dietary profile was incomplete, and the dietician, working remotely, did not review food preferences, leaving the responsibility to the dietary manager. The resident's care plan included honoring preferences, but this intervention was not followed.
A resident with a history of malnutrition and intact cognition was served a lunch meal that included a burnt roll and overcooked beef patties, leading to complaints about the food's palatability and appearance. Despite daily checks by dietary staff, the resident reported that poor-quality food was a recurring issue and declined offers for a replacement meal.
Staff failed to ensure a sanitary environment and prevent infection transmission, as evidenced by persistent pest infestations in resident rooms and common areas, improper pest control practices, and residents with soiled clothing accessing clean linens from an unsecured closet, leading to potential cross-contamination.
Multiple residents were left without adequate visual privacy due to missing or insufficient privacy curtains and damaged window blinds. Staff and residents reported that curtains did not fully extend around beds or were missing, and a window blind allowed individuals outside to see into a resident's room. Staff acknowledged the shortage of curtains and the ongoing privacy concerns.
Failure to Prevent Substance Abuse and Accident Hazards
Penalty
Summary
Facility staff failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for four residents with known substance abuse histories. These residents continued to use illicit drugs and alcohol, often returning to the facility under the influence after leaves of absence. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse, despite repeated incidents of overdose, intoxication, and the creation of weapons from facility materials. One resident with multiple medical and psychiatric diagnoses, including COPD, bipolar disorder, and polysubstance abuse, was repeatedly sent to the emergency room for overdoses involving alcohol and drugs such as heroin and cocaine. Documentation showed that the resident was found with drug paraphernalia in his room and refused drug testing, yet the care plan interventions were limited and not promptly updated to address these behaviors. Another resident with a history of traumatic brain injury and depression was found with alcohol on several occasions, experienced falls, and was discovered making weapons out of cutlery. This resident also admitted to using drugs and alcohol obtained outside the facility, and staff interventions were limited to confiscation of items and brief periods of one-on-one monitoring. Additional residents were found under the influence of illicit substances, admitted to recent drug use, and in some cases required emergency medical attention for withdrawal or overdose. Despite these incidents, care plans were not adequately updated to reflect the need for increased supervision or monitoring, and interventions were generally limited to education, documentation, and notification of supervisors. Interviews with staff and administration confirmed awareness of the ongoing substance abuse issues, but also revealed a lack of effective strategies or consistent monitoring to prevent recurrence, resulting in continued hazards and risk to resident safety.
Failure to Address Resident Substance Abuse and Safety Risks
Penalty
Summary
Facility staff failed to administer the building in a manner that effectively and efficiently used its resources to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The administration did not act on multiple incidents of residents using illicit drugs and alcohol within the facility, nor did it ensure that all residents were protected from these substances being brought into the building. Additionally, the facility did not address incidents where a resident created sharp, stabbing weapons from dining room cutlery. Several residents with known substance abuse histories were involved in repeated incidents, including smoking in the facility, cheeking narcotic medications, being sent to the emergency room for intoxication or altered mental status, and using or possessing illicit substances such as heroin, methamphetamine, marijuana, and alcohol. There were also documented instances of residents leaving the facility to obtain illegal substances and returning under the influence, as well as a resident being found with a knife/boxcutter and creating weapons from forks. Despite these events, the facility did not implement effective interventions or update care plans to address the ongoing substance abuse and related noncompliant behaviors. A review of the facility's admission contract revealed a clear policy prohibiting the possession or use of alcohol and controlled substances without permission and a physician order, with violations subject to discharge. However, the facility failed to enforce this policy or take appropriate action in response to repeated violations. The interim administrator was unaware of the ongoing issues, and clinical records showed a lack of or ineffective interventions to prevent recurrence, resulting in continued substance use, overdoses, and safety risks within the facility.
Widespread Environmental and Sanitation Deficiencies
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across multiple units. Surveyors observed extensive pest infestations, including fruit flies, large flies, cockroaches, and red bugs, present in resident rooms, common areas, and even in light fixtures. Sticky insect traps were found heavily laden with insects, and residents reported that pest control services only sprayed hallways, not individual rooms. Pest control logs confirmed monthly visits, but pests persisted throughout the facility. In addition to pest issues, rooms were found with broken window blinds, urine-soaked bathrooms, pervasive odors of urine and feces, sticky and debris-covered floors, stained and soiled privacy curtains, and stained water cups. Maintenance staffing was inconsistent, with the position vacant for a period and a new director only recently hired during the survey. Multiple residents were observed in unsanitary and uncomfortable conditions. Some residents were found in urine-soaked clothing, with one resident wandering the corridor saturated in urine and another with soiled, disheveled clothing and dry, scaly skin. Residents reported dissatisfaction with the appearance and cleanliness of their rooms, noting unpainted wall patches, clutter, and the presence of roaches. In several cases, residents refused to pick up clothing due to fear of disturbing roaches hiding underneath. Staff interviews confirmed awareness of the poor conditions, with some staff attributing persistent odors to residents refusing to bathe and others acknowledging the lack of homelike appearance in rooms. Common areas and shared facilities also exhibited significant deficiencies. Water was observed leaking and pooling in the entryway, creating unsanitary conditions as people tracked water into the building. Shower rooms had rusty pipes, missing or soiled privacy curtains, and were used for storage of equipment. Debris, clothing piles, and open trash bags were found in resident rooms, and privacy was compromised by broken or missing blinds and curtains. Despite staff being made aware of these issues during the survey, no additional information or evidence of resolution was provided by the facility leadership.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program, as evidenced by persistent infestations of insects and pests in resident rooms and throughout the building. Observations revealed a sticky insect trap in one resident's bathroom that was so densely covered with insects it appeared furry, and another resident's room had small red bugs under a bed. Both residents and staff confirmed that pest control services only sprayed hallways and not resident rooms, citing reluctance to move items in the rooms. During the survey, fruit flies, large flies, cockroaches, and bed bugs were observed in all living units and common areas, and pest control logs showed that monthly services were being conducted, but the pest problem persisted. Multiple staff and residents acknowledged the ongoing presence of pests, with one CNA removing a cockroach from a surveyor's back and residents commenting on the widespread bug issue. During a Resident Council meeting, complaints about roaches were voiced, and staff confirmed frequent sightings of bugs. The facility's documentation and staff interviews indicated that pest control efforts were insufficient to address the infestation, as pests continued to be observed in various areas, including hallways, shower rooms, elevators, and stairwells.
Failure to Apply OT-Recommended Splint for Contracture Management
Penalty
Summary
Facility staff failed to apply an Occupational Therapy (OT) recommended splinting/orthotic device for a resident with a history of stroke, right hemiparesis, and expressive aphasia. The resident had a physician's order to apply a resting hand splint to the right upper extremity for up to four hours daily, with skin checks and hand hygiene per shift, as part of contracture management. The OT discharge plan also recommended daily use of the orthotic for 2-4 hours as tolerated. Despite these orders and recommendations, observations conducted over several days did not show the resident wearing the splint, and the resident's right arm was consistently noted to be bent upwards. Interviews with the OT confirmed that staff were expected to apply the splint daily during the day shift, beginning on the specified date. However, there was no documentation in the resident's record indicating that the splint had been applied or that the resident's tolerance to the device had been monitored. The administrative team was informed of these findings, and no additional information or concerns were provided by facility leadership.
Failure to Obtain and Document Dental Services for Residents
Penalty
Summary
Facility staff failed to obtain necessary dental services for two residents with intact cognitive abilities. One resident, with diagnoses including COPD and major depressive disorder, expressed concerns about obtaining dentures and reported that staff had not followed up despite his requests. Documentation showed a dental assessment recommending an upper full denture, but social services staff were unaware of the resident's needs or the assessment's recommendations. The resident's care plan included a goal to maintain and follow consults as ordered, but there was no evidence that the dental recommendation was acted upon. Another resident, diagnosed with traumatic subdural hemorrhage and high blood pressure, also reported dental concerns and feeling self-conscious about his dental status. There was no documentation of the resident's oral status in the record, despite a care plan identifying oral/dental health problems and interventions to monitor and report oral issues. Social services staff were not aware of the resident's desire for dental services, and no follow-up was documented prior to the scheduled dental visit. Both cases demonstrate a lack of follow-through in obtaining and documenting dental services as identified in assessments and care plans.
Failure to Maintain Accurate Clocks for Resident Orientation
Penalty
Summary
Facility staff failed to provide reasonable accommodation for the needs and preferences of four residents by not ensuring that the clocks in their rooms displayed the correct time. Multiple observations over several days revealed that clocks in the rooms of these residents were either set to the wrong time, not functioning, or not adjusted for time changes. Staff members, including those delivering care, food trays, and other services, did not address or correct the inaccurate clocks despite being present in the rooms and having opportunities to notice the issue. Residents affected by this deficiency included individuals with various medical conditions such as dementia with agitation, diabetes, hypertension, legal blindness, epilepsy, seizures, major depressive disorder, hemiplegia, hemiparesis, osteoarthritis, and chronic kidney disease. These residents were alert, oriented, and able to communicate their needs and concerns. Several residents expressed confusion or frustration due to the incorrect time displayed on the clocks, with one resident relying on the clock to determine meal times and another noting the difficulty in seeing their personal watch due to visual impairment. Another resident commented on the staff's lack of attention to the clock's accuracy, observing that it was only changed once a year. Interviews with staff, including a registered nurse and the director of nursing, confirmed the importance of accurate clocks for resident orientation. However, despite their acknowledgment of this need, no staff member took action to correct the clocks during the survey period. The deficiency was consistently observed and reported to facility leadership, who agreed that clocks should be accurate, but no further information or corrective action was provided at the time of the survey.
Failure to Prevent Misappropriation of Resident Property Due to Inadequate Labeling and Return Procedures
Penalty
Summary
Facility staff failed to prevent the misappropriation of resident property across all three living units. Unlabeled clothing found in the laundry was placed in a designated area for residents to search through, rather than being systematically returned to the rightful owners. Family members were not routinely involved in searching for missing items, and there were documented grievances from residents and families regarding missing clothing. In one instance, a family member reported seeing another resident wearing a jacket that did not belong to them. Both the Social Services and Housekeeping departments acknowledged that unidentified clothing was a recurring issue, and new staff in these roles were not aware of prior procedures for handling such items. For one resident, who had a history of cerebral infarct, diabetes mellitus, major depressive disorder, and dysphagia, there was no documentation of missing property, but the facility's process allowed residents to select from unclaimed and donated clothing, which was then labeled and kept by the resident. The Director of Nursing, also new to the facility, confirmed that clothing was often sent to laundry without identification, leading to items not being returned to their owners. Multiple grievances about missing clothing and personal property were noted in the facility's logs, indicating a systemic failure to safeguard residents' belongings.
Failure to Timely Review and Revise Care Plans After Substance Use and Safety Incidents
Penalty
Summary
Facility staff failed to review and revise care plans for five residents following incidents of non-compliance with alcohol and substance abuse, as well as other safety concerns. For one resident with multiple complex diagnoses, including COPD, bipolar disorder, and a history of substance abuse, the care plan was not updated after repeated incidents of smoking, cheeking narcotic medications, intoxication, and heroin use, despite documentation of these events in the clinical record. The care plan lacked specific goals and did not reflect the resident's ongoing behaviors or the interventions needed to address them. Another resident with a history of traumatic brain injury, depression, and substance abuse was involved in multiple incidents, including possession of alcohol, methamphetamine, and weapons, as well as making weapons in the facility. The care plan addressed some substance use behaviors but did not include interventions for weapon-making or adequately address the repeated substance use incidents. Similar deficiencies were noted for other residents with histories of drug use, who experienced episodes of intoxication, withdrawal, and refusal of drug testing or ER evaluation, yet their care plans were not revised to reflect these events or to implement additional supervision or monitoring. Additionally, one resident who had been receiving 1:1 staff supervision for several weeks did not have this intervention reflected in their care plan in a timely manner. The MDS Coordinator acknowledged that the care plan update was delayed, despite the resident's ongoing need for increased supervision. Interviews with facility leadership confirmed that care plans were not adequately reviewed or revised in response to significant changes in residents' conditions or behaviors, as required by facility policy.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of in-service training per year. Record review showed that three CNAs did not complete the mandated annual training hours. During an interview, the Human Resources Manager confirmed that the training requirement was not met for these CNAs and explained that the facility had not had a full-time Human Resources Manager, with the current manager working at multiple facilities and temporarily filling the role. No additional information or concerns were provided by facility leadership during the final interview.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
Facility staff failed to provide care that maintained or enhanced the quality of life for a resident with multiple diagnoses, including paranoid schizophrenia, diabetes, chronic kidney disease, intellectual disabilities, and several mental health disorders. Over several days, the resident was repeatedly observed in bed, dressed only in a hospital gown, with greasy hair, strong body odor, and dirty nails. The resident was not regularly assisted out of bed, dressed in personal clothing, or groomed to ensure cleanliness and dignity. Interviews confirmed that the resident was typically not helped into a wheelchair or dressed in personal clothing unless necessary for specific activities, and that bathing was usually performed in bed rather than in a shower. The resident's preference evaluation indicated that choosing what to wear, participating in group activities, and engaging in favorite activities were important to him. Despite having personal clothing available and facility expectations that residents be kept clean and appropriately dressed, staff did not consistently meet these standards. The unit manager confirmed the facility's expectations, and the administrator was made aware of the findings, but no additional information was provided to address the observed deficiencies.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed for self-administration of medication, as required by policy. During an initial tour, a medication bottle of Polyethylene Glycol was found on the resident's nightstand, and the resident stated it was a prescription she had picked up before coming to the facility. There was no documentation of a self-administration assessment or a physician's order permitting the medication to be kept at the bedside. Both the RN and LPN interviewed confirmed that medications should not be left at the bedside without an assessment and physician order, and neither was aware of any such assessments or orders for residents on the unit. The resident in question had multiple diagnoses, including COPD, hypertension, chronic kidney disease, diabetes, acute respiratory failure, and congestive heart failure, and required assistance with activities of daily living. The clinical record showed an active order and scheduled administration for Polyethylene Glycol, which was being administered as ordered by staff. However, the presence of the medication at the bedside without proper assessment or order constituted a failure to follow facility policy and regulatory requirements regarding self-administration of medications.
Failure to Provide Complete Advanced Beneficiary Notices
Penalty
Summary
Facility staff failed to properly complete and provide Advanced Beneficiary Notices (ABNs) for two residents who were discharged within the past six months. Specifically, the forms for these residents lacked critical information, including the date when insurance coverage would end, the estimated cost for continued services, and instructions regarding the appeal process. Additionally, neither the residents nor their representatives signed the forms, and there was no documentation that letters were sent to inform them of their rights or responsibilities. The forms were completed by therapy staff, but lacked essential details such as the name of the responsible party, date, and time of contact. During the review, it was noted that the facility had periods without a vetted, acceptable social worker, which may have contributed to the improper administration of the required notices. The newly hired social worker acknowledged the deficiencies in the documentation after reviewing the forms. The DON and Administrator were informed of these findings during the survey debriefing, and facility staff did not provide any additional information to address the identified issues.
Failure to Ensure Resident Privacy During ADL Care
Penalty
Summary
Facility staff failed to ensure personal privacy for three residents during the provision of Activities of Daily Living (ADL) care. In one instance, a resident with dementia, diabetes, hypertension, and legal blindness was assisted with dressing by a Certified Nursing Assistant (CNA) without a privacy curtain around the bed. The resident's roommate was present and able to see the care being provided, and the CNA, an agency employee, attempted to shield the resident as much as possible but acknowledged the lack of adequate privacy. Another resident, with diagnoses including epilepsy, seizures, and a history of abuse, also did not have a full privacy curtain during ADL care. Only a quarter panel curtain was available, which did not provide complete visual privacy. The roommate was present in the room during care, and the CNA again attempted to shield the resident but was limited by the inadequate curtain. A third resident, with chronic kidney disease and a history of falls, was observed receiving incontinence care with only a partial privacy curtain in place. The door to the room was closed, but the resident was visible from the doorway. Multiple staff members entered the room while the resident was exposed and receiving care, despite knocking beforehand. Staff interviews confirmed awareness of the lack of privacy curtains in some rooms and acknowledged that entering during care was inappropriate.
Failure to Notify Ombudsman of Resident Hospital Discharge
Penalty
Summary
Facility staff failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the hospital discharge of a resident. The deficiency was identified through resident record review, staff interviews, and examination of facility documents. Specifically, the Social Services Director confirmed that there was no documentation of ombudsman notification at the time of the resident's transfer to the hospital. The resident involved had a history of stroke with right hemiparesis and expressive aphasia, and was assessed as having moderately impaired cognitive abilities. The resident was transferred to the hospital after being observed with a large amount of dark bloody liquid from the rectum and complaints of lower abdominal pain radiating to the groin. The transfer was ordered by the on-call practitioner, and the resident was subsequently admitted to the hospital with a GI bleed. The lack of timely notification to the ombudsman was confirmed during interviews with facility staff.
Failure to Complete PASARR Screenings Prior to Admission
Penalty
Summary
Facility staff failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for four residents with mental health or intellectual disability diagnoses. For one resident with bipolar disorder, anxiety, and dementia, no PASARR documentation was found in the electronic health record, and the only available document was an incomplete and outdated PASARR II embedded in a Medicaid Assisted Living Annual Reassessment. The facility had experienced frequent turnover in the social worker position, resulting in a lack of oversight for preadmission screenings. Another resident with bipolar disorder and other medical conditions was admitted without a PASARR Level I being completed prior to admission from an acute care hospital. The resident was receiving psychotropic medications, and staff interviews confirmed that no PASARR documentation was found in the clinical record. The facility's policy required PASARR screenings to be completed and documented prior to admission, but this was not followed. Two additional residents, one with PTSD, major depressive disorder, and mood disorder, and another with schizoaffective disorder and moderate cognitive impairment, were also admitted without PASARR Level I screenings. Staff interviews and record reviews confirmed that no PASARR documentation was present for these residents, and staff acknowledged that the screenings should have been completed prior to admission. The deficiency was identified through observation, clinical record review, and staff interviews.
Failure to Provide and Administer Ordered Medications and Treatments
Penalty
Summary
Facility staff failed to follow professional standards of quality by not ensuring that a resident had all prescribed medications and treatments available and administered as ordered by the physician. The resident, who had multiple diagnoses including paranoid schizophrenia, diabetes, chronic kidney disease, intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder with psychotic features, and anxiety, had physician orders for several topical creams to be applied twice daily for skin protection and treatment. Clinical record review showed that these creams were repeatedly documented as unavailable or awaiting delivery from the pharmacy on multiple dates, resulting in missed doses. Interviews with nursing staff and the DON revealed that the facility's policy required nurses to notify the physician, check for alternative therapies, update orders, and inform the pharmacy and responsible parties when medications were unavailable. However, documentation and staff statements indicated that these procedures were not consistently followed, leading to lapses in medication administration and failure to implement the facility's medication policy as required.
Failure to Provide Vision Services for Resident with Glaucoma
Penalty
Summary
Facility staff failed to ensure that a resident with a diagnosis of glaucoma received necessary vision services and assistive devices. The resident, who is wheelchair-bound and requires assistance with all care except eating, reported difficulty seeing and stated he needed glasses, as his vision was worsening. Although the resident was scheduled for an optometrist appointment, he refused the initial appointment and it was not rescheduled by staff. Clinical record review showed the resident was not receiving prescribed eye drops for intraocular pressure and had not had any follow-up exams with an ophthalmologist since admission. The deficiency was identified through observation, interview, and record review, and was brought to the attention of the facility administrator.
Failure to Prevent and Address Pressure Ulcers in High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including Alzheimer's disease, muscle weakness, chronic kidney disease, and a history of repeated falls, was admitted and later readmitted to the facility. The resident was dependent on staff for all activities of daily living and was frequently incontinent. Despite these risk factors for skin breakdown, the facility failed to implement and document appropriate skin integrity interventions and assessments for an extended period. Clinical record review revealed that while the resident was identified as being at risk for impaired skin integrity, there was no care plan focus, goal, or intervention related to pressure ulcers documented between February and June. Weekly wound assessments and progress notes during this period only referenced a pressure ulcer to the coccyx, with no mention of wounds to the lower extremities. Additionally, there were no physician orders or wound care interventions documented for the resident's left or right lower extremities during this time. It was not until a specialized wound care evaluation was conducted in June that pressure ulcers to the resident's lower extremities were identified and treated. Prior to this, the facility's documentation and care planning failed to address or prevent the development of these avoidable pressure ulcers, despite the resident's high risk and the facility's own policies requiring regular skin assessments. The deficiency was confirmed through observation, staff interviews, and review of facility documentation and clinical records.
Failure to Provide Proper Foot and Nail Care
Penalty
Summary
Facility staff failed to provide appropriate foot and nail care to one resident with multiple chronic conditions, including diabetes, chronic kidney disease, and congestive heart failure. During an observation, the resident was found with long, discolored, and jagged toenails, and very dry skin on the feet. The resident expressed embarrassment about the condition of her feet and stated that it had been a long time since she received foot care. Clinical record review showed no documentation of recent podiatry visits or foot care, despite the resident being listed to be seen by the podiatrist in previous months. Interviews with staff revealed uncertainty about when the resident last received podiatry care, and the unit secretary confirmed that while residents were scheduled for podiatry visits, not all were seen if unavailable or if they refused. Only one podiatrist note was found in the clinical record from several months prior, with no further documentation of foot care provided. The deficiency was brought to the attention of facility leadership, but no additional information was provided.
Failure to Address Resident Food Preferences and Unplanned Weight Loss
Penalty
Summary
Facility staff failed to ensure that a resident's food preferences were addressed and did not act on a significant unplanned weight loss of 13.25% over six months. The resident reported dissatisfaction with the quality and taste of the food, describing it as burnt, overcooked, and bland, and stated that no one from the dietary department had discussed food preferences with him since admission. The clinical record showed a steady decline in weight from 234 lbs. to 203 lbs. over six months, and the resident confirmed the weight loss was unintentional. The resident also indicated he had not seen the Registered Dietician, and the only inquiry about food preferences was during admission, limited to allergies and foods he could not eat. Review of the clinical documentation revealed incomplete or unanswered sections regarding food and beverage preferences, and the nutritional assessment inaccurately noted stable weight and no recent weight loss. The care plan identified the resident as at risk for weight loss but interventions such as reviewing dietary preferences were not effectively implemented. The Registered Dietician, who works remotely, stated she relies on electronic health records and does not handle food preferences, delegating this responsibility to the dietary manager. No further information was provided by the facility administration when concerns were raised.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
Facility staff failed to ensure that two residents were free from significant medication errors. For one resident with multiple chronic conditions, including hypertension, hypothyroidism, and anxiety, staff did not administer prescribed medications as ordered by the physician. Specifically, Lisinopril, Levothyroxine, and Lorazepam were documented as unavailable on several occasions, and the resident did not receive these medications on those dates. Blood pressure readings during the period when Lisinopril was unavailable showed elevated values. Interviews with staff revealed that the required procedures for handling unavailable medications, such as notifying the physician, pharmacy, and responsible parties, were not consistently followed. A review of the facility's stat box indicated that alternative dosages of the required medications were available, but these were not utilized. For another resident admitted after a hospital stay with chronic pain syndrome and a recent fracture, staff failed to administer Methadone, a significant medication, for four consecutive days. The resident was on a long-term Methadone regimen for chronic pain and opioid use disorder. Documentation showed that the Methadone prescription was faxed to the pharmacy, but the medication was not delivered before the resident left the facility against medical advice. Nursing notes indicated ongoing communication issues with the pharmacy and the Methadone clinic, resulting in the resident not receiving the medication during her stay. The resident and her family were aware of the delay, and the resident ultimately chose to leave the facility due to the lack of medication. Facility policy required staff to notify the physician, obtain new orders, and inform the pharmacy when medications were unavailable. However, in both cases, these procedures were not properly implemented, leading to significant medication errors. The findings were shared with facility leadership, and no additional information was provided by the facility at the time of the survey.
Failure to Honor Resident's Right to Manage Financial Affairs
Penalty
Summary
Facility staff failed to honor a resident's right to manage their own financial affairs. The resident, who had diagnoses including Non-ST-elevation Myocardial Infarction, muscle weakness, type 2 diabetes mellitus with hyperglycemia, and essential hypertension, was assessed as cognitively intact with a perfect score on the Brief Interview for Mental Status (BIMS). Despite this, the Business Office Manager applied to have the facility designated as the resident's Social Security payee without the resident's consent. The application was made even though a physician's statement confirmed the resident was capable of managing their own funds, both currently and in the future. Interviews with the resident confirmed that they were aware of and able to manage their own financial affairs, and that they had not authorized the facility to act as their payee. The facility's policy required notification and specific steps before applying for representative payee status, but the resident reported that a payment plan was already in place and expressed concern about being pressured to leave due to unpaid balances. The Business Office Manager acknowledged submitting the application for payee status, despite documentation and professional assessment indicating the resident's capability.
Failure to Offer Opportunity to Formulate Advance Directives
Penalty
Summary
Facility staff failed to ensure that two residents were given the opportunity to formulate an advance directive. One resident, with diagnoses including depression and multiple physical impairments, was admitted and readmitted to the facility, and was assessed as having moderately impaired cognitive abilities. Despite being coded as a full code in the medical record, there was no documentation that the resident had been offered the opportunity to develop an advance directive, and the resident was unaware of having one. Another resident, with chronic kidney disease and other medical conditions, was also admitted and readmitted, and was assessed as cognitively intact. This resident was similarly coded as a full code, but there was no evidence in the records or from staff interviews that the resident had been given the opportunity to formulate an advance directive. Interviews with the Social Services Director, nursing staff, and DON revealed that no advance directive documentation was available for these residents, and the usual storage locations for such documents were missing or unavailable.
Failure to Protect Resident and Report Sexual Abuse Allegation
Penalty
Summary
Facility staff discouraged a resident from communicating with external local entities, including the police, during an abuse allegation, and failed to allow evidence from a police report in the investigation of a sexual abuse situation involving two residents. The incident involved a resident with a traumatic brain injury and no cognitive impairment, who was sexually harassed and assaulted by his roommate, a resident with a history of drug and alcohol abuse. Despite the victim's immediate report to staff and requests from both the resident and his spouse for police involvement, facility staff did not notify law enforcement or Adult Protective Services (APS) as required. The facility's documentation and staff interviews revealed that the abuse was witnessed by staff, but the administration failed to initiate a comprehensive investigation or report the incident to the state agency within the mandated timeframe. The facility's own abuse policy required police involvement when a crime was alleged, but this was not followed. Additionally, the facility failed to conduct required staff training and background checks, and did not provide adequate protection or supervision to prevent further abuse. The initial facility report was incomplete, contained inaccuracies, and was only produced after surveyors requested documentation several days after the incident. Further review showed that the facility did not interview all relevant parties, including staff witnesses, the victim's spouse, or other residents who may have been affected. The facility's failure to implement its abuse policies resulted in the lack of protection for the victim and inadequate investigation and reporting of the abuse. The state agency ultimately found the abuse to be substantiated, at least in part, based on the evidence provided.
Failure to Protect Resident from Abuse and Inadequate Response to Alleged Sexual Assault
Penalty
Summary
Facility staff failed to protect a resident from abuse by a roommate with a known history of illicit drug and alcohol use. The resident, who had a traumatic brain injury but was cognitively intact and required some assistance with mobility and hygiene, was exposed to repeated incidents of drug use, sexual harassment, and ultimately an alleged sexual assault by his roommate. Documentation and interviews revealed that the roommate frequently returned to the facility under the influence, used drugs within the facility, and made ongoing sexual advances toward the resident, culminating in an incident where the aggressor blocked the door, made explicit threats, and physically assaulted the resident, who had to push past to escape and immediately reported the incident to staff. Despite multiple documented incidents of drug use and behavioral issues by the aggressor, the facility's interventions were limited to monitoring, education, and documentation, without implementing effective measures to prevent further incidents or protect other residents. The care plan for the aggressor noted the risk of complications from substance use but did not include adequate interventions to address the ongoing behaviors. Staff interviews confirmed awareness of the aggressor's conduct and the escalating situation, yet no comprehensive action was taken to mitigate the risk or ensure resident safety. The facility failed to follow its own abuse policies, including timely reporting to state agencies, conducting a thorough investigation, and involving law enforcement when a crime was alleged. The initial facility report was delayed and incomplete, omitting key details and failing to acknowledge prior knowledge of the abuse. Staff did not interview all relevant witnesses or other potentially affected residents, and background checks and required abuse prevention training for staff were found to be deficient. The resident was only protected by being moved to another room, and no additional supervision or preventive measures were implemented for the aggressor.
Failure to Implement Abuse, Neglect, and Theft Prevention Policies and Procedures
Penalty
Summary
Facility staff failed to implement abuse prevention policies, resulting in multiple deficiencies related to the protection, reporting, and investigation of abuse, neglect, and theft. In one case, a resident with a traumatic brain injury and no cognitive impairment was sexually harassed and assaulted by a roommate who had a history of drug and alcohol use within the facility. Despite staff witnessing the incident and the victim reporting it immediately, the facility did not notify police, failed to conduct a comprehensive investigation, and delayed reporting the incident to the state agency. Staff also did not interview all relevant parties or provide additional supervision to the alleged aggressor, and the facility's documentation of the event was incomplete and inaccurate. In another incident, a resident with schizoaffective and bipolar disorder, who was cognitively intact, was found to have a switchblade in her bedside table while experiencing suicidal ideation. The resident reported her intent to harm herself and the presence of the weapon to staff, who confiscated the knife and called emergency services. However, the facility failed to report the incident to the State Survey Agency within the required two-hour timeframe, and no facility synopsis or incident report was initially filed. A third deficiency involved a resident with depression and multiple physical disabilities who alleged being handled roughly by a CNA during incontinent care. The resident reported the incident to the unit manager and later to the state health department, but the facility did not report the allegation to the State Survey Agency in a timely manner. The staff member involved was no longer employed at the facility, but the required internal investigation and reporting procedures were not followed as outlined in the facility's abuse and neglect policy.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
Facility staff failed to timely report allegations of abuse, neglect, or theft to the appropriate authorities for multiple residents. In one case, a resident with a traumatic brain injury and no cognitive impairment was sexually harassed and assaulted by his roommate, who had a history of drug and alcohol use within the facility. Despite staff witnessing the incident and being informed by the victim and his spouse, the facility did not notify the state agency, police, or Adult Protective Services (APS) within the required timeframe. The facility also failed to conduct a comprehensive investigation, did not interview all relevant parties, and inaccurately documented the timing and nature of the report. Staff training and background checks were found to be deficient, and the facility's abuse policies were not implemented as required. Another incident involved a resident with schizoaffective and bipolar disorder who expressed suicidal ideation and was found with a switchblade in her bedside table. The resident was sent to the hospital for evaluation, and the police confiscated the weapon. However, the facility did not report the incident to the State Survey Agency within the mandated two-hour window. Interviews with staff confirmed the presence of the weapon and the resident's intent, but no timely facility synopsis or incident report was filed as required by policy. A third case involved a resident with depression and multiple physical disabilities who alleged being physically abused by a staff member during incontinent care. The resident reported the incident to the unit manager and later to the state health department, but the facility did not report the allegation to the State Survey Agency in a timely manner. The staff member involved was no longer employed at the facility, but the required internal investigation and reporting procedures were not followed. The facility's abuse policy mandates immediate reporting and investigation of such incidents, which was not adhered to in these cases.
Failure to Investigate and Report Sexual Abuse Allegation
Penalty
Summary
Facility staff failed to fully investigate an allegation of sexual abuse and harassment involving two residents, despite multiple reports and direct observations by staff. One resident, who was cognitively intact and required some assistance with mobility and hygiene, reported being sexually assaulted and harassed by his roommate, who had a history of illicit drug use and behavioral issues. The incident was witnessed by staff, reported to Adult Protective Services (APS) by a complainant, and discussed with the facility administration, yet the facility did not initiate a comprehensive investigation or notify law enforcement as required by policy. Documentation revealed that the aggressor resident frequently returned to the facility under the influence of drugs and alcohol, with several instances recorded in nursing notes. Despite these documented behaviors and a care plan noting the risk of complications from substance use, interventions were limited to monitoring and education. Staff interviews confirmed awareness of ongoing issues, including the aggressor's grooming and pursuit of the victim, but no effective measures were taken to prevent escalation or protect the victim. The facility's abuse policy, which mandates background checks, staff training, resident protection, comprehensive investigation, and timely reporting to authorities, was not followed. The facility did not report the abuse allegation to the state agency within the required timeframe and only produced a Facility Reported Incident (FRI) document after being prompted by surveyors, several days after the event. The initial FRI was incomplete and contained inaccuracies, failing to reflect the full extent of the incident and the facility's prior knowledge. No statements were collected from staff witnesses, other residents were not interviewed, and the victim's spouse was not consulted. The facility also failed to provide additional supervision for the aggressor or to notify police, despite requests from the victim and his spouse. These failures resulted in the abuse not being properly investigated or reported, and residents were not adequately protected from further harm.
Inaccurate MDS Assessment for Resident Discharge Status
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident who was admitted following an acute hospital stay and subsequently left the facility against medical advice (AMA). The resident's diagnoses included chronic pain syndrome and a healing fracture of the left radius. The 5-day MDS assessment indicated the resident had intact cognitive abilities, as shown by a perfect score on the Brief Interview for Mental Status (BIMS). However, the MDS assessment incorrectly coded the resident as being discharged to a hospital, rather than reflecting the actual discharge status of leaving AMA to the community. This error was identified through staff interviews and clinical record review, which revealed that the discharge documentation in the MDS did not match the nursing notes and progress notes in the resident's medical record. The MDS Coordinator confirmed that the assessment was inaccurate, as the resident was not discharged to a hospital but left the facility AMA. The findings were shared with facility leadership, and no additional information was provided by staff at the time.
Failure to Provide Adequate ADL Care and Hygiene
Penalty
Summary
Facility staff failed to provide appropriate Activities of Daily Living (ADL) care for three residents, as evidenced by direct observation, resident and staff interviews, and review of clinical documentation. One resident, with diagnoses including dementia, diabetes, hypertension, and legal blindness, reported not receiving lotion after bathing, despite her request and no documented contraindication in her medical record or care plan. The resident stated that staff told her she could not have lotion, but there was no physician order or care plan entry supporting this restriction. During care, no lotion was applied, and the CNA was unaware of any available lotion for the resident. Another resident, who is diabetic, was observed with long, discolored, and jagged toenails, as well as very dry skin on her feet. The resident expressed embarrassment and stated it had been a long time since she received foot care. Review of the clinical record showed she was scheduled to be seen by a podiatrist but there was no documentation of podiatry visits or foot care provided in recent months, except for a single note from the previous year. Staff interviews confirmed that proper nail and skin care should be provided, especially for diabetic residents, but there was no evidence this care was delivered. A third resident, with multiple diagnoses including schizophrenia, diabetes, chronic kidney disease, and intellectual disabilities, was repeatedly observed with greasy hair, long and dirty fingernails, body and urine odor, and dressed only in a hospital gown while in bed. The resident reported that staff did not regularly get him up, dress him, or provide showers, and documentation confirmed only two showers in over a month. The care plan indicated the need for staff assistance with all ADLs, including bathing, dressing, and hygiene. During a meal observation, the resident was positioned too low in bed to eat properly, struggled to open food containers, and ate with his hands, with staff failing to provide necessary set-up assistance.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Facility staff failed to provide appropriate incontinence care for a resident who was occasionally incontinent of urine. The resident, who had diagnoses including high blood pressure and bilateral lower extremity swelling, was cognitively intact and able to communicate his needs. On two separate occasions, the resident was observed with urine-saturated pants and a puddle of urine beneath his wheelchair, leaving a trail of urine on the floor. The resident reported that he washed himself and changed his incontinence briefs as needed, but staff did not assist him with incontinence care during these incidents. The resident's care plan specified the use of disposable briefs, regular checks and changes as needed, perineal care, and changing clothing after incontinence episodes. Despite these interventions being documented, staff did not provide the necessary care or respond to the resident's needs during the observed episodes. The resident was also seen retrieving washcloths and towels from a linen closet without staff assistance. The administrative team was informed of these findings, and no additional information or concerns were provided.
Failure to Provide Ordered Medications and Treatments Due to Unavailability
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident with multiple diagnoses including epilepsy, seizures, confirmed abuse, major depressive disorder, anxiety disorder, and a brain neoplasm, several medications such as Oxycodone and Lorazepam were documented as unavailable on multiple occasions. Despite the presence of Oxycodone in the facility's Omnicell inventory and Lorazepam 0.5 mg tablets being available, there was no documentation that these resources were checked or utilized appropriately. Progress notes repeatedly indicated that medications were on order or awaiting pharmacy delivery, and staff interviews confirmed that the expected procedures for obtaining and administering medications were not consistently followed. Another resident with complex medical and psychiatric conditions, including schizophrenia, diabetes, chronic kidney disease, and bipolar disorder, did not receive ordered topical treatments such as moisture barrier cream, Cerave lotion, and Eucerin cream. These treatments were documented as unavailable or awaiting pharmacy delivery over an extended period. Staff interviews revealed that the process for addressing unavailable medications involved notifying the physician, considering substitutions, and documenting changes, but records indicated that these steps were not always completed as required. Facility policy required nursing staff to notify the attending physician, obtain new orders, and inform the pharmacy when medications were unavailable. However, documentation and staff interviews showed that these procedures were not reliably implemented, resulting in missed doses and treatments for the affected residents. The deficiency was confirmed through clinical record review, staff interviews, and examination of facility documentation.
Failure to Honor Resident's Cultural Food Preferences
Penalty
Summary
Facility staff failed to meet the cultural and ethnic meal preferences of a resident who expressed a desire for food from her native country, Ghana. The resident, who had a history of magnesium and vitamin D deficiency and was assessed as having moderately impaired cognitive abilities, reported that she would like to eat red beans and rice, but this preference was not accommodated. Review of the resident's dietary profile revealed that the Diet History and Food Preference document was left blank at admission, and the resident stated that she only received her preferred meal for the first time during the survey period, despite having been in the facility for an extended period. Interviews with the dietary manager indicated that food preferences are generally accommodated when communicated, but the manager claimed the resident had not previously expressed her preferences. The dietician, who works remotely, stated that she does not review food preferences, considering it the responsibility of the dietary manager, and only provides recommendations as needed. The resident's care plan included an intervention to identify and honor preferences, but this was not implemented. Facility policy requires the dietician to oversee food and nutrition services, including person-centered education, but the lack of documentation and follow-through resulted in the resident's cultural dietary needs not being met.
Failure to Provide Palatable and Attractive Meal to Resident
Penalty
Summary
Facility staff failed to ensure that a resident's lunch was palatable and attractive, as required. The resident, who had a diagnosis of unspecified protein calorie malnutrition and was at risk for weight loss and poor hydration, was observed complaining about the quality of the lunch meal. The resident's care plan included monitoring meal intake to support optimal nutrition and hydration. During the survey, the test tray meal sampled by the surveyor and dietary manager showed that the roll appeared burnt and the beef patties were dark brown around the edges. The resident, who was cognitively intact, expressed dissatisfaction with the meal, specifically noting the burnt bread and overcooked patties, and stated that the food was consistently of poor quality. The dietary manager confirmed that trays are checked daily by staff or herself to ensure meal quality, but the resident declined offers for a replacement meal, expressing ongoing frustration with the food served. The findings were shared with facility leadership, and no additional information was provided by staff at that time.
Failure to Maintain Sanitary Environment and Prevent Infection Transmission
Penalty
Summary
Facility staff failed to maintain a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections. Observations revealed that one resident's bathroom contained a sticky tape insect trap hanging from the ceiling, which was heavily covered in insects. Both staff and the resident confirmed that pest control services only sprayed the hallways and not the resident rooms, as they did not want to move items in the rooms. Throughout the survey, fruit flies, large flies, and cockroaches were observed in all living units and common areas, despite monthly pest control services. Pest control logs confirmed ongoing pest issues, and staff interviews acknowledged the continued presence of pests. Additionally, another resident's room was found to have small red bugs on the floor, and the resident's roommate was observed wearing stained, dirty clothing with wet spots. Staff again confirmed that pest control did not treat resident rooms. On a separate unit, residents were observed accessing clean linens from an unlocked linen closet while wearing urine-saturated clothing, raising concerns about cross-contamination. The Environmental Services Director stated that the lock to the linen closet had been missing for about a month, and the Maintenance Director confirmed ongoing issues with keeping the closet locked due to misplaced keys and locks.
Failure to Provide Adequate Visual Privacy for Residents
Penalty
Summary
Facility staff failed to ensure adequate visual privacy for multiple residents by not providing sufficient privacy curtains or window coverings in several resident rooms. In several instances, residents did not have curtains that fully extended around their beds, leaving them exposed during personal care activities. For example, one resident with dementia and legal blindness was observed receiving ADL care without any privacy curtain around the bed, and another resident with a history of abuse and mental health diagnoses had only a quarter panel curtain that did not provide full coverage. Staff interviews confirmed that there was a shortage of curtains and hooks, and that curtains were often removed for laundering, leaving rooms without adequate privacy. Another resident reported that the curtains in his room did not fit properly, making it difficult to maintain privacy while using a urinal. He stated that he had to rely on keeping the door closed to avoid being seen, as the curtain could not be pulled to fully cover the bed. Observations confirmed that the curtain did not fit around the bed, and the Director of Housekeeping acknowledged ongoing issues with obtaining enough curtains and hooks for all rooms. Additionally, a resident receiving incontinence and ADL care was only partially shielded by a privacy curtain, and the door to the room was closed but did not prevent staff from entering while the resident was exposed. Staff interviews revealed that some had previously reported the lack of privacy curtains, and that the practice was to close the door if curtains were unavailable. In another case, a resident's window blind was damaged, allowing individuals outside to see into the room. Both nursing and maintenance staff recognized this as a privacy issue, and the blind remained unrepaired during the survey period.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
