Glenburnie Rehab & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 1901 Libbie Ave, Richmond, Virginia 23226
- CMS Provider Number
- 495391
- Inspections on file
- 29
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Glenburnie Rehab & Nursing Center during CMS and state inspections, most recent first.
Facility staff did not update care plans for three residents after new wounds or pressure injuries were identified, despite clinical documentation and treatment recommendations. Care plans failed to reflect new or worsening skin conditions, and staff interviews confirmed that care plans should include all current wounds and interventions, in accordance with facility policy.
Staff failed to implement timely and appropriate interventions for pressure injury prevention and treatment for three residents, including delays in following wound care recommendations, improper infection control practices during wound care, and lack of updates to care plans and treatment records. There was confusion among staff regarding responsibility for entering and implementing wound care orders, resulting in missed or delayed treatments.
A resident with a history of acute respiratory failure, CHF, and OSA was not provided with CPAP therapy as ordered in the hospital discharge summary. Although staff communicated with a NP and a respiratory therapist about setting up a device, there was no documentation that CPAP was initiated during the resident's stay. Staff interviews confirmed that the facility is responsible for providing a CPAP if the resident cannot bring their own, but this was not done.
Staff did not follow infection control procedures by failing to use enhanced barrier precautions for a resident with chronic wounds and a Foley catheter. An LPN provided wound care without donning PPE or ensuring appropriate signage, and there was no documentation of enhanced barrier precautions being implemented since the resident's admission, despite facility policy and staff interviews confirming these requirements.
A resident with severe cognitive impairment and total incontinence was not offered incontinence care for over seven hours while being moved between rooms. Staff interviews confirmed that incontinent residents should be checked at least every two hours, and management acknowledged that extended lack of care can cause emotional distress and loss of dignity.
A resident with significant mobility limitations and pressure injuries was unable to access their call bell, which was found on the floor and out of reach. Despite care plan interventions to keep items within reach and remind the resident to use the call light, staff did not ensure the call bell was accessible, and an LPN acknowledged it had fallen earlier. Facility policy requires call bell cords to be off the floor and properly clipped, but this was not followed.
A resident's room was observed over several days to have a roughly plastered wall section and white plaster dust on the headboard and floor. Both maintenance and housekeeping staff confirmed the room was not in good repair or clean, contrary to facility policy requiring regular inspection and maintenance of resident rooms.
A resident admitted with sleep apnea and using a C-PAP machine did not have this device or related care needs documented in the baseline care plan within 48 hours of admission. Staff confirmed the omission, and administrative staff were notified during the survey.
Facility staff did not timely implement the care plan for a resident with pressure injuries, resulting in delayed wound care treatments and interventions such as wound dressings and use of an air mattress. Documentation and staff interviews confirmed that care plan orders were not followed as recommended, and the facility's policy lacked guidance on the importance of adhering to care plans.
A resident who was fully dependent on staff for bathing did not receive a bath or shower on two occasions, with no documentation of refusal. Interviews with CNAs confirmed that care is expected to be provided and documented daily, and facility policy supports regular bathing routines.
Staff failed to provide incontinence care for a cognitively impaired, fully incontinent resident over a period exceeding seven hours, despite facility practice and staff interviews indicating that such care should be provided at least every two hours. The resident was moved between common areas but was not taken for incontinence checks or care during this time.
A resident with a history of fractures and recent knee surgery reported severe, unrelieved pain, but staff failed to provide immediate pain management or contact the on-call physician. Documentation showed a delay in reinstating as-needed Oxycodone, and no evidence that the attending provider was notified or that a pain assessment was completed as required by facility policy.
A resident with a critically low potassium level had a lab result communicated to nursing staff overnight, but repeated attempts to reach the on-call physician were unsuccessful. Nursing staff did not escalate the issue to the medical director or backup provider, and the attending physician was not made aware of the critical result. Facility policy and expectations for 24-hour physician coverage were not met.
Staff failed to accurately document medication administration for two residents, including missing entries for a prescribed medication on the eMAR for a resident with severe cognitive impairment and incomplete controlled drug records for another resident receiving pain management. These deficiencies were confirmed through staff interviews and record reviews.
A resident with severe cognitive impairment and a history of wandering was involved in multiple fire incidents, including setting fire to a mattress and bathroom tissue, due to inadequate supervision and failure to monitor for fire-starting materials. Staff did not consistently inspect the resident's room or belongings, and some residents who smoked did not use required lock boxes for their smoking materials. Staff interviews revealed a lack of awareness and education regarding the need for monitoring, and the facility did not conduct a thorough investigation into how the resident obtained lighters, resulting in repeated safety hazards.
Facility staff did not effectively implement a QAPI program after a fire incident caused by a resident who used a lighter in their room. Although a plan was in place requiring lock boxes for smoking materials and staff education, a resident reported not using a lock box, and staff interviews revealed they were not informed or educated about the incident or necessary interventions. The administrator was unaware of the plan's ineffectiveness, and the facility's policy assigning responsibility for QAPI oversight was not followed.
Facility staff did not maintain or provide valid, signed agreements for contracted podiatry and eye care services. When requested, only unsigned agreements dated the day before the survey were available, and the administrator could not locate the original contracts, contrary to facility policy requiring signed approval for third-party service agreements.
A resident did not receive physician visits within the required sixty-day interval, as facility records showed a gap between documented visits. Although the resident saw two outside providers during this period, they were not seen by a facility physician, contrary to facility policy requiring provider visits at least every 60 days after the initial 90 days post-admission.
Facility staff did not post complete daily nurse staffing records for 30 days, omitting required resident census information for all shifts. Staff interviews revealed a lack of training on documenting census data, and facility policy did not address this requirement.
Multiple residents did not receive their medications within the required timeframes, with repeated late or missed doses of critical medications such as Acyclovir, Cresemba, Metoprolol, Eliquis, Carvedilol, Gabapentin, and others. Nursing staff confirmed that medications were not always administered as ordered, and medication administration records showed significant delays. Facility policy and professional standards requiring timely administration were not followed.
Staff failed to monitor and document required blood pressure readings before administering antihypertensive medications to two residents, resulting in medications being given outside of physician-ordered parameters. Nursing staff and the DON confirmed that vital sign checks and documentation were required but not performed, and facility policy on medication administration was not followed.
Facility staff did not maintain a resident's room and bathroom in a clean and dignified state, as evidenced by persistent holes, stains, and debris in the flooring and on fall mats, despite scheduled cleaning. The resident, who was moderately cognitively impaired, reported feeling bad about the room's condition and uncomfortable using the bathroom. The director of environmental services agreed the environment was not clean or dignified, in violation of the facility's policy on resident rights.
A resident's room and bathroom were found to be in an unclean and unhomelike condition, with damaged flooring, stains, and debris persisting despite regular housekeeping. Facility staff, including environmental services and maintenance, confirmed the poor state of the environment and acknowledged the need for repairs, while the resident expressed dissatisfaction with the bathroom conditions.
A resident with AML and other complex medical needs did not receive medications as ordered, with multiple late or missed doses documented. Nursing staff confirmed that the care plan, which required timely medication administration, was not implemented as prescribed.
Staff did not update or revise care plans for three residents after significant changes or incidents, including the start of hospice care and multiple falls. In each case, care plans failed to reflect new interventions or changes in condition, such as hospice services or the use of fall mats, despite staff acknowledging that such updates were required. Documentation and observations confirmed that care plans were not reviewed or revised as expected following these events.
Staff failed to administer ordered blood glucose checks and insulin at bedtime for a resident with diabetes and did not complete wound care treatments for another resident's skin tear on multiple occasions. Documentation in the MAR and eTAR confirmed these omissions, and staff interviews verified that these treatments were not performed as required.
Staff failed to implement and document required fall prevention measures for two residents with a history of falls. One resident, dependent for mobility and with multiple diagnoses, was not provided with all care plan interventions such as bilateral bed rails and non-skid socks, resulting in multiple falls. Another resident, moderately impaired and with recent falls, was observed without fall mats in place despite documentation that they were needed. Staff interviews and care plan reviews confirmed that fall prevention interventions were not consistently in place or documented.
A resident did not receive meals in the physician-ordered mechanically altered texture due to a delay in communicating the diet change from nursing to dietary staff. The process required nurses to update records and hand-deliver a diet communication slip, but the form was not completed until several days after the order, resulting in the resident not receiving food in the correct form.
A resident did not receive their prescribed Flonase medication for two days due to unavailability, and the facility staff failed to notify the physician and responsible party. The facility's policy required such notifications and documentation, which were not completed. An LPN indicated that over-the-counter medications should not be marked as waiting for pharmacy delivery, and the administrative staff were informed of the findings.
Two residents were subjected to verbal abuse by an intoxicated LPN who was not scheduled to work. The LPN yelled and cursed at residents, making threats of physical harm. Despite the residents' cognitive impairments preventing them from recalling the incident, staff corroborated the abusive behavior. The facility failed to immediately review or revise the residents' care plans or conduct trauma assessments, violating their policy on abuse and neglect.
A facility failed to protect two residents from verbal abuse by an intoxicated LPN who was not scheduled to work. The LPN was observed yelling and making threats, and claimed to have over-medicated another resident. The residents involved could not recall the incident due to cognitive impairment, and the facility did not document the incident in their care plans or conduct necessary trauma assessments.
A resident with a history of wandering and severe cognitive impairment eloped from the facility without supervision. The investigation into the incident was incomplete, lacking documentation on the functionality of the resident's wander guard and door alarms. The resident was found and returned without injury, but the investigation did not meet the facility's policy standards.
The facility failed to update the care plans for two residents following a verbal abuse incident involving an intoxicated LPN. Despite the incident being substantiated, the care plans for the affected residents, who were cognitively impaired, were not reviewed or revised to include new interventions. Staff interviews revealed confusion about responsibility for updating care plans after such incidents.
A resident in an LTC facility was found lethargic and only responsive to sternal rubs after an LPN, who was reportedly intoxicated, claimed to have overmedicated them. Despite the resident's condition, the nurse practitioner only advised continued monitoring, and the family took the resident to the hospital, where they were admitted with elevated troponin and lactic acid levels. The investigation found no evidence of medication administration by the LPN on the day of the incident.
A resident with severe cognitive impairment was involved in a fire incident in their room, where a mattress and privacy curtain were burned. Despite a previous incident where a lighter was confiscated from the resident, the facility failed to prevent the resident from accessing another lighter. Another resident discovered the fire and extinguished it. The facility's lack of effective supervision and interventions led to this deficiency.
A facility failed to provide necessary social services to a resident after a verbal abuse incident involving an intoxicated LPN. The resident, who was moderately impaired, did not receive a trauma screen or social service assessment following the incident. The facility's policy required addressing psychosocial needs, but these procedures were not followed, leading to a deficiency.
A resident did not receive Flonase as prescribed due to unavailability in the facility. Despite the physician's order and documentation in the MAR, the medication was not administered on multiple days. Staff interviews revealed that the facility's process for obtaining medications was not fully effective, as Flonase was not found in the medication room or stock room. The central supply staff member indicated that their supplier did not carry Flonase, and the facility's policy for notifying the provider and responsible party was not fully followed.
A resident with Type II Diabetes Mellitus was repeatedly administered Humalog insulin despite physician orders to withhold it when blood sugar was below 150. This occurred multiple times over three months, as documented in the eMAR. An LPN confirmed the oversight, which was against the facility's medication administration policy.
The facility failed to maintain an operational resident call system in seven rooms, as observed during a survey. The call systems in these rooms were not functioning, with issues such as missing pull stations and non-activating call bells/lights. The director of maintenance acknowledged the problem, citing a wait for parts to fix the systems. The facility's policy requires monthly inspections and documentation of repairs, but this was not adhered to, leading to the deficiency.
The facility failed to maintain a safe and sanitary environment in the rehab restroom, where a ceiling tile was covered with a black substance due to a leak. Staff interviews revealed the issue had been ongoing for years, worsening recently, leading to the restroom's closure. The director of maintenance was aware of the leak and was awaiting a repair quote.
Failure to Update Care Plans Following New Wounds and Pressure Injuries
Penalty
Summary
Facility staff failed to revise and update care plans for three residents after the development of new wounds or pressure injuries. For one resident, the care plan was not updated to reflect a newly identified pressure injury on the left heel, despite clinical documentation and treatment recommendations by the wound nurse practitioner. The care plan only referenced prior skin impairments and did not include the new wound, as confirmed by both the regional director of clinical operations and the unit manager during interviews. Another resident developed a stage 3 pressure ulcer on the left buttock, as documented in the skin and wound progress notes. The care plan for this resident did not include the presence of the stage 3 pressure ulcer or any interventions to address it, even though the wound nurse practitioner had provided specific treatment recommendations. Staff interviews confirmed that the care plan should have been updated to include all current wounds and interventions. A third resident developed an abrasion on the left gluteal fold that required treatment. The care plan was not updated to reflect the presence of this wound, despite clinical documentation and treatment recommendations. Staff interviews consistently indicated that care plans are intended to map out all aspects of resident care, including wounds, and that all nurses have the ability to update care plans as needed. The facility's policy requires care plans to be updated on an ongoing basis as changes occur, but this was not followed in these cases.
Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
Facility staff failed to implement timely and appropriate interventions to prevent and treat pressure injuries for three residents. For one resident, staff did not follow the wound nurse practitioner's recommendations for wound care, including delayed implementation of prescribed treatments and failure to provide an air mattress as recommended. Observations revealed improper infection control practices during wound care, such as not using personal protective equipment (PPE), cross-contaminating clean and dirty supplies, and placing clean gloves and wound cleanser on soiled bed linens. The resident reported not receiving heel boots as recommended, and documentation showed delays in updating care plans and treatment administration records to reflect new or worsening wounds. Another resident was admitted with moisture-related skin irritation and later developed a Stage 3 pressure ulcer. The wound nurse practitioner's recommendations for wound care and preventive measures, such as floating the heels, were not implemented. The treatment administration record did not show evidence of the recommended interventions being carried out, and the care plan was not updated to reflect the presence of the Stage 3 pressure ulcer or the necessary interventions. Interviews with staff revealed a lack of clarity regarding roles and responsibilities for implementing wound care recommendations, with some staff unaware of the process for ensuring that recommendations were entered into orders and care plans. A third resident developed a new wound during their stay, and the wound nurse practitioner's treatment recommendations were not implemented prior to discharge. The care plan was not updated to include the new wound, and the treatment administration record did not reflect the prescribed care. Staff interviews indicated that recommendations from the wound nurse practitioner were not always translated into actionable orders or care plan updates, and there was confusion about who was responsible for ensuring implementation. Facility policy required notification of providers and implementation of treatments as ordered, but this was not consistently followed.
Failure to Provide Required CPAP Therapy for Resident with Sleep Apnea and CHF
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident who required CPAP therapy following a hospital stay for acute respiratory failure secondary to congestive heart failure and obstructive sleep apnea. The hospital discharge summary specified the need for CPAP at night, but a review of the resident's clinical record showed no evidence that CPAP therapy was initiated during the resident's stay. Progress notes indicated that staff communicated with a nurse practitioner regarding the placement of a BiPAP device, and a respiratory therapist was notified to set up the machine, but there was no documentation that the CPAP was ever provided. Interviews with staff revealed that the admitting nurse is responsible for verifying CPAP orders with the physician and informing them if the facility does not have a CPAP machine available. Staff also stated that it is the facility's responsibility to provide a CPAP device if the resident is unable to bring their own from home. Despite these procedures, the facility did not provide the required CPAP therapy, and no policy or additional information regarding CPAP provision was supplied when requested by surveyors.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control procedures for one of eight residents reviewed, specifically by not applying enhanced barrier precautions for a resident with chronic wounds and a Foley catheter. During wound care, the LPN responsible did not don any personal protective equipment (PPE) such as gown or gloves prior to entering the resident's room or providing care. Additionally, there was no signage or PPE related to isolation precautions visible outside the resident's room. Review of the clinical record showed no orders for or evidence of enhanced barrier precautions being implemented since the resident's admission, despite the presence of risk factors. Interviews with the director of nursing and the regional director of clinical operations confirmed that enhanced barrier precautions are required for residents with chronic wounds or indwelling medical devices. Facility policy also mandates the use of gown and gloves during high-contact care activities for such residents. However, these precautions were not followed for the resident in question, as evidenced by both observation and documentation review.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
Facility staff failed to provide care in a dignified manner for one resident who was observed from 10:07 a.m. to 5:30 p.m. without being offered incontinence care. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken back to her room for incontinence care. Continuous observation confirmed that no staff member provided or offered incontinence care throughout the entire period. Interviews with CNAs and an LPN confirmed that incontinent residents should be checked at least every two hours, with some requiring more frequent checks, especially those unable to communicate their needs. Staff acknowledged that failing to provide timely incontinence care can lead to skin breakdown and is not consistent with treating residents with dignity. Facility management agreed that lack of incontinence care for an extended period could result in emotional distress and a diminished quality of life for the resident.
Failure to Ensure Resident Call Bell Accessibility
Penalty
Summary
Facility staff failed to accommodate the needs of a resident by not ensuring the resident's call bell was accessible. The resident, who was admitted with diagnoses including diabetes mellitus, pressure injury, and embolism, was assessed as cognitively intact but required moderate to total assistance for mobility and activities of daily living. The resident's care plan included interventions to place common items within reach and to remind the resident to use the call light for assistance. However, during observation, the call bell was found dangling from the side rail to the floor, out of the resident's reach, and the resident was unaware of its location. An interview with an LPN revealed that the call bell had likely fallen off the bed earlier and had not been returned to an accessible position. Facility policy requires that call bell cords not be in contact with the floor and be properly clipped. The administrative staff, including the interim administrator, DON, and vice president of operations, were made aware of the finding. No additional information was provided prior to the survey exit.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Facility staff failed to maintain a homelike and clean environment in one of the resident rooms, specifically room [ROOM NUMBER]-B. Multiple observations over several days revealed a section of wall behind the head of the bed that was roughly plastered, measuring approximately 15 inches wide and 36 inches long. White plaster dust was noted coating the top of the headboard and the floor under the head of the bed during each observation. The call bell was within reach, but the room's condition remained unchanged across the observed dates. During interviews, the maintenance director acknowledged that the wall required further work, including sanding, re-mudding, and painting, and confirmed that the room was not in good repair or homelike. The housekeeping director also stated that the room should not have been left in its observed condition, describing it as neither clean nor homelike. The facility's policy requires regular inspection and maintenance of patient rooms to ensure safety and proper upkeep, including the replacement of damaged wall or floor tiles. Despite these policies, the room remained in disrepair and unclean throughout the survey period.
Failure to Include C-PAP Use in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop a baseline care plan addressing the use of a C-PAP machine for one resident within 48 hours of admission. The resident was admitted with a diagnosis that included sleep apnea and was documented as cognitively intact and oriented. The admission assessment and nurse's notes confirmed the resident's use of a C-PAP machine, and the device was observed in the resident's room. However, review of the baseline care plan did not show any documentation regarding the C-PAP use. Staff interviews confirmed that the purpose of the care plan is to ensure all staff are informed about the resident's care needs, and that the C-PAP should have been included. Administrative staff were made aware of the omission during the survey, but no additional information was provided prior to the survey team's exit.
Failure to Implement Care Plan for Pressure Injuries
Penalty
Summary
Facility staff failed to implement the care plan for a resident with pressure injuries, as evidenced by delays in carrying out wound care treatments and interventions as ordered by the wound nurse practitioner. The resident was admitted with existing skin impairments, including a Stage 2 sacral pressure injury and deep tissue injuries (DTIs) on both heels. The care plan and treatment recommendations included specific wound care regimens, use of an air mattress, and heel-floating interventions. However, documentation review showed that these treatments were not initiated in a timely manner. For example, wound care orders for the sacrum and right heel were not implemented until several days after being recommended, and the air mattress was not provided until even later. Similarly, a new wound on the left heel was not treated according to recommendations until over a week after the order was given. Interviews with facility staff, including a unit manager and administrative staff, confirmed that all staff are responsible for implementing care plan elements, which are designed to address the resident's diagnoses and needs. Despite this, the care plan interventions for the resident's pressure injuries were not followed as ordered. Additionally, a review of the facility's care planning policy revealed no information emphasizing the importance of adhering to the care plan, further highlighting the lack of implementation for this resident's wound care needs.
Failure to Provide and Document Bathing for Dependent Resident
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically bathing, to a dependent resident on two separate days in October 2025. The resident, who was completely dependent on staff for bathing according to the most recent Minimum Data Set (MDS) admission assessment, did not receive a shower or bath on these days as documented in the point of care records. There was no evidence in the records that the resident refused bathing on either day. Interviews with two CNAs revealed that both staff members stated they routinely bathe and document care for all assigned residents daily. The lead CNA confirmed that if a bath is not documented in the electronic medical record, there is no way to verify that the care was provided. Facility policy indicates that bathing typically occurs after breakfast or the evening meal, and the resident's choice of bath type and timing is respected when possible. No additional information was provided prior to the survey exit.
Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide timely incontinence care for one resident who was observed continuously from 10:07 a.m. to 5:30 p.m. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken to her room for incontinence checks or care. Staff interviews confirmed that the standard practice is to check incontinent residents at least every two hours, with some staff indicating even more frequent checks for residents unable to communicate their needs. However, the assigned CNA admitted that, despite walking by and checking in on the resident, she did not take the resident to her room for incontinence care at any time during her shift. The resident's most recent assessment indicated severe cognitive impairment, inability to communicate needs effectively, and total dependence on staff for toileting. Facility management and staff acknowledged that extended periods without incontinence care could lead to skin breakdown and emotional distress. A review of the facility's urinary elimination policy did not specify the required frequency for incontinence care, and no additional relevant documentation was provided prior to the survey exit.
Failure to Provide Timely Pain Management for Resident with Severe Pain
Penalty
Summary
Facility staff failed to provide appropriate pain management for a resident with a history of fractures and recent surgical wounds on both knees. The resident was observed multiple times reporting knee pain and stated that while pain was usually managed, there were instances of severe pain that were not relieved by medication. On one occasion, the resident reported experiencing 10/10 pain in both knees and requested as-needed Oxycodone, but was informed by nursing staff that it was no longer on her medication list. The nurse documented the request and updated the MD Communication Book but did not provide immediate intervention or contact the on-call physician for alternative pain relief. A review of the resident's clinical records showed that an order for as-needed Oxycodone was not reinstated until several hours later, and there was no evidence that the attending nurse practitioner or physician was made aware of or addressed the severe pain episode at the time it occurred. Interviews with facility staff confirmed that the appropriate protocol would have been to contact the on-call physician for immediate pain management, especially for a report of 10/10 pain. The facility's pain management policy required a pain assessment whenever a patient experienced unusual pain, but there was no documentation of such an assessment or timely intervention in this case.
Failure to Provide 24-Hour On-Call Physician Services for Critical Lab Result
Penalty
Summary
Facility staff failed to provide 24-hour on-call physician services for one resident when a critical laboratory result was received. The resident had a potassium level of 2.9 mEq/L, which is below the normal range. Nursing staff documented that they attempted to contact the on-call physician multiple times during the early morning hours, but did not receive a return call. The progress notes indicate that the on-call physician was not reached despite repeated attempts, and the issue was not escalated to the medical director or backup provider as per facility expectations. Interviews with administrative and clinical staff confirmed that nurses are expected to reach an on-call physician at all times and should escalate to the medical director if unable to do so. The attending physician stated that there is always a backup provider available and that the on-call service has their contact information. He also confirmed he was not made aware of the resident's critical potassium level and would have ordered immediate treatment if notified. No additional documentation or policy regarding 24-hour physician coverage was provided prior to the survey exit.
Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for two residents. For one resident with severe cognitive impairment and a diagnosis including gastro-esophageal reflux disease, staff did not document the administration of Protonix on the electronic medication administration record (eMAR) as required. Although nursing notes indicated the medication was given while the resident was waiting for dialysis, the eMAR entry for the scheduled time was left blank. The nurse responsible later acknowledged in a written statement that the medication was administered but the eMAR was not signed immediately due to oversight. For another resident, who was cognitively intact and admitted with diagnoses including nerve damage and chronic pain, staff failed to accurately document the administration of Oxycodone on the Controlled Drug Administration Record. The eMAR showed that the resident received the medication at two scheduled times, but the corresponding entries were missing from the controlled substance log. The DON confirmed that the nurse forgot to document the administration on the controlled drug record as required. Both deficiencies were identified through staff interviews and clinical record reviews. The failures involved not immediately documenting medication administration in the appropriate records, as confirmed by staff and administrative interviews. No additional information or documentation was provided by facility leadership prior to the survey exit.
Failure to Prevent and Investigate Repeated Fire Incidents Involving Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to thoroughly investigate and implement effective interventions following multiple fire incidents involving a resident with severe cognitive impairment. The resident, who had a history of wandering, collecting items, and previous smoking, was found with a lighter and was involved in several fire-related incidents, including a fire on a mattress, burn spots on privacy curtains, and a toilet tissue roll set on fire in his bathroom. Despite these events, staff did not consistently monitor the resident or his room for fire-starting materials, nor did they ensure that interventions such as the use of lock boxes for smoking materials were properly implemented for all residents. Clinical records and staff interviews revealed that the resident was severely cognitively impaired, with a low BIMS score, and was unable to recall the fire incidents or how he obtained lighters. Documentation showed that after each incident, staff searched the resident and his room but failed to identify how the resident continued to access fire-starting materials. There was also a lack of consistent and ongoing supervision, as the resident was observed unsupervised in his room and wandering the halls. Staff interviews indicated a lack of awareness and education regarding the need to monitor the resident and inspect his belongings for lighters or other fire-starting materials. Additionally, the facility did not ensure that all residents who smoked used lock boxes for their smoking materials, and some residents left their lock boxes unlocked or did not use them at all. Staff did not routinely inquire whether other residents had been approached for lighters or smoking materials, and there was no documentation of a thorough investigation into how the resident obtained these items. The facility's failure to implement and maintain effective supervision and safety interventions resulted in repeated fire incidents and placed all residents at risk.
Failure to Implement Effective QAPI Program Following Fire Incident
Penalty
Summary
Facility staff failed to implement an effective QAPI (Quality Assurance and Performance Improvement) program related to a fire incident involving residents. On the date of the incident, a resident lit a roll of toilet paper on fire in his bathroom, which was extinguished by staff. Both residents in the affected room were evacuated, and the fire department responded. The resident responsible for the fire had a known history of attempting to use a lighter in the room and was placed on one-on-one supervision until cleared by psych evaluation. Assessments for pain, skin, and respiratory status were conducted for both residents involved. Despite the QAPI plan outlining steps to prevent recurrence, including the use of lock boxes for smoking materials and staff education, the facility failed to ensure these measures were effectively implemented. During interviews, a resident who smoked stated she did not use a lock box and hid her belongings in her room, with a lock box found open and unsecured. Multiple staff members, including CNAs, LPNs, and a housekeeper, reported not receiving education or instructions regarding the fire incident, interventions for the resident involved, or the need to inspect rooms for lighters and smoking paraphernalia. The administrator acknowledged not noticing the ineffectiveness of the QAPI plan. The facility's policy assigns responsibility to the administrator for directing the QAPI plan to identify and address risks or deficiencies, but the documented actions and staff interviews indicate a lack of follow-through and communication regarding the interventions required to prevent similar incidents.
Lack of Signed Contracts for Podiatry and Eye Care Services
Penalty
Summary
Facility staff failed to maintain and provide evidence of signed agreements for contracted podiatry and eye care services. During a review of facility contracts, no agreements were found for these services. When requested, the director of nursing presented agreements dated the day prior to the survey, but these were unsigned by a facility representative. The administrator stated that the facility began using the podiatry and eye care companies before her employment and was unable to locate the original contracts. Facility policy requires that all contracts with third-party providers be approved and signed by designated officers prior to the initiation of services, and unsigned agreements are not considered valid.
Failure to Provide Timely Physician Visits
Penalty
Summary
Facility staff failed to provide timely physician visits for one of nine residents reviewed, specifically for Resident #5. Clinical record review showed that the resident had physician visits on 4/22/24 and 7/16/24, with no physician visits documented between these dates, resulting in a gap longer than the required sixty days. The director of nursing confirmed that most residents are to be seen quarterly unless receiving skilled nursing services and acknowledged that, although the resident saw two outside providers during this period, they were not seen by a facility physician as required by facility policy. The facility's policy mandates that after the first 90 days post-admission, residents must be seen by a provider at least every 60 days.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to post a complete and accurate daily nursing staffing record for 30 consecutive days, as required. Review of staffing posting sheets for a 30-day period revealed that none included resident census information for any shift. Interviews with a CNA indicated that while she was trained to calculate RN, LPN, and CNA hours, she had not been trained to record the resident census for each shift. The facility's policy on the Daily Nurse Staffing Summary also lacked guidance regarding the inclusion of resident census information. No additional information was provided prior to the survey exit. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Administer Medications Timely According to Professional Standards
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards of practice for multiple residents. For one resident with acute myeloblastic leukemia, congestive heart failure, and renal insufficiency, there were repeated instances of late or missed administration of critical medications, including Acyclovir, Cresemba, Revumenib Citrate, and Cefdinir. The medication administration audit revealed numerous occasions where medications were given outside the prescribed timeframes, sometimes hours late or not until the following day. Interviews with nursing staff confirmed that medications were not always administered as ordered, and that this constituted a failure to implement the care plan interventions. Additional deficiencies were observed for three other residents. One resident was observed receiving Metoprolol and Eliquis later than the scheduled administration times, as documented in the electronic medication administration record. Another resident was given Carvedilol and Gabapentin outside of the scheduled times. A third resident reported receiving evening and bedtime medications late, sometimes after midnight or in the early morning, which was corroborated by the medication administration records showing significant delays for multiple medications, including Xarelto, Nabumetone, Bupropion, Hydromorphone, Gabapentin, Finasteride, and Seroquel. Staff interviews indicated an understanding of the one-hour window before and after scheduled medication times, but also revealed that late administration was not consistently communicated to physicians, as required when significant delays occurred. Facility policy required medications to be administered in a safe and effective manner, and reference materials cited the standard of administering medications within 60 minutes of the scheduled time. The failure to adhere to these standards was confirmed through observation, record review, and staff interviews.
Failure to Monitor and Follow Medication Hold Parameters for Antihypertensives
Penalty
Summary
Facility staff failed to properly monitor and follow medication administration orders for two residents, resulting in the administration of antihypertensive medications without adhering to required blood pressure parameters. For one resident, an LPN administered Carvedilol without obtaining a blood pressure reading beforehand, despite physician orders specifying the medication should be held if the systolic blood pressure was less than 110. Review of the electronic medication administration record (eMAR) and clinical records showed no evidence of blood pressure monitoring prior to administration, and staff interviews confirmed that vital signs should have been checked and documented as per facility policy. For another resident, staff administered Metoprolol Succinate on multiple occasions even when the resident's systolic blood pressure was below the ordered threshold of 110. The eMAR documented administration of the medication with blood pressures as low as 88/55, 97/73, and 108/58, contrary to the physician's hold parameters. Interviews with nursing staff and the DON confirmed that medications with vital sign parameters require supplementary documentation and should be held if the resident's vital signs fall outside the specified range. Facility policy also required checking for vital signs prior to medication administration, but this was not followed in these cases.
Failure to Maintain Resident Room and Bathroom in a Dignified Condition
Penalty
Summary
Facility staff failed to maintain a resident's room and bathroom in a dignified and clean condition. Multiple observations over two days revealed the resident's bathroom had approximately 14 holes in the linoleum flooring, with sizes ranging from one-and-a-half inches to six inches in length and up to three inches in width. The flooring was curling away from the wall under the sink and behind the toilet, with multiple cuts, black substances, and several stained areas throughout. The area around the resident's bed had two fall mats with food stains and debris, and the room floor had visible food debris, dirt, and stained areas from food and spilled liquids. These conditions persisted despite the housekeeper cleaning the room during one of the observations. The resident, who was moderately cognitively impaired but able to make daily decisions, expressed feeling bad about the condition of the room and uncomfortable using the bathroom in its state. The director of environmental services confirmed the room and bathroom were not clean or dignified after reviewing the conditions. The facility's policy states that residents have the right to live in safe, decent, and clean conditions, but this standard was not met for this resident.
Failure to Maintain Clean and Homelike Resident Room and Bathroom
Penalty
Summary
Facility staff failed to maintain a resident's room and bathroom in a clean, safe, and homelike condition. Multiple observations over two days revealed the resident's bathroom had approximately 14 holes in the linoleum flooring, with sizes ranging from one-and-a-half inches to six inches in length and up to three inches in width. The flooring was curling away from the wall under the sink and behind the toilet, with multiple cuts, black substances, and several stained areas. The floor area around the resident's bed had two fall mats with food stains and debris, and the room floor itself had food debris, dirt, and stained areas from food and spilled liquids. These conditions persisted even after the housekeeper had cleaned the room. Interviews with facility staff, including the director of environmental services and the assistant director of maintenance, confirmed the unclean and unhomelike state of the room and bathroom. The assistant director of maintenance acknowledged that the bathroom floor needed repair or replacement and that no work order had been submitted for the issue. The resident, who was moderately cognitively impaired, stated that while the room felt homelike, the bathroom did not. The facility's policy affirms residents' rights to live in safe, decent, and clean conditions, which was not upheld in this instance.
Failure to Implement Care Plan for Timely Medication Administration
Penalty
Summary
Facility staff failed to implement the comprehensive care plan for a resident diagnosed with acute myeloblastic leukemia (AML) and other significant medical conditions, including congestive heart failure and renal insufficiency. The care plan required administration of specific medications as ordered for AML management. Review of the medication administration audit reports revealed multiple instances where medications such as Acyclovir, Cresemba, Revumenib Citrate, and Cefdinir were administered late or not at the scheduled times as prescribed by the physician. These delays and missed doses occurred repeatedly over several days, as documented in the medication administration records. Interviews with nursing staff confirmed that the care plan interventions, specifically timely medication administration, were not being followed. Staff acknowledged that medications not given as ordered meant the care plan was not being implemented. The facility's own care planning policy requires licensed nurses and the interdisciplinary team to develop and implement individualized care plans to provide necessary health-related care. The deficiency was brought to the attention of facility administration, but no further information was provided prior to the survey exit.
Failure to Revise and Update Care Plans After Significant Changes and Incidents
Penalty
Summary
Facility staff failed to review and/or revise the comprehensive care plans for three residents following significant changes in their conditions or care needs. For one resident, the care plan was not updated to reflect the initiation of hospice care, despite physician orders specifying hospice involvement, do-not-hospitalize status, and no further diagnostic testing. The care plan only documented a DNR directive and had not been revised to include hospice services, even though staff interviews confirmed that such updates were expected as part of the care planning process. Another resident experienced multiple falls, including one with injury, and was discussed in high-risk meetings where fall mats were identified as an intervention. However, the care plan did not document the use of fall mats, and there was no physician order for them. Observations confirmed that fall mats were not present in the resident's room during multiple checks, and staff acknowledged that the care plan should have included this intervention following the falls and risk meetings. A third resident had a fall without injury, but the care plan was not reviewed or updated after the incident. Progress notes indicated the fall and described the circumstances, but no new interventions were implemented, and the care plan's revision dates did not correspond to the fall event. Staff interviews confirmed that care plans are expected to be reviewed after any fall, but this was not evidenced in the documentation for this resident.
Failure to Administer Ordered Treatments and Wound Care
Penalty
Summary
Facility staff failed to provide care and services as ordered for two residents. For one resident with diagnoses including muscular dystrophy, diabetes mellitus, and congestive heart failure, staff did not administer blood glucose checks and insulin at bedtime as ordered by the physician. The medication administration record (MAR) for this resident showed that on a specific date, the required blood sugar check and insulin administration at bedtime were not completed, although other scheduled doses and checks before meals were documented. Staff interviews confirmed that a blank MAR indicated the task was not performed. For another resident, staff did not complete wound care treatments for a skin tear on the left upper arm as ordered by the physician. The electronic treatment administration record (eTAR) showed that on several dates in November and December, the required wound care was not documented as completed. Staff interviews confirmed that treatments are evidenced as completed by signing off on the eTAR, and the facility's policy requires treatments to be provided as ordered. The administrator and director of nursing were made aware of these findings.
Failure to Implement and Document Fall Prevention Measures for Two Residents
Penalty
Summary
Facility staff failed to provide a safe environment and implement fall prevention measures for two residents, resulting in deficiencies related to accident hazards and supervision. For one resident with diagnoses including muscular dystrophy, diabetes mellitus, and congestive heart failure, the admission documentation and care plan identified a history of falls and specified interventions such as non-skid socks, bed in lowest position, and use of bed rails. However, there was no evidence that these fall prevention measures were implemented. Progress notes indicated that only one side rail was in place despite orders for bilateral rails, and the resident experienced multiple falls from bed. Staff interviews confirmed that fall prevention interventions were not in place, and the care plan did not reflect the necessary measures outlined in the admission assessment. Another resident, who was moderately impaired in decision-making and had a recent history of falls with and without injury, was observed multiple times in bed without fall mats in place, despite documentation from a high-risk meeting indicating that fall mats were an intervention. The care plan and physician orders did not include fall mats, and staff interviews revealed that fall mats should have been in place but were not. The resident reported recent falls, including one resulting in injury, and was observed without socks and with the call bell in reach, but without the required fall prevention equipment. The facility's Fall Management Program policy states that all patients are considered at risk for falls and that evidence-based interventions should be implemented. Despite this, the facility failed to ensure that fall prevention measures were consistently implemented and documented for both residents, as required by their own policies and the residents' care plans. Administrative staff, including the administrator and director of nursing, were made aware of these concerns during the survey.
Failure to Timely Communicate and Implement Diet Texture Change
Penalty
Summary
Facility staff failed to provide food in a form designed to meet the individual needs of a resident. Specifically, a physician ordered a change in diet texture for a resident from regular texture to dysphagia mechanically altered texture. The order for the diet change was dated 11/25/24, but the dietary communication form reflecting this change was not completed until 11/30/24. During this period, the resident did not receive meals in the prescribed mechanically altered texture. Interviews with dietary and nursing staff revealed that the process for communicating diet changes involved nurses updating the electronic medical record and manually delivering a diet communication slip to the dietary department. The dietary manager confirmed that meal tickets and food preparation were based on these communication forms. Facility policy required licensed nurses to promptly complete and send the communication form to dietary services for any diet changes. The delay in communication resulted in the resident not receiving food in the appropriate form as ordered by the physician.
Failure to Notify Physician and Responsible Party of Medication Unavailability
Penalty
Summary
The facility staff failed to notify the physician and the responsible party when a medication, Flonase, was not available for administration to Resident #2. The physician had ordered Flonase Allergy Relief Nasal Suspension to be administered daily, but the medication was not given on two consecutive days, as indicated by the medication administration record (MAR). The MAR showed a notation of 'Other/ See progress notes' for these days, and on the third day, the administration block was left blank. Nurse's notes documented that the medication had been ordered and the pharmacy contacted, but there was no documentation of notifying the physician or the responsible party about the unavailability of the medication. An interview with an LPN revealed that the facility had a process for obtaining medications, including checking other medication carts, the medication room, and a backup pharmacy system. The LPN stated that over-the-counter medications like Flonase should not have been documented as waiting for pharmacy delivery, and that the nurse should have contacted the doctor and responsible party if the medication was not administered. The facility's policy on medication unavailability required notifying the provider and responsible party and documenting this in the medical record, which was not done in this case. The administrative staff, including the administrator and regional director of clinical services, were informed of these findings.
Failure to Protect Residents from Verbal Abuse by Intoxicated LPN
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a staff member, specifically an LPN who was reported to have arrived at work intoxicated and belligerent. The LPN was observed yelling and cursing at residents, including making threats of physical harm. This incident occurred in front of the nurse's station, where other staff members witnessed the behavior. The LPN was not scheduled to work at the time and was removed from the facility by the police after being reported by a supervisor. The residents involved, identified as having low BIMS scores, were unable to recall the incident due to cognitive impairments. Despite this, staff interviews corroborated the supervisor's report of the LPN's abusive behavior. The facility's documentation did not show any immediate review or revision of the residents' care plans following the incident, nor was there evidence of trauma assessments being conducted for the affected residents. The facility's policy on abuse and neglect was not adhered to, as evidenced by the lack of immediate follow-up and documentation regarding the incident. The LPN's behavior was substantiated through employee interviews, although the allegation of over-medication was not supported by evidence. The facility's response included terminating the LPN and filing a police report, but the deficiency lies in the initial failure to protect the residents from abuse and the lack of immediate care plan adjustments or trauma assessments.
Failure to Implement Abuse Policy Leads to Verbal Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy to protect two residents from verbal abuse by a staff member. On the day of the incident, an LPN arrived at the facility intoxicated and was observed yelling and cursing at residents. The LPN was not scheduled to work and claimed to be there to complete documentation. Witnesses reported that the LPN made threatening remarks to the residents and claimed to have over-medicated another resident the previous night. The residents involved in the verbal abuse incident were unable to recall the event due to low BIMS scores, indicating cognitive impairment. The facility's comprehensive care plans for these residents did not document the verbal abuse incident, and there was no evidence of trauma screening or social service assessments being completed following the incident. Staff interviews corroborated the supervisor's report of the LPN's behavior, and the police were called to remove the LPN from the premises. The facility's policy on abuse and neglect requires immediate removal of the accused individual and thorough documentation of the incident. However, the facility's response to the incident was inadequate, as there was a lack of documentation in the residents' care plans and progress notes regarding the verbal abuse. Additionally, the facility did not conduct necessary assessments to address the potential trauma experienced by the residents involved.
Incomplete Investigation of Resident Elopement
Penalty
Summary
The facility staff failed to conduct a complete and thorough investigation into an elopement incident involving a resident identified as R5. On the date of the incident, R5, who had a history of wandering and was assessed as high risk for elopement, exited the facility without supervision. The resident was later found sitting on a curb by emergency medical services and returned to the facility without injury. The investigation summary documented the incident but lacked critical details regarding the functionality of the resident's wander guard and the door alarms at the time of the elopement. The resident had been admitted to the facility with a severely impaired mental status, as indicated by a low score on the BIMS assessment, and had documented wandering behaviors. A wander guard was ordered for the resident, with instructions for its placement and function to be checked regularly. However, the investigation folder did not include documentation on whether the wander guard was functioning properly or if the door alarms were operational during the incident. Interviews with administrative staff revealed that the wander guard had stopped working, which was not initially included in the investigation report. The facility's policy required a thorough internal investigation of such incidents, including collecting evidence and interviewing relevant parties. However, the investigation into R5's elopement did not meet these standards, as it failed to address the root cause of the incident, specifically the malfunctioning wander guard and door alarms. The lack of comprehensive documentation and analysis of the incident led to the deficiency noted in the report.
Failure to Update Care Plans After Abuse Incident
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents, Resident #9 and Resident #10, following a verbal abuse incident involving a staff member. On December 14, 2024, a Licensed Practical Nurse (LPN) arrived at the facility intoxicated and belligerent, verbally abusing residents, including Resident #9 and Resident #10. The incident was substantiated through staff interviews, and the LPN was removed from the property and terminated. Despite the severity of the incident, the care plans for the affected residents were not reviewed or updated to reflect the abuse or to include any new interventions. Resident #9, who was severely impaired in making daily decisions as indicated by a low score on the Brief Interview for Mental Status (BIMS), was involved in the incident. The facility's policy required care plans to be updated as changes occurred, yet no revisions were made to Resident #9's care plan following the abuse. Interviews with facility staff revealed a lack of clarity and responsibility regarding who should update the care plans after such incidents, with the MDS coordinator and other staff members indicating that they did not typically review care plans after abuse incidents. Similarly, Resident #10, who was moderately impaired in decision-making, also did not have their care plan reviewed or revised following the incident. The assistant director of social services and other staff members confirmed that while trauma screenings and follow-ups were conducted, the care plans were not updated. The facility's failure to update the care plans for both residents after the abuse incident highlights a significant deficiency in adhering to their own care planning policies.
Failure to Provide Adequate Care Following Alleged Overmedication
Penalty
Summary
The facility staff failed to provide adequate care and services to maintain a resident's highest level of well-being, specifically for Resident #4. On 12/14/24, the staff became aware of a potential medication overdose involving Resident #4, who was found lethargic and only responsive to sternal rubs. Despite this, the nurse practitioner only gave telephone orders to continue monitoring the resident, and the family eventually decided to take the resident to the emergency room. The facility's documentation and interviews revealed that an LPN, who was reportedly intoxicated and belligerent, claimed to have overmedicated the resident during a previous shift. The investigation into the incident revealed that the LPN in question was not scheduled to work at the time of the incident but had arrived at the facility, allegedly intoxicated, and was verbally abusive to residents. The LPN was removed from the property, and the police were called. Witness statements corroborated the supervisor's report of the LPN's inappropriate behavior, including threats and claims of overmedicating a resident. However, the investigation found no evidence of medication administration by the LPN on the day of the incident, and the allegation of overmedication was unsubstantiated due to a lack of supporting evidence. Interviews with other staff members indicated that Resident #4 was being monitored for changes in condition, but there was a lack of documentation and communication regarding the resident's status and the nurse practitioner's recommendations. The facility's policy required critical nursing assessment and decision-making in potentially life-threatening situations, but the response to Resident #4's condition was inadequate. The resident was eventually taken to the hospital by family members, where they were admitted with elevated troponin and lactic acid levels, indicating a serious medical condition.
Failure to Prevent Fire Incident Due to Inadequate Supervision
Penalty
Summary
The facility staff failed to provide adequate supervision and interventions to prevent a fire incident involving a resident with severe cognitive impairment. The resident, who scored a four out of 15 on the BIMS, indicating severe cognitive impairment, was found with a lighter on 12/30/24, but no further lighters were found after a room search. Despite this, the resident was later involved in a fire incident on 1/1/25, where a mattress and privacy curtain were burned. The resident was unable to recall the fire incident due to cognitive impairment. Another resident, who was not cognitively impaired, discovered the fire upon returning to his room and managed to extinguish it using sheets. This resident reported the incident to staff, who responded but found no active fire or smoke upon arrival. The facility's maintenance team confirmed that the fire was not electrical in nature, and a lighter was later found on the bed of the resident who discovered the fire. Interviews with staff revealed that the resident with cognitive impairment had a history of wandering and socializing with other residents, including those who smoked. The facility had previously confiscated a lighter from this resident, but it was unclear how the resident obtained another lighter. The facility's failure to implement effective interventions and supervision to prevent the resident from accessing lighters and starting a fire led to the deficiency.
Failure to Provide Social Services After Verbal Abuse Incident
Penalty
Summary
The facility failed to provide medically related social services to a resident following a verbal abuse incident involving a staff member. The incident occurred when an LPN, who was reportedly intoxicated and belligerent, verbally abused several residents, including Resident #10. The LPN was not scheduled to work and was removed from the facility by the police after making threats and claiming to have over-medicated another resident. The investigation substantiated the verbal abuse but found no evidence to support the medication misuse claim. Resident #10, who was moderately impaired in decision-making as indicated by a BIMS score of nine out of 15, did not receive a trauma screen or social service assessment following the incident. The facility's documentation lacked evidence of any follow-up or care plan revision addressing the verbal abuse. Interviews with staff revealed that social services typically conducted trauma screens and care plan reviews after such incidents, but this was not done for Resident #10. The facility's policy required social work staff to identify and address patients' psychosocial needs, including providing emotional support and documenting interventions. However, the report indicates that these procedures were not followed for Resident #10 after the verbal abuse incident. The failure to conduct a trauma screen and update the care plan represents a deficiency in the facility's provision of medically related social services.
Medication Unavailability for Resident
Penalty
Summary
The facility staff failed to ensure that medications were available at the scheduled time of administration for a resident, specifically Flonase, which is used to treat allergies. The physician's order dated 12/17/24 documented that Flonase Allergy Relief Nasal Suspension was to be administered as two sprays in each nostril once a day. However, the medication administration record (MAR) for January 2025 showed that on 1/12/25 and 1/13/25, a code indicating 'Other/See progress notes' was documented, and on 1/14/25, the administration block was left blank. Nurse's notes indicated that the medication had been ordered and the pharmacy had been contacted, but the medication was still unavailable. Interviews with staff revealed that the facility had a process for obtaining medications, including checking other medication carts, the medication room, and a backup pharmacy system. However, Flonase was not found in the medication room or stock room, and the central supply staff member stated that their supplier only carried a generic saline nasal spray, which was not equivalent to Flonase. The facility's policy required notifying the provider and responsible party of medication unavailability and documenting this in the medical record, but it appears this process was not fully followed. The director of nursing and other administrative staff were informed of these findings, but no further information was provided before the survey exit.
Failure to Withhold Insulin as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the staff did not adhere to the physician's order to hold Humalog insulin when the resident's blood sugar was below 150. This oversight occurred multiple times over three months, with documented instances in January, February, and March 2024. The resident, who has a diagnosis of Type II Diabetes Mellitus, was administered Humalog insulin despite having blood sugar levels below the threshold specified in the physician's order. The facility's electronic medication administration record (eMAR) showed that the insulin was administered on several occasions when the resident's blood sugar was below 150, contrary to the physician's instructions. An LPN confirmed during an interview that the insulin should have been withheld on those occasions. The facility's policy on medication administration requires adherence to prescriber's orders, which was not followed in this case. The deficiency was brought to the attention of the facility's administrative and clinical staff, but no further information was provided before the survey exit.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility staff failed to maintain an operational resident call system for seven of 72 resident rooms, as observed during a survey. Specifically, the call systems in rooms 111A, 133A, 205B, 209B, 211B, 222B, and 230A were not functioning properly. In room 111A, the call system pull station in the bathroom was missing, preventing the call bell/light from being activated. In the other rooms, the call bell/lights by the beds did not activate when the button was pushed. This deficiency was confirmed through observations conducted with the director of maintenance and the maintenance assistant. During an interview, the director of maintenance acknowledged that some call bells/lights in resident rooms were not working and stated that he was waiting on parts to fix them. The facility's policy requires that each nursing unit call system be thoroughly inspected and tested monthly to verify operating efficiency, with documentation of malfunctions and repairs. However, the failure to maintain a functioning call system in these rooms indicates a lapse in adherence to this policy. The administrative staff, including the administrator and the interim director of nursing, were made aware of the issue.
Rehab Restroom Maintenance Deficiency
Penalty
Summary
The facility staff failed to maintain a safe, functional, and sanitary environment in the rehab restroom, as evidenced by a leak and a ceiling tile covered with a black substance. During an observation, it was noted that approximately one fourth of a 12-inch by 24-inch ceiling tile was covered with this substance. Interviews with staff members revealed that the substance had been present for a significant period, initially thought to be a water stain, but it became more pronounced and mold-like over time. The rehab staff eventually decided to shut down the bathroom due to the worsening condition. Further interviews indicated that the issue had been ongoing for several years, with the tile being replaced previously, but the problem resurfaced and worsened in the past 12 weeks. The director of maintenance acknowledged the issue, attributing it to a leak in a water pipe and was in the process of obtaining a quote for repairs. The administrator and interim director of nursing were informed of the concern, highlighting a failure to adhere to the facility's policy of maintaining a high-quality environment.
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Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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