Mountain Laurel Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Rural Retreat, Virginia.
- Location
- 514 North Main Street, Rural Retreat, Virginia 24368
- CMS Provider Number
- 495417
- Inspections on file
- 20
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mountain Laurel Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral issues was subjected to physical and mental abuse by an LPN, who aggressively handled the resident during an episode of agitation. The LPN forcefully grabbed the resident, pushed him against a desk, and tilted his wheelchair back, resulting in the resident falling and sustaining a head injury. Multiple staff witnessed the incident, and facility documentation confirmed the LPN's actions violated abuse prevention policies.
Facility staff failed to provide care and treatment according to provider orders and professional standards for multiple residents, including not administering emergency diabetic medication during a hypoglycemic episode, delaying and failing to notify providers about necessary diagnostic x-rays after a fall, not ensuring completion of ordered chest x-rays, and not following medication orders or discontinuations as directed by hospice. These actions resulted in residents not receiving timely or appropriate interventions for their conditions.
Facility staff failed to provide appropriate behavioral health services and timely medication management for two residents with significant mental health needs, including one hospice patient with a history of trauma and another resident with ongoing psychosis and suicidal ideation. The facility did not involve family in assessments, delayed or omitted administration of prescribed medications, failed to incorporate resident preferences and trauma history into care plans, and did not seek psychiatric services or follow up on recommendations for inpatient psychiatric care. Immediate actions to ensure resident and staff safety were lacking after incidents of aggression and threats.
A resident with multiple comorbidities and a history of UTIs did not receive a provider-ordered urinalysis after her family raised concerns about her mental status. Despite documentation that the test was not obtained and communication in shift reports, there was no follow-through to ensure the lab order was completed. The resident's condition worsened, leading to transfer to the emergency department, where she was diagnosed and treated for a UTI, dehydration, and altered mental status.
Facility staff failed to provide timely radiology and diagnostic services for two residents. In one case, a resident with multiple comorbidities experienced a fall and had a provider order for a hip x-ray, but the x-ray was delayed for two days and the provider was not notified. In another case, a resident who experienced a choking incident had a chest x-ray ordered, but it was not performed until four days later, with no documentation explaining the delay. These actions were not in accordance with facility policy or service agreements.
Facility staff failed to provide necessary care and services for two residents. One resident with severe dementia and behavioral issues was handled aggressively by an LPN during an incident, resulting in a fall and head injury. Another resident with cerebral palsy and intellectual disabilities missed a scheduled day support program because staff did not have the resident ready for transport, despite the resident's interest and care plan requirements.
A resident with a history of cardiac issues experienced severe bradycardia and upper respiratory symptoms, prompting an EKG that revealed a critical abnormality requiring immediate follow-up. Although the urgent EKG results were faxed to the facility overnight, staff did not notify the provider until several hours later, delaying the resident's transfer to the ER. This failure to promptly communicate urgent diagnostic findings was not in accordance with facility policy.
Facility staff did not respond to repeated Resident Council concerns about the lack of proper knives with meals, resulting in residents having to use inadequate utensils or their hands to eat certain foods. Despite ongoing complaints and staff acknowledgment of the issue, the problem persisted over several months, with surveyor observations confirming the absence of knives during meal service.
Facility staff did not consistently provide or document advance directive information for several residents with complex medical conditions. Some residents reported not receiving any explanation about advance directives before signing forms, and required documentation was incomplete or missing. These deficiencies were identified through record reviews and interviews, revealing a lack of adherence to facility policy regarding advance directive discussions.
Staff failed to provide a homelike environment by not supplying adequate utensils, such as knives, with meals, leading residents to use their fingers or request family assistance. Bathing areas had missing tiles and a non-functional whirlpool tub, with maintenance issues left unresolved. Additionally, a resident's wheelchair and another's toilet remained soiled over several days, and trays under ice machines in nutrition rooms were found dirty and containing debris.
Facility staff did not complete or document required background checks, reference checks, and license verifications for multiple new hires, including nurses, CNAs, housekeepers, dietary aides, and therapy staff, as required by the facility's abuse, neglect, and exploitation prevention policy.
Facility staff did not provide required written notification of transfer or discharge reasons to four residents and their representatives, and failed to notify the ombudsman in one case. The affected residents had complex medical conditions and varying cognitive abilities. Staff interviews and record reviews confirmed the absence of documentation, and facility policy requiring timely notification was not followed.
Facility staff did not provide required written bed-hold notices to several residents or their representatives when residents were transferred to the hospital, despite facility policy mandating this action. Affected residents had complex medical conditions and included both cognitively impaired and intact individuals. Record reviews and staff interviews confirmed the absence of documentation showing that the bed-hold policy was communicated at the time of transfer.
Several residents with complex medical conditions did not receive or review their baseline care plans within 48 hours of admission, as required by facility policy. In multiple cases, baseline care plans were either not created on time or not provided to residents or their representatives, and documentation lacked signatures or evidence of review. Staff interviews revealed confusion about who was responsible for this process, leading to inconsistent communication and documentation.
Facility staff did not meet professional standards in several areas, including failing to perform and document required PICC line care for a resident, inaccurately documenting the application of compression stockings for another resident who did not have them, and not properly obtaining or documenting laboratory tests and medication orders for multiple residents. These deficiencies were identified through interviews, record reviews, and policy comparisons.
A resident who was totally dependent on staff for ADLs, including incontinence care, was observed to have remained in a wet brief and clothing for an extended period due to insufficient staff availability for two-person care. Additionally, an LPN documented being unable to complete provider orders, such as wound care and dressing changes, for five residents because of increased patient load, with each nurse responsible for 28 residents. Staffing patterns and workload were confirmed by the facility's staffing coordinator, and the issue was discussed with facility leadership.
Facility staff failed to obtain ordered laboratory tests for four residents, including missing PT/INR monitoring for a resident on anticoagulants, not obtaining a wound culture for a resident with an abscess, incomplete INR testing for a resident with a prosthetic heart valve, and not completing a basic metabolic panel for a resident with chronic kidney disease. These actions did not meet the facility's policy for timely laboratory services.
Staff failed to properly label and store refrigerated and frozen food items, with multiple opened and undated containers found in resident nutrition areas. Additionally, dietary staff served green beans and collard greens using a smaller scoop than required by the menu, resulting in residents receiving less than the intended portion size before the error was corrected.
Surveyors observed that staff did not properly dispose of or contain garbage and waste, with dumpster doors left open and various debris such as medical gloves, cups, and towels found scattered around the disposal area. These findings were discussed with facility leadership.
Facility staff did not receive required training on the QAPI program, as confirmed by leadership and a review of staff files. Only one CNA had documentation of QAPI training, and no further evidence was provided to surveyors.
Surveyors identified multiple deficiencies in the development and implementation of comprehensive care plans, including failure to update care plans with relevant mental health history, inconsistent documentation and practices regarding toileting assistance, omission of a PICC line from a care plan, failure to use bed bolsters as ordered, and incorrect identification of medication purposes and interventions. These issues were observed through staff interviews, resident and family input, and review of clinical records and care plans.
Staff failed to provide necessary ADL care for four residents, including not offering regular bathing to a resident with severe cognitive and mobility impairments, delaying incontinence care for a dependent resident resulting in saturated clothing and wheelchair pads, and neglecting nail care for two residents who were dependent on staff for personal hygiene. These deficiencies were identified through observations, interviews, and record reviews.
Surveyors identified multiple deficiencies involving inaccurate and incomplete documentation in resident medical records, including failure to accurately record diagnostic procedures, medication administration, code status, and dialysis weights. Staff also documented medication administration routes incorrectly and maintained duplicate medication orders, leading to discrepancies between actual care provided and what was recorded.
Facility staff failed to maintain an effective QAPI program, resulting in repeated deficiencies in following provider orders, ensuring medication availability, preventing expired food items, and adhering to infection control guidelines. These issues were identified through multiple surveys and affected several residents, with no evidence of sustained improvement presented to surveyors.
A resident with moderate cognitive impairment and multiple medical conditions was left exposed during incontinence care when a CNA failed to close the door and privacy curtain, resulting in a loss of dignity and respect. The resident expressed discomfort about being exposed to the hallway and others in the room, and staff confirmed that proper privacy measures were not followed.
A resident with multiple chronic conditions experienced significant weight gain over several months. While the Registered Dietician updated the care plan after each weight change, there was no documentation that the physician was notified, as required by facility policy. The DON confirmed that no evidence of physician notification could be found.
A resident with moderate cognitive impairment and incontinence was left exposed during care when a CNA provided incontinence care with the room door open and the privacy curtain only partially closed. The resident's roommate was present and able to view the care, and the resident later expressed discomfort about the lack of privacy. The DON confirmed that proper privacy measures were not followed.
A resident admitted from the hospital did not have all prescribed medications and supplements addressed in their admission orders, including a delay in ordering enoxaparin and missing orders for Epipen, Baqsimi nasal spray, and several vitamins and supplements, despite facility policy requiring immediate care orders from a provider.
Staff failed to accurately complete MDS assessments for two residents: one was not coded for the use of a right-hand splint and elbow brace despite documented orders and care plan, and another was incorrectly coded as receiving anticoagulant medication when clinical records showed none was administered. These inaccuracies were identified through staff interviews, record reviews, and direct observation.
Facility staff did not complete Level I PASARR screenings for two residents with significant mental health diagnoses, despite facility policy requiring such screenings prior to admission. Both residents' records lacked documentation of the required screening, and staff interviews revealed confusion and lack of awareness regarding responsibility for PASARR completion.
Nursing staff failed to complete a provider-ordered wound care treatment for a resident with a pressure ulcer on the left buttock. The resident, who had multiple medical conditions and moderate cognitive impairment, did not receive the prescribed wound care on one occasion due to increased patient load, as documented by an LPN. The order was discontinued after the wound was assessed as healed, and the issue was reviewed with facility leadership.
A resident with a history of mental health disorders and high fall risk was repeatedly found outside unsupervised, smoking cigarettes obtained from the ground, and attempting to leave the facility. Despite care plans and facility policies requiring supervision and secure storage of smoking materials, staff did not consistently enforce these measures, resulting in the resident experiencing a fall and ongoing exposure to accident hazards.
A resident with multiple medical conditions and moderate cognitive impairment did not have documented evidence of receiving or refusing a therapeutic diet as ordered by the provider during several evening meals. Staff interviews did not confirm missed meals, but facility records lacked required documentation for meal delivery or refusals on the specified dates, except for one instance of partial intake.
Facility staff did not provide or document required respiratory treatments for two residents. One resident did not receive incentive spirometer therapy as ordered, with staff unable to confirm the order's intent or provide supporting documentation. Another resident, under hospice care, did not receive scheduled nebulizer treatments, and the DON confirmed no evidence of administration in the clinical record.
Facility staff did not coordinate care with the dialysis center for a resident with end stage renal disease, failing to obtain and document pre- and post-dialysis weights as required by policy. The dialysis book meant to accompany the resident was left blank, and staff interviews confirmed that necessary paperwork and communication with the dialysis provider were not consistently completed.
Medical providers failed to ensure accurate and appropriate physician orders for two residents. One resident had incentive spirometer orders entered with a delayed start date and no supporting documentation, while another had duplicate allopurinol orders signed by a provider without recognizing the duplication. Both issues involved orders entered or signed without proper verification or documentation.
A resident with multiple comorbidities, including diabetes, was readmitted from the hospital with instructions to discontinue several diabetic medications. Facility staff did not ensure the attending physician reviewed the discharge summary or addressed the changes in diabetic management, resulting in no provider orders or monitoring for diabetes after readmission. This led to a lack of documented oversight and intervention for the resident's diabetes, despite ongoing hyperglycemia.
Facility staff failed to ensure timely availability and administration of ordered medications for three residents, resulting in missed or delayed doses of antibiotics and pain medication due to lack of in-house supply and delays in pharmacy delivery, despite facility policy requiring a STAT supply of commonly used medications.
Facility staff did not ensure that monthly medication regimen reviews were completed by a pharmacist and that recommendations were reported to and acted upon by providers in a timely manner for several residents with complex medical needs. Documentation of provider review and action on pharmacist recommendations was delayed or missing, and some reviews were not completed for multiple months.
Facility staff administered Lantus insulin to a resident with diabetes on multiple occasions despite blood sugar readings below the physician-ordered hold parameter. The resident, who was cognitively intact and had a care plan for diabetes management, received the medication contrary to both the physician's order and facility policy, as confirmed by the DON.
Facility staff did not monitor two residents for behaviors or side effects related to prescribed psychotropic medications, despite both residents being cognitively intact and having multiple diagnoses. Required monitoring was not present in the medication records, and facility policy mandating ongoing evaluation of psychotropic medication effects was not followed.
An LPN made two medication errors during a medication pass, resulting in a medication error rate of 7.14%. A resident with multiple cardiac conditions received an incorrect dose of famotidine and had their metoprolol withheld inappropriately, contrary to physician orders. The errors were identified during a survey and confirmed by the LPN upon review.
A resident with multiple complex medical conditions did not receive the full five-day course of Levofloxacin as ordered by the provider, due to a missed dose when the resident was out of the facility for a hospital transfer. The facility's staff did not ensure the medication was administered as prescribed, resulting in a significant medication error.
Staff failed to dispose of expired medications and biologicals in one medication room, where expired laboratory tubes, D3 medication, and influenza vaccines were found and confirmed by the ADON.
Facility staff obtained INR laboratory tests for a resident more frequently than ordered by the physician, performing the test multiple times per week instead of only on Mondays as prescribed. The resident, who was cognitively intact and on anticoagulant therapy, confirmed frequent blood draws, and the DON acknowledged the error.
A resident with multiple chronic conditions and moderate cognitive impairment did not consistently receive their documented daily preference for boiled eggs at breakfast. Despite the preference being recorded on the resident's tray ticket and acknowledged by the dietary manager, the resident reported and surveyors confirmed that boiled eggs were not provided on several occasions, with the dietary manager attributing this to supply issues.
Facility staff did not involve the Medical Director when they were unable to secure a surgical consult for a resident with a rectal prolapse, despite multiple follow-up attempts and ongoing delays. The resident had several medical conditions and was cognitively intact, but staff did not escalate the issue to the Medical Director, who later confirmed he was not contacted.
Staff did not follow infection control protocols for a resident on enhanced barrier precautions due to a PEG tube, failing to wear required PPE and placing soiled items on the floor during incontinence care. The care plan and signage indicated the need for gloves and gowns, but staff were unaware or did not comply with these requirements.
Staff did not offer pneumococcal conjugate vaccines (PCV20 or PCV21) to two residents with moderate cognitive impairment and significant medical histories, despite facility policy and CDC guidelines requiring assessment and offering of the vaccine upon admission. Clinical records showed the vaccines were not up to date and had not been offered, and staff could not provide documentation that the required steps were completed.
A resident with complex medical and psychiatric needs was transferred and subsequently discharged after behavioral incidents, despite evidence from hospice and EMTs that the resident was calm and non-combative. The facility failed to document specific unmet needs or adequate attempts to address the resident's behaviors before issuing a 30-day discharge notice, and medication management was inconsistent. The required documentation supporting the discharge was not present in the medical record.
Failure to Protect Resident from Physical and Mental Abuse by LPN
Penalty
Summary
Facility staff failed to protect a resident's right to be free from physical and mental abuse during an incident involving an LPN and a resident with multiple complex medical and psychiatric diagnoses, including severe vascular dementia, traumatic brain injury, and a history of agitation and behavioral disturbances. The resident, who was moderately cognitively impaired, became physically aggressive with staff and other residents, leading to an intervention by an LPN. According to multiple staff and witness statements, the LPN responded by grabbing the resident's arms aggressively, pushing the resident up against a desk, and then tilting the resident's wheelchair back onto two wheels in an attempt to move the resident down the hall. During this process, the resident continued to resist, and the LPN ultimately let go of the wheelchair, causing the resident to fall backward and strike his head on the floor, resulting in a contusion and a scalp hematoma. Documentation in the clinical record and facility incident reports indicated that the LPN's actions were physically forceful and included aggressive handling of the resident. Witnesses described the LPN as slamming the resident against the desk and making statements such as, "We aren't doing this," and, "If anyone wants to report me for abuse then so be it." The incident was corroborated by multiple staff statements and was reported to have caused both physical harm and mental distress to the resident. The resident was subsequently sent to the emergency room for evaluation of the head injury sustained during the fall. The facility's own investigation and staff interviews confirmed that the LPN's intervention escalated the situation and resulted in the resident's injury. The facility's abuse policy prohibits the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and the actions taken by the LPN were found to be in violation of this policy. The incident was substantiated as abuse, and the LPN involved was not permitted to return to the facility following the investigation.
Failure to Provide Care and Treatment According to Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care services in accordance with professional standards of practice for multiple residents, as evidenced by several documented incidents. For one resident with diabetes, staff did not follow standing orders for hypoglycemic management during a critical episode. Despite a blood glucose reading of 30, staff did not administer glucagon as required by protocol, and there was confusion and lack of documentation regarding the availability and administration of emergency medications. The resident was transferred to a higher level of care due to the unresolved hypoglycemic event. Another resident who experienced a fall and complained of hip pain did not receive a timely x-ray as ordered by the medical provider. The x-ray, which was supposed to be performed promptly, was delayed over the weekend, and staff failed to notify the provider about the delay. The resident continued to report pain, and only after several days was sent to the hospital, where a hip fracture was diagnosed, requiring surgical intervention. Documentation errors were also noted, with staff incorrectly recording that the x-ray had been completed when it had not. Additional deficiencies included failure to ensure a resident received a chest x-ray as ordered, with no evidence the procedure was completed or documented. In another case, staff did not administer Seroquel as ordered and failed to discontinue multiple medications per hospice instructions, resulting in discrepancies between the medication administration record and provider orders. There were also failures to follow medication orders related to a change in condition for another resident, with prescribed treatments not administered and incomplete documentation of assessments and interventions.
Failure to Provide Appropriate Behavioral Health Services and Medication Management
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to residents with mental disorders, psychosocial adjustment difficulties, and histories of trauma. For one resident, who was a hospice patient with a history of trauma, the facility did not involve the family in the comprehensive admission assessment and failed to administer medications ordered for paranoia and agitation in a timely manner. The resident exhibited escalating behaviors, including physical aggression towards staff and other residents, but the facility did not incorporate the resident's preferences or trauma history into the care plan. Additionally, there was no evidence that psychiatric services were sought, despite the facility's stated ability to care for residents with complex psychiatric needs. The clinical record showed that the resident's behaviors were not effectively managed, and staff responses included physical interventions that resulted in injury to the resident. Medication orders for antipsychotic and anxiolytic medications were delayed in being added to the medication administration record (MAR) and were not administered as prescribed, even when the resident was exhibiting ongoing behaviors. The facility also failed to communicate and collaborate effectively with hospice staff, who reported that their offers to assist in managing the resident's behaviors were declined, and that the facility proceeded with a 30-day discharge notice based on the resident's psychiatric history rather than current behaviors. For another resident, the facility did not follow up on a Pre-admission Screening and Resident Review (PASARR) that recommended inpatient psychiatric hospitalization due to psychiatric instability. The resident remained in the facility without a psychiatric evaluation for inpatient treatment, despite ongoing symptoms such as hallucinations, delusions, threats towards others, and suicidal ideation. The facility did not take immediate action to ensure the safety of other residents after threats were made, and there was a lack of documentation and communication regarding these incidents. Both cases demonstrate failures in assessment, care planning, medication management, and coordination of behavioral health services for residents with significant mental health needs.
Failure to Obtain Provider-Ordered Urinalysis Resulting in Hospital Transfer
Penalty
Summary
Facility staff failed to obtain a provider-ordered urinalysis for a resident with a history of chronic kidney disease, bladder cancer, diabetes, and recurrent urinary tract infections. The urinalysis was ordered after the resident's husband expressed concerns about changes in her mental status, but the test was not completed. Documentation by an LPN indicated the urinalysis was not obtained during the shift, and although it was noted in shift and 24-hour reports, it was not communicated in the MD/Nursing communications report. No requisition for the urinalysis was found in the lab book, and the laboratory company confirmed that no urinalysis was performed for the resident on the ordered date. Following the missed urinalysis, the resident's condition deteriorated, with staff documenting decreased oral intake, altered mental status, and increased resistiveness to care. The resident's husband repeatedly contacted the facility due to ongoing concerns about her health and ultimately requested that she be sent to the emergency department. Upon transfer, the resident was found to have abnormal urinalysis results, dehydration, and altered mental status, and was treated with IV fluids and antibiotics for a urinary tract infection. The facility's policy required timely provision or procurement of laboratory services when ordered by a provider. Despite this, the ordered urinalysis was not obtained, and there was a lack of effective communication and follow-through among staff to ensure the test was completed. The failure to obtain the urinalysis contributed to the resident's transfer to a higher level of care and subsequent treatment for a UTI and related complications.
Delayed Radiology and Diagnostic Services for Two Residents
Penalty
Summary
Facility staff failed to provide or obtain timely radiology and diagnostic services for two residents, resulting in deficiencies related to delayed x-ray procedures. In the first case, a resident with multiple diagnoses, including dementia, hypertension, and chronic kidney disease, experienced a fall and complained of left hip pain. Although a provider ordered a left hip x-ray the day after the fall, the x-ray was not performed as scheduled due to a delay by the mobile x-ray company, which did not arrive until two days later. Facility staff did not notify the medical provider of the delay, and documentation inaccurately reflected that the x-ray had been completed. The resident continued to experience pain and was eventually sent to a higher level of care, where a left hip fracture requiring surgical repair was diagnosed. Interviews with staff and family members confirmed that the x-ray was not performed as ordered and that communication with the provider regarding the delay was lacking. The facility's agreement with the mobile x-ray company stipulated availability of radiology services seven days a week, and facility policy required prompt physician notification in the event of changes in condition, such as accidents with potential for physician intervention. Despite these policies, the delay in obtaining the x-ray and the lack of provider notification were not addressed in a timely manner. In the second case, another resident with a history of cerebral infarction, metabolic encephalopathy, and other conditions experienced a choking incident, prompting a provider order for a chest x-ray to rule out aspiration pneumonia. The chest x-ray was not obtained until four days after the order was placed, and there was no documentation explaining the delay. The Director of Nursing confirmed the delay and was unable to provide a reason for it. Facility policy required that radiology and other diagnostic services be provided to meet residents' needs, but this was not followed in this instance.
Failure to Provide Necessary Care and Services for Two Residents
Penalty
Summary
Facility staff failed to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being for two residents. For one resident with multiple complex diagnoses, including severe dementia, traumatic brain injury, and a history of behavioral issues, staff did not recognize the resident as an individual or provide a safe and supportive environment during a behavioral incident. The resident became physically aggressive, and an LPN intervened in a manner described by multiple witnesses as aggressive, including grabbing the resident's arms, pushing the resident in a wheelchair, and tilting the wheelchair onto two wheels. This resulted in the resident falling backward and sustaining a head injury. Documentation and witness statements indicated that the LPN's actions escalated the situation, and the resident was subsequently sent to the emergency room for evaluation of a scalp hematoma. The incident was further complicated by inconsistent accounts from staff and a lack of immediate provision of medications by the facility nurse, despite the hospice nurse's request. The resident's daughter was notified, and the resident was described as calm during transport and at the hospital. Upon return from the hospital, the resident was found in soiled clothing and bedding, indicating a lack of attention to personal care needs. The facility's own investigation and staff statements confirmed the aggressive handling of the resident by the LPN, and the facility's policy on abuse, neglect, and exploitation was reviewed as part of the survey. For another resident with spastic quadriplegic cerebral palsy and intellectual disabilities, the facility failed to ensure attendance at a scheduled day support program. Despite a care plan specifying participation in day support three times a week, the resident was not ready for transport when the day support staff arrived, due to incomplete morning care and medication administration. The day support staff were unable to wait, and the resident remained at the facility, missing the program. Interviews with the resident, family, and staff confirmed the resident's enjoyment of and desire to attend the program, and that the failure to send the resident was due to the facility's inability to prepare the resident in time.
Delay in Provider Notification of Urgent EKG Results
Penalty
Summary
Facility staff failed to promptly notify the provider of urgent diagnostic results for a resident with a history of complete AV block, cardiac pacemaker, hypertension, and asthma. The resident experienced bradycardia and upper respiratory symptoms, and an EKG was ordered after persistent low heart rates were observed. The EKG report, which indicated severe bradycardia and possible third-degree heart block requiring immediate follow-up, was faxed to the facility at 12:47 AM. However, the provider was not notified of these urgent results until approximately 7:30 AM, resulting in a delay of several hours before action was taken. During this period, the resident continued to feel unwell and expressed significant fatigue. The delay in provider notification was confirmed through clinical record review and staff interviews, with staff stating that the results were not received or acted upon until the morning. Facility policy required prompt notification of abnormal diagnostic results to the ordering provider, but this was not followed in this instance, leading to a delay in the resident's transfer to the emergency room for further evaluation and treatment.
Failure to Address Resident Council Grievances Regarding Meal Utensils
Penalty
Summary
Facility staff failed to consider and act upon the grievances and recommendations of the Resident Council regarding the consistent lack of appropriate utensils, specifically knives, with resident meals. Over several months, Resident Council meeting minutes repeatedly documented concerns about not receiving knives or only receiving plastic knives, which were inadequate for cutting meat and spreading condiments. Residents reported having to use their fingers or forks to eat items like pork chops due to the absence of proper knives. The issue persisted despite multiple documented complaints, with residents also noting the frequent use of plastic plates and utensils, especially on weekends. During interviews, residents confirmed the ongoing problem, and staff acknowledged a shortage of knives in the kitchen, with an order for additional knives placed months prior. Surveyor observations during meal service corroborated the absence of knives on meal trays. Documentation provided by the administrator regarding staff education and room rounds did not address the specific concern about knives. No further information or evidence of resolution was provided to the survey team before the exit meeting.
Failure to Provide and Document Advance Directive Information for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that multiple residents were provided with the opportunity to formulate, review, or discuss advance directives upon admission or during their stay. Several residents with significant medical histories, including conditions such as peripheral vascular disease, respiratory failure, congestive heart failure, diabetes, atrial fibrillation, and dementia, were not given clear information or the chance to express their wishes regarding advance directives. In some cases, documentation of advance directive discussions was missing, incomplete, or not witnessed, and residents reported that no one had reviewed the information with them prior to their signatures being obtained. For example, one resident with chronic illnesses was listed as their own responsible party and had a form marked as declined, but when interviewed, indicated that no one had explained advance directive information before the form was signed. Another resident, who was alert and oriented, had a DNR order and a signed advance directive form, but also stated that the facility staff had not reviewed advance directive information with them upon admission. In both cases, the forms lacked witness signatures, and there was no evidence in the clinical record that the required discussions had taken place. Additionally, a resident with a DDNR order had an incomplete form, with required sections left unchecked, and other residents with cognitive capacity were not provided with or did not recall receiving information about advance directives. Facility policy required that advance directive information be provided and discussed upon admission, but documentation and resident interviews revealed that this process was not consistently followed. These deficiencies were identified through clinical record reviews, resident and staff interviews, and examination of facility policies.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to provide a safe, clean, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies observed during the survey. Residents consistently did not receive knives with their meals, and when knives were provided, they were plastic and inadequate for cutting certain foods such as pork chops. Resident Council minutes over several months documented repeated complaints about the lack of proper utensils, with residents expressing frustration and reporting that they had to ask families to bring in knives or resort to eating with their fingers. Staff interviews confirmed a shortage of knives in the kitchen, and although a purchase order for new silverware was provided, the issue persisted at the time of the survey. The facility also failed to maintain clean and functional bathing areas. Residents reported missing tiles and an inoperative whirlpool tub in two of the four bathing areas. Observations confirmed missing and chipped tiles, as well as a whirlpool tub with non-functional jets and a leaking door. Staff acknowledged the ongoing issues, with maintenance efforts hampered by difficulties in sourcing replacement parts and uncertainty about whether the whirlpool would be replaced. The administrator was aware of the problems but could not confirm plans for a replacement tub for residents who preferred baths. Additional deficiencies included unclean resident equipment and nutrition areas. One resident's wheelchair was repeatedly observed to be soiled with a dry, tan-colored substance over several days, despite staff being responsible for cleaning and a cleaning schedule being in place. Another resident's toilet and bedside commode were found with brown matter smeared on them over multiple days, contrary to the facility's policy of daily cleaning. Furthermore, white trays placed beneath ice machines in nutrition rooms were found to contain debris such as food waste, wrappers, and other contaminants, with staff confirming these trays were not part of the manufacturer's setup and should be monitored daily for cleanliness.
Failure to Complete Required Employee Screening for Abuse, Neglect, and Exploitation
Penalty
Summary
Facility staff failed to implement their policy regarding the screening of new hires for abuse, neglect, and exploitation. Specifically, for 13 out of 25 new hires, required background checks, reference checks, and license verifications were either not completed or not documented. The policy in place required that all potential employees, including contracted and temporary staff, be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that documentation of these screenings be maintained. However, upon review, the facility was unable to provide evidence that these screenings had been conducted for the identified new hires, including licensed nurses, certified nursing assistants, housekeepers, dietary aides, and therapy staff. During the survey, the team requested and reviewed the facility's Abuse, Neglect, and Exploitation policy, which outlined the required screening procedures. The surveyors found that for several new hires, there were missing background checks, reference checks, and license verifications. The facility was only able to provide some of the missing documentation after the survey began, and for the majority of the identified staff, no further information was provided prior to the exit conference. No information about residents or their conditions was included in the report.
Failure to Provide Written Transfer/Discharge Notification to Residents, Representatives, and Ombudsman
Penalty
Summary
Facility staff failed to provide written notification of the reasons for transfer and/or discharge to residents and their representatives in four cases out of fifty-five sampled. In each instance, the clinical record review and staff interviews revealed that no evidence could be found that written notice was given to either the resident or their representative at the time of transfer to the hospital. The residents involved had significant medical histories, including conditions such as cerebral infarction, diabetes, chronic kidney disease, dementia, mood disorders, hemiplegia, hypertension, seizures, and respiratory failure. Cognitive assessments indicated that some residents were severely impaired, while others were cognitively intact. For one resident, the facility also failed to provide evidence that the local long-term care ombudsman was notified of the transfer or discharge, as required. Staff interviews confirmed that no documentation or notification was sent to the ombudsman, the resident, or the family in this case, due to a lack of awareness that the resident had been transferred. Facility policy required that transfer notices be provided as soon as practicable to both the resident and their representative, but this was not followed in the cited cases. The surveyors requested documentation and reviewed facility policies, but no further information or evidence of compliance was provided prior to the survey exit. The deficiency was discussed with facility leadership during end-of-day meetings, and the lack of written notification was confirmed by staff, including the DON, ADON, and social worker, who stated that discharge notifications were not completed.
Failure to Provide Bed-Hold Notices Upon Resident Transfer
Penalty
Summary
Facility staff failed to provide written bed-hold notices to residents and/or their representatives upon transfer to a hospital or for therapeutic leave, as required by facility policy. In multiple instances, surveyors found no evidence in the clinical records that the bed-hold policy was given at the time of transfer, despite requests for documentation. The facility's own policy, reviewed and revised on 12/1/22, states that written notice specifying the duration of the bed-hold policy must be provided at the time of transfer for hospitalization. Specific cases included residents with significant medical histories and varying cognitive abilities. One resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and acute respiratory failure, was transferred to the hospital without documentation of a bed-hold notice being provided. Another resident, cognitively intact and diagnosed with hemiplegia, diabetes, and other conditions, was also transferred without evidence of receiving the required notice. Additional residents with complex medical backgrounds, including dementia, chronic kidney disease, and depression, were similarly affected. Staff interviews and record reviews confirmed that in each case, no documentation could be found to show that the bed-hold policy was communicated to the resident or their representative at the time of transfer. The issue was discussed with facility leadership during survey meetings, and the only documentation provided was the facility's policy itself, not evidence of compliance for the affected residents.
Failure to Provide and Document Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement baseline care plans and/or provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission for seven out of fifty-five sampled residents. In several cases, baseline care plans were either not created within the required timeframe or, when created, were not reviewed with the resident or their representative, nor was a written summary provided as required by facility policy. Documentation often lacked signatures or other evidence that the care plan had been reviewed or received by the resident or their representative. Multiple residents with complex medical histories, including conditions such as bipolar disorder, seizures, chronic kidney disease, atrial fibrillation, diabetes, and Parkinson's disease, were affected by these deficiencies. For example, one resident with cognitive impairment and another who was cognitively intact both reported not receiving or reviewing their baseline care plans. In some cases, family members expressed concerns about care practices, such as toileting, and reported not being involved in care planning discussions or provided with care plan documentation. Interviews with staff revealed confusion and inconsistency regarding who was responsible for providing and reviewing baseline care plans with residents and their representatives. Some staff believed it was the responsibility of the nurse on the hall, while others assumed the social worker handled it. Facility policy clearly stated that a supervising nurse or MDS nurse/designee was responsible for providing the written summary and obtaining signatures, but this process was not consistently followed, resulting in a lack of documentation and communication with residents and their representatives.
Failure to Meet Professional Standards in Care, Documentation, and Medication Management
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of quality for multiple residents. For one resident with a PICC line, staff did not perform required dressing changes or flushes after the completion of IV antibiotics, and there was no documentation of these actions or provider orders for them. The dressing was observed to be compromised and the date illegible, with the resident unable to recall when it was last changed. The facility's own policy required dressing changes every seven days and immediate changes if the dressing integrity was compromised, but these standards were not met. Another resident with an order for TED hose/compression stockings did not have the stockings available for approximately two weeks, yet staff continued to document their application and removal as if the care was provided. The resident confirmed not having the stockings during this period, and the facility's documentation policy required factual and accurate records, which was not followed in this case. Additional deficiencies included failure to obtain and document laboratory tests as ordered for a resident on anticoagulant therapy, improper documentation and clarification of medication orders for a resident who was NPO but had oral medications documented as given, and failure to clarify and address duplicate medication orders for another resident, resulting in inaccurate medication administration records. These actions and inactions were identified through resident and staff interviews, clinical record reviews, and facility policy reviews.
Failure to Provide Adequate Nursing Staff Resulting in Missed Care and Incomplete Treatments
Penalty
Summary
Facility staff failed to provide adequate nursing staff each day to meet the needs of all residents, resulting in deficiencies in care for six residents. One resident with spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia was observed to be totally dependent on staff for activities of daily living, including incontinence care. The resident was documented as always incontinent and required two staff members for transfers and care. Despite care plan interventions specifying incontinence checks every two hours and as needed, the resident was observed seated in the same location throughout the day, and when incontinence care was finally provided, the resident's brief, clothing, and wheelchair pad were found to be saturated and wet. Staff interviews revealed that CNAs were responsible for high numbers of residents, with one CNA stating she had 16 residents that day, which was fewer than usual, and that she could not complete her work without stopping due to lack of available assistance for two-person care tasks. Additionally, for five other residents, an LPN documented being unable to complete provider orders due to increased patient load. The clinical records for these residents included notes stating that certain treatments, such as wound care and dressing changes, were not completed because of the nurse's workload. The LPN did not specify which tasks were left incomplete in some cases, and the documentation was entered as a medication administration note. The LPN was responsible for 28 residents during the shift, and a review of the staffing schedule confirmed that this was typical staffing for the unit, with two nurses and five CNAs assigned to 56 residents. The facility's staffing coordinator confirmed the usual staffing patterns and acknowledged the workload assigned to staff. The issue of incomplete care and documentation due to staffing levels was discussed with facility leadership, including the administrator, director of nursing, and regional clinical staff. No additional information or clarification regarding the incidents was provided to the survey team prior to the exit conference.
Failure to Obtain Provider-Ordered Laboratory Tests for Multiple Residents
Penalty
Summary
Facility staff failed to obtain provider-ordered laboratory tests for four residents, resulting in missing or incomplete lab results as required by medical orders. For one resident with chronic atrial fibrillation and on anticoagulant therapy, PT/INR tests were not obtained on three separate occasions despite clear orders for weekly monitoring. The resident's care plan included interventions for labs as ordered, but the clinical record lacked the required PT/INR results, and the facility was unable to provide them upon surveyor request. Another resident with a left lower buttock abscess and multiple comorbidities had a wound culture ordered by the wound provider, but the initial culture was not obtained as required. The lab later rejected two wound cultures for unclear reasons, and a repeat culture was only obtained during a subsequent provider visit, which revealed significant bacterial growth. The facility could not provide results or documentation for the initial culture order during the survey period. Additional deficiencies included failure to obtain daily INR tests for a resident with a prosthetic heart valve and altered cardiovascular status, as only three out of five ordered tests were completed. Nursing notes confirmed that the tests were not obtained on two of the required days. Another resident with chronic kidney disease and other conditions had a basic metabolic panel ordered, but the results were not found in the clinical record. The order was later discontinued after consultation with a nurse practitioner, but the initial test was not completed as ordered. In all cases, the facility's policy required timely provision or procurement of laboratory services as ordered by providers, which was not met.
Deficiencies in Food Storage, Labeling, and Serving Sizes
Penalty
Summary
Facility staff failed to store and label resident food items in accordance with professional standards for food service safety. During observations in two resident unit pantry/nutrition areas, multiple food items in both refrigerators and freezers were found to be unlabeled, undated, or improperly stored. Examples included opened containers of ice cream, handheld pastries, and other food items that lacked use-by or expiration dates, as well as items not labeled with residents' names. Some items, such as a jar of strawberry jam, were found with the lid ajar, and a container of milk was past its date. These findings were inconsistent with the facility's own policies, which require labeling, dating, and proper storage of refrigerated and frozen foods. Additionally, the facility staff did not serve food according to the menu's specified serving sizes. During a midday meal observation, dietary staff used three-ounce scoops to serve green beans and collard greens, despite the menu indicating a four-ounce serving size for these items. The Dietary Manager confirmed the incorrect scoop was used and that some resident trays had already been sent out with the smaller portion before the error was corrected. These actions resulted in residents receiving less than the intended portion sizes for their meals.
Improper Disposal and Containment of Facility Garbage and Waste
Penalty
Summary
Facility staff failed to ensure proper disposal and containment of garbage and waste, as observed by surveyors and the Dietary Manager. During an inspection of the facility's outdoor garbage disposal area, it was noted that one dumpster had both doors open and the other had one door open. Additionally, various debris, including blue medical gloves, plastic drinking cups, a piece of foil, a disposable towel, small medication cups, and an empty plastic cup previously containing jello or pudding, were found scattered on the ground around the dumpsters. These observations were discussed with facility leadership during a meeting following the inspection. No information regarding specific residents or their medical conditions was provided in the report.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
Facility staff failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members. During the survey, the team leader requested documentation of staff training and competencies, which, according to the facility assessment, should include QAPI for all staff. Upon review, the Administrator was unable to produce any records of QAPI training or education for facility staff, except for one Certified Nursing Assistant who had completed QAPI training previously. No additional evidence of QAPI training for other staff was provided to the survey team prior to the exit conference. The deficiency was identified through staff interviews and document reviews, with the lack of QAPI training being confirmed by facility leadership and the absence of supporting documentation in staff files.
Deficiencies in Comprehensive Care Planning and Implementation
Penalty
Summary
Facility staff failed to develop and/or revise comprehensive, person-centered care plans to meet the needs of several residents, as identified through observation, staff interviews, clinical record reviews, and facility document reviews. For one resident with a complex mental health history, the care plan did not reflect pertinent diagnoses such as a history of suicide attempt and abuse, nor did it include individualized interventions. Additionally, staff did not consistently follow the care plan regarding the administration of ordered medications for behavioral symptoms, with documentation showing missed or delayed administration of antipsychotic and anxiolytic medications. Another resident's care plan did not accurately reflect the level of assistance required for safe toileting. There was inconsistency between the care plan, staff practices, and family expectations regarding toileting methods, with conflicting documentation about the use of bedpans versus transferring to the toilet. The care conference notes lacked specific documentation of discussions with the family about these concerns, and the care plan did not clearly address the resident's physical limitations and preferences. Additional deficiencies included the failure to address the presence of a peripherally inserted central catheter (PICC) in a resident's care plan, and the failure to implement care plan interventions such as the use of bed bolsters for fall prevention. In another case, a resident's care plan did not correctly identify the purpose of an anticonvulsant medication and included incorrect interventions referencing anti-Parkinson's medications without supporting diagnoses. These deficiencies were identified during surveyor observations, interviews, and record reviews, and were discussed with facility leadership during exit conferences.
Failure to Provide Required ADL Care Including Bathing, Incontinence, and Nail Care
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) care for four residents, resulting in deficiencies related to bathing, incontinence care, and nail care. One resident with multiple complex diagnoses, including severe cognitive impairment and mobility deficits, was not offered a full bed bath or shower at least twice a week as required. Bathing records showed that over a five-day period, the resident received only one partial bath, with no documentation of refusals, despite care plan interventions specifying extensive assistance with bathing. Staff interviews revealed inconsistencies in the understanding and delivery of bathing routines, and observations noted delays in changing soiled clothing after incidents such as vomiting. Another resident, who was totally dependent on staff for ADLs due to spastic quadriplegic cerebral palsy and was always incontinent, was not provided timely incontinence care. Observations throughout the day showed the resident remained in the same location, and when incontinence care was finally provided, the resident's brief, clothing, and wheelchair pad were found to be fully saturated. Staff interviews indicated that care was delayed due to the need for two-person assistance and lack of available staff, despite care plan interventions and facility policy requiring checks and care every two hours. Two additional residents, both dependent on staff for personal hygiene, were not provided adequate nail care. One resident's toenails were observed to be long, and the resident reported being unable to care for them independently. The other resident had long, thick toenails and fingernails that were jagged with debris present. Staff interviews and observations confirmed that nail care was not being performed as required by care plans, with some staff deferring responsibility to a podiatrist. These deficiencies were confirmed through direct observation, staff and resident interviews, and review of facility records and policies.
Multiple Documentation and Medication Record Deficiencies Identified
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for multiple residents, resulting in several documentation deficiencies. For one resident, staff inaccurately documented that a left hip x-ray was completed, despite evidence that the x-ray was not performed as scheduled. Another resident's clinical record contained inconsistent documentation regarding the date of death, with a nurse practitioner entering an incorrect date in the medical record. Additionally, staff failed to document the administration of Tylenol for a resident experiencing pain, with the responsible LPN admitting to administering the medication but not recording it in the medication administration record (MAR). Further deficiencies included the failure to ensure medication orders were correct for a resident who was to receive nothing by mouth (NPO) but had multiple oral medication orders and documentation of administration. Another resident's provider notes incorrectly stated the resident's code status as full code when a do not resuscitate (DNR) order was in place, and staff documented the administration of an antibiotic via the wrong route. The facility also failed to document pre- and post-dialysis weights for a resident with end stage renal disease, despite facility policy requiring this information to be recorded in the clinical record. Additional issues were identified with the administration and documentation of allopurinol for a resident with gout, where duplicate orders led to the MAR reflecting two doses administered on several days, though only one dose was actually given. These deficiencies were identified through staff interviews, clinical record reviews, and facility policy reviews, and were discussed with facility leadership during the survey process.
Repeated QAPI Failures in Quality of Care, Pharmacy, Nutrition, and Infection Control
Penalty
Summary
Facility staff failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by repeated deficiencies in multiple areas including Quality of Care, Pharmacy Services, Food and Nutrition Services, and Infection Control. These deficiencies were identified through staff interviews, clinical record reviews, and facility document reviews, and were noted to have recurred across several standard and abbreviated surveys over a period of several years. Specifically, staff did not consistently follow medical provider orders for a significant number of sampled residents, did not ensure that provider-ordered medications were available and administered as ordered, and allowed expired food items to remain in use. Additionally, staff failed to adhere to established infection control guidelines. The report details that the same areas of deficiency were cited in previous surveys, indicating a lack of effective monitoring and revision of plans of correction. For example, failures to follow medical provider orders and ensure medication availability were cited in both past and current surveys, as was the presence of expired food and lapses in infection control practices. Despite the facility having a policy outlining a systemic approach to performance improvement, there was no evidence provided to the survey team that demonstrated effective tracking or sustained improvement in these areas prior to the exit conference.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
Facility staff failed to maintain the dignity and respect of a resident during incontinence care. The incident involved a certified nurse's aide (CNA) providing care to a resident with multiple diagnoses, including cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety. The resident was assessed as moderately cognitively impaired. During the care, the CNA left the resident's door open and did not fully close the privacy curtain between the resident and her roommate, resulting in the resident's bare bottom being exposed while the roommate was present and the door was open to the hallway. The resident expressed discomfort about the situation, specifically noting concern about men walking in the hallway and potentially entering the room while she was exposed. The CNA acknowledged that the door was not properly closed, and the director of nursing confirmed that both the door and privacy curtain should have been closed during care. The deficiency was identified through observation, staff interview, and resident interview.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
Facility staff failed to notify the physician of a significant change in condition for one resident who experienced notable weight gain. The resident had multiple diagnoses, including diabetes, atherosclerosis, peripheral vascular disease with a left below-knee amputation, gastroesophageal reflux disease, essential hypertension, and major depressive disorder. Clinical records showed that the resident's weight increased from 127.5 lbs to 146 lbs within a little over a month, and from 126.8 lbs to 153 lbs over six months, representing a 14.51% and 20.66% gain, respectively. The Minimum Data Set (MDS) assessment identified these as significant weight gains. Although the Registered Dietician reviewed each significant weight gain and updated the care plan accordingly, there was no evidence found in the clinical record that the primary care provider was notified of these changes. The facility's own policy required physician notification in the event of significant weight changes. During interviews and document reviews, the Director of Nursing confirmed that no documentation existed to show the provider had been informed, and no further information was provided to the survey team before the exit conference.
Failure to Ensure Resident Privacy During Incontinence Care
Penalty
Summary
Facility staff failed to ensure personal privacy for a resident during incontinence care. During an observation, a certified nurse's aide (CNA) was providing care to a resident with the room door open and the privacy curtain only partially pulled, leaving the resident's buttocks exposed. The resident's roommate was present in the room and facing toward the resident receiving care. The CNA acknowledged that the door did not latch properly and believed it was closed, but it was not. The surveyor entered the room after knocking and was able to see the resident exposed, prompting an immediate exit and closure of the door. The resident involved had diagnoses including cerebral infarction, chronic kidney disease, and chronic pain syndrome, and was assessed as moderately cognitively impaired with frequent urinary incontinence and occasional bowel incontinence. The resident later expressed discomfort about the lack of privacy, specifically noting concern about people in the hallway and the need for the door to be closed during personal care. The director of nursing confirmed that both the door and privacy curtain should have been closed during such care.
Failure to Address Resident's Medication Needs Upon Admission
Penalty
Summary
Facility staff failed to ensure that a resident's medication needs were addressed as part of the admission orders. Upon admission from the hospital, the resident's discharge summary included instructions to continue several medications and supplements, including enoxaparin, Epipen, Baqsimi nasal spray, ergocalciferol, olopatadine eye drops, and various vitamins and supplements. However, the facility's medical provider did not order enoxaparin until two days after admission, and there was no documentation explaining the omission for the intervening day. Additionally, orders for Epipen and Baqsimi nasal spray were not obtained until prompted by a surveyor, and several other medications and supplements listed in the hospital discharge summary were not addressed in the admission orders at all. The resident was documented as alert, oriented, with adequate vision and grossly intact hearing at the time of admission. The facility's own policy required that a physician or other qualified provider give orders for the resident's immediate care and needs upon admission, including medication orders if indicated. Despite this, the admission provider failed to address all medications and supplements specified in the hospital discharge summary, and the facility's standing orders did not cover all of the resident's needs, such as the Baqsimi nasal spray for low blood sugar.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
Facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident with multiple diagnoses including mild cognitive impairment, cerebral infarction, and right-side hemiparesis, staff did not code the use of a right-hand splint and right elbow extension brace on the MDS assessment, despite provider orders, care plan documentation, and treatment administration records confirming the use of these devices for contracture management. The resident was observed by the surveyor wearing the splint, and the care plan and orders clearly indicated the need for these interventions, but the MDS did not reflect this information. For another resident with diagnoses such as cerebral infarction, metabolic encephalopathy, and moderate cognitive impairment, staff incorrectly coded the MDS to indicate the use of anticoagulant medication during the assessment period. A review of the clinical record did not show evidence that the resident received any anticoagulant medication in the relevant seven-day period. The MDS Coordinator confirmed the error after reviewing the record. No additional information regarding these concerns was provided to the survey team prior to the exit conference.
Failure to Complete Required PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
Facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was completed for two residents with significant mental health diagnoses. One resident had diagnoses including cerebral infarction, metabolic encephalopathy, convulsions, unspecified psychosis, major depressive disorder, and generalized anxiety disorder, and was assessed as moderately cognitively impaired with delusions and wandering behavior. Despite residing in the facility for approximately five months, no Level I PASARR was found in the clinical record, and staff interviews confirmed that the screening had not been completed. The facility policy required all applicants to be screened for serious mental disorders or intellectual disabilities prior to admission, and for records of the pre-screening to be maintained in the resident's medical record. However, staff were unclear about their responsibilities regarding PASARR completion, with the social worker and admissions coordinator both stating they had not been instructed to complete the screenings. A second resident with diagnoses including suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features also did not have a Level I PASARR in their clinical record. The resident was cognitively intact according to the most recent assessment. Staff interviews revealed a lack of awareness and training regarding the facility's policy on PASARR responsibilities, with both the social worker and admissions director stating they had never completed or been told to complete Level I PASARRs. The facility's policy designated the social services director as responsible for tracking PASARR status, but the social worker was unaware of this policy. No further information or documentation regarding PASARR completion was provided to the survey team prior to the exit conference.
Failure to Complete Provider-Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility nursing staff failed to complete a provider-ordered treatment for a pressure ulcer on a resident's left buttock. The resident had diagnoses including paranoid schizophrenia, diabetes, and chronic pain syndrome, and was assessed as moderately impaired in cognitive skills. The resident was identified as being at risk for pressure ulcers and had a provider order to cleanse the open area, apply barrier cream, and cover with a bordered gauze dressing daily and as needed. On one occasion, the treatment was not completed as ordered, with documentation indicating that the LPN was unable to perform the wound care due to increased patient load. The provider order for the wound care was discontinued the following day after the wound was assessed as healed. The deficiency was identified through staff interview, clinical record review, and facility document review, and was discussed with facility leadership during an end-of-day meeting. No additional information regarding the missed treatment was provided to the survey team prior to the exit conference.
Failure to Prevent Accident Hazards and Provide Supervision for High-Risk Resident
Penalty
Summary
Facility staff failed to ensure an environment free from accident hazards and did not provide adequate supervision for a resident with a history of suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features. The resident was assessed as cognitively intact, at high risk for falls, and at risk for wandering. Despite these risks, the resident was repeatedly found outside the facility unsupervised, smoking cigarettes obtained from the ground, and attempting to leave the premises. The resident's care plan included interventions for self-care deficits, fall risk, and behavioral issues, but these were not effectively implemented to prevent the resident from accessing hazardous areas or engaging in unsafe behaviors. Multiple nursing notes documented incidents where the resident was found outside, sometimes in the driveway or attempting to leave, and on one occasion, the resident fell while outside, hitting his head and abdomen. Staff were aware of the resident's revoked smoking privileges due to policy violations, yet the resident continued to access cigarettes and lighters. Observations by the surveyor confirmed the resident was outside unsupervised, and staff acknowledged this was a recurring issue. Facility policy required supervision and secure storage of smoking materials, but these measures were not consistently enforced for this resident.
Failure to Document and Provide Evidence of Therapeutic Diet Delivery
Penalty
Summary
Facility staff failed to provide evidence that a resident with multiple complex medical diagnoses, including atrial fibrillation, dementia, heart failure, and a history of falls, received or refused a therapeutic diet as ordered by the medical provider during several evening meals. The resident was assessed as moderately cognitively impaired and had a care plan in place to provide and monitor a regular diet, with intake to be recorded at each meal. However, meal intake records for specific dates showed no documentation of meal percentages consumed or refusals for the evening meals in question. Interviews with staff and the local ombudsman did not yield direct observations of the resident missing meals, and staff recalled the resident typically ate independently after tray setup, preferring finger foods. Despite this, the facility was unable to provide documentation for meal delivery or refusals on the specified dates, except for one instance where partial intake was recorded. The facility's policy required encouragement of resident participation in meals, but no further information was provided to demonstrate compliance with ordered dietary interventions during the identified periods.
Failure to Provide and Document Ordered Respiratory Care
Penalty
Summary
Facility staff failed to provide ordered respiratory care and treatments for two residents. For one resident, there were medical provider orders for the use of an incentive spirometer, including specific instructions for use and monitoring of vital signs and breath sounds before and after each treatment. However, the start date for the treatment was incorrectly entered, and staff could not find documentation that the incentive spirometer was provided or that the orders were carried out. Further investigation revealed uncertainty among staff and the medical provider regarding whether the order was intended for this resident, and no supporting documentation was found in the clinical record. For another resident, who was under hospice care, the hospice plan of care included scheduled nebulizer treatments with albuterol and ipratropium every eight hours. The resident's hospice certification and plan of care confirmed these treatments were to be continued. However, there was no evidence in the clinical record that the nebulizer treatments were administered between the hospice visit and the resident's death. The DON confirmed the absence of documentation for these treatments after reviewing the records. Interviews with facility staff, including the RN who entered the orders, the Medical Director, and the DON, confirmed the lack of documentation and uncertainty regarding the administration of the ordered respiratory treatments. The survey team discussed these findings with facility leadership, highlighting the failure to provide and document required respiratory care as ordered for both residents.
Failure to Coordinate Dialysis Care and Document Required Weights
Penalty
Summary
Facility staff failed to coordinate care with the dialysis center for a resident diagnosed with end stage renal disease who required dialysis three times a week. The resident's care plan included interventions to coordinate care with the dialysis provider as needed, and facility policy required obtaining pre- and post-dialysis weights and ensuring communication with the dialysis center. However, during clinical record review, there was no documentation of pre- or post-dialysis weights for the resident, and the dialysis book intended to accompany the resident to dialysis contained only blank pages. Interviews with staff revealed that required paperwork was not consistently sent with the resident to dialysis, and staff did not obtain or document the necessary weights as outlined in facility policy. The absence of completed documentation and lack of coordination with the dialysis center were confirmed by both the Assistant Director of Nursing and the Unit Manager. No further information or documentation regarding the coordination of care was provided to the survey team prior to the exit conference.
Failure to Ensure Accurate and Appropriate Physician Orders for Residents
Penalty
Summary
Medical providers at the facility failed to ensure that physician orders addressed the needs of two residents. For one resident, incentive spirometer orders were entered with a delayed start date and without supporting documentation in the clinical record. The orders were signed by a medical provider without adjustment, and both the nurse who entered the orders and the medical director could not confirm for whom the orders were intended. The nurse suggested the orders may have been entered for the wrong resident and could not locate documentation to support their necessity. For another resident, duplicate orders for allopurinol were entered by non-prescribing staff and subsequently signed by a medical provider without identifying the duplication. The duplicate orders remained active until a different medical provider later discontinued one of them after recognizing the duplication. Both residents were assessed as alert and oriented, with adequate cognitive and sensory function documented at the time of the deficiencies.
Failure to Review and Address Diabetic Medication Changes Post-Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident's attending physician reviewed the hospital discharge summary following a hospital stay, specifically neglecting to address changes in the resident's diabetic medications. The discharge summary indicated that several diabetic medications, including insulin and metformin, were to be discontinued. However, upon the resident's readmission, there was no documentation of a medical provider reviewing or addressing these medication changes, nor were there new provider orders or progress notes explaining the discontinuation or providing alternative diabetic management. The resident had a complex medical history, including Type 2 Diabetes Mellitus with chronic kidney disease, atrial fibrillation, morbid obesity, and other significant comorbidities. Despite a care plan goal to prevent complications related to diabetes, the clinical record showed no evidence of diabetic medication orders or blood glucose monitoring after the resident's return from the hospital. The last recorded blood sugar check was prior to the hospital transfer, and subsequent lab results revealed persistently high glucose levels and an elevated A1C, indicating poor glycemic control. Interviews with administrative staff confirmed the absence of provider documentation or orders regarding the resident's diabetes management after readmission. The facility's policy required verification of transfer orders and provider review, but this process was not followed. The resident was unaware of his current diabetic medication regimen, and staff could not provide an explanation for the lack of diabetic care orders until the issue was identified during the survey.
Failure to Provide Timely Access to Ordered Medications
Penalty
Summary
Facility staff failed to ensure that ordered medications were available and administered as prescribed for three residents. For one resident with multiple diagnoses including neuropathy, diabetes, Alzheimer's disease, and atrial fibrillation, an order for Rocephin (Ceftriaxone Sodium) to treat a suspected urinary tract infection was not fulfilled because the medication was not available in the in-house supply. Staff used the last available dose, and subsequent attempts to obtain the medication from the Cubex system were unsuccessful. The pharmacy was not restocked in a timely manner, and the medication was placed on hold until it arrived, resulting in a missed dose. Another resident with diagnoses such as diabetes, obstructive and reflux uropathy, hypertension, and atrial fibrillation did not receive a one-time ordered dose of Ceftriaxone Sodium (Rocephin) as scheduled. The medication was not available in the Cubex system at the time of administration, and the dose was delayed until it could be obtained from the pharmacy. Facility policy indicated that a STAT supply of commonly used medications should be maintained in-house, but this was not followed in these instances. A third resident, with a history of femur fracture, chronic atrial fibrillation, restless leg syndrome, and osteoarthritis, did not receive two scheduled doses of Lyrica for pain management because the medication was not available. Nursing notes documented calls to the pharmacy and provider to obtain a new prescription and indicated that the medication was on order and awaiting delivery. The care plan for this resident included medicating as ordered for comfort, but the medication was not administered as prescribed due to unavailability.
Failure to Complete and Act Upon Medication Regimen Reviews
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews (MRRs) were completed by a licensed pharmacist and that recommendations from these reviews were reported to and acted upon by medical providers in a timely manner for multiple residents. For one resident with multiple complex diagnoses, including progressive multifocal leukoencephalopathy and chronic kidney disease, the MRR completed by the pharmacist was not acknowledged or signed by a medical provider until well after the recommendation was made. The recommendation involved evaluating the use of multiple antidepressants and considering a dose reduction, but documentation of timely provider review and action was lacking. Another resident with severe cognitive impairment and multiple chronic conditions did not have evidence of MRRs being completed for several consecutive months. When MRRs were completed, the reports and recommendations were not promptly available in the clinical record, and provider responses were delayed. Recommendations included monitoring thyroid therapy and clarifying medication stop dates, but provider acknowledgment and action were not documented until weeks after the pharmacist's recommendations. A third resident with severe cognitive impairment had a pharmacist's recommendation for a dose reduction of Depakote that was not addressed by the medical provider for several months. The facility's policy required that MRR irregularities be reported and acted upon, but documentation showed significant delays in provider response and action. These deficiencies were confirmed through staff interviews, clinical record reviews, and facility policy review, with no additional information provided to the survey team prior to exit.
Failure to Hold Insulin per Physician Parameters
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of Lantus insulin. The resident, who had diagnoses including cerebral infarction, type 2 diabetes mellitus, and hypertension, was cognitively intact according to the most recent MDS assessment. The resident's care plan included diabetes management with medication as ordered by the physician. The physician's order for Lantus insulin specified that it should be held if the resident's blood sugar (BS) was less than 150. Review of the electronic medication administration records (eMAR) for February and March showed that the resident received Lantus insulin multiple times when their BS was below the ordered hold parameter of 150. Specific instances included administration with BS readings of 147, 129, 104, 128, 142, 131, and 117. The DON confirmed that the insulin should have been held according to the physician's parameters. Facility policy also required medications to be held when vital signs were outside prescribed parameters. No additional information was provided prior to the survey exit.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
Facility staff failed to ensure that two residents were free from unnecessary psychotropic medications by not monitoring for behaviors or side effects associated with these medications. For one resident with diagnoses including Bipolar Disorder, Seizures, Insomnia, Chronic Kidney Disease, Borderline Personality Disorder, and Atrial Fibrillation, there were no orders or documentation for behavior or side effect monitoring related to prescribed psychotropic medications such as Effexor, Trazadone, Depakote, and Ziprasidone during the month of March. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15, and was a new admission to the facility. The lack of monitoring was confirmed by facility leadership during the survey process. Another resident, with diagnoses including Progressive Multifocal Leukoencephalopathy, Anorexia, Chronic Kidney Disease, Acute Kidney Failure, Anxiety Disorder, Repeated Falls, Ataxia, Acute Respiratory Failure with Hypoxia, and Wasting Disease Syndrome, was also not monitored for behaviors or side effects related to psychotropic medications in April. This resident was prescribed multiple psychotropic medications, including Citalopram, Doxepin, Trazadone, and Lorazepam. The resident was cognitively intact, with a BIMS score of 15 out of 15. The April medication administration and treatment records did not include any psychotropic drug monitoring, despite the care plan indicating the need to observe and document adverse reactions. Facility policy required ongoing evaluation of the effects of psychotropic medications on residents' physical, mental, and psychosocial well-being, consistent with clinical standards and the residents' comprehensive care plans. However, in both cases, the required monitoring was not implemented or documented as required, leading to the identified deficiencies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 28 opportunities, resulting in a 7.14% error rate. During a medication pass, an LPN administered the incorrect dose of famotidine to a resident with diagnoses including atrial fibrillation, heart failure, bradycardia, and GERD. The LPN gave 10 mg of famotidine instead of the ordered 20 mg. Additionally, the LPN withheld the resident's metoprolol based on a pulse of 60, despite the physician's order specifying to hold the medication only if the pulse was less than 60 or systolic blood pressure was less than 100. Upon review, the LPN acknowledged the errors when prompted by the surveyor, confirming that the correct famotidine dose should have been two 10 mg tablets and that metoprolol should not have been withheld. These errors were discussed with facility leadership, including the Administrator and Director of Nursing, during the survey process. No further information was provided to the survey team prior to the exit conference.
Failure to Administer Prescribed Antibiotic as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not administering Levofloxacin as ordered by the provider. The provider's order specified that the resident was to receive Levofloxacin 750 mg orally once daily for five days, starting on 3/11/25. However, review of the medication administration record (MAR) and clinical documentation showed that the resident only received four doses of the medication, rather than the prescribed five. On the first scheduled day, the resident was marked as being on a leave of absence due to a hospital transfer and did not receive the medication. The resident involved had multiple complex diagnoses, including Progressive Multifocal Leukoencephalopathy, Chronic Kidney Disease, Acute Kidney Failure, and Acute Respiratory Failure with Hypoxia, among others. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Despite the facility's policy requiring medications to be administered as ordered, the missed dose was not addressed, resulting in the resident not receiving the full prescribed course of antibiotic therapy.
Expired Medications and Biologicals Not Disposed in Medication Room
Penalty
Summary
Facility staff failed to dispose of expired medications and biologicals in one of two medication rooms, specifically the [NAME] side medication room. During an observation conducted by the surveyor and the Assistant Director of Nursing (ADON), multiple expired items were found, including 16 red top laboratory tubes with expiration dates of 12/31/24 and 11/30/24, a box of opened green top tubes with an expiration date of 03/31/25, four bottles of D3 medication expired as of 03/2025, and four boxes of Influenza vaccine labeled 2023-2024 formula with an expiration date of 06/30/24, each containing 10 syringes. The ADON confirmed these items were expired upon review. The issue was subsequently discussed with the Administrator, Director of Nursing, and Regional Director of Clinical Services. No additional information regarding this issue was provided to the survey team prior to the exit conference.
Laboratory Tests Performed Without Proper Physician Order
Penalty
Summary
Facility staff obtained laboratory tests for a resident without a proper physician's order. Specifically, the resident had a physician's order for an international normalized ratio (INR) test to be performed every Monday. However, clinical record review and laboratory reports showed that the INR was obtained on multiple days throughout the week, not just on Mondays as ordered. The electronic medication administration record indicated that the INR was documented as being obtained daily, except for one day, which was inconsistent with the physician's order. The resident involved had diagnoses including cerebral infarction, type 2 diabetes mellitus, and a prosthetic heart valve, and was on anticoagulant therapy. The resident was cognitively intact and confirmed during an interview that blood was drawn for INR testing about three times a week. The DON acknowledged that the INR should only have been obtained on Mondays, as per the physician's order. Facility policy requires laboratory services to be provided only when ordered by an appropriate practitioner.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's documented food preference for boiled eggs each day. The resident, who has diagnoses including cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety, was assessed as moderately cognitively impaired with a Brief Interview for Mental Status score of 8 out of 15. The resident's face sheet and tray ticket both indicated a preference and instruction for boiled eggs daily. However, during multiple observations and interviews, the resident reported not receiving boiled eggs for breakfast, and surveyors confirmed that the breakfast trays did not contain boiled eggs on those occasions. The dietary manager acknowledged awareness of the resident's preference, stating that the information was obtained through direct communication with residents and recorded on meal tickets. Despite this, the dietary manager admitted that boiled eggs were not consistently provided, citing supply issues and a lack of regular ordering. The deficiency was discussed with facility leadership, but no additional information was provided prior to the survey exit.
Failure to Involve Medical Director in Securing Surgical Consult
Penalty
Summary
Facility staff failed to involve the Medical Director when they encountered ongoing difficulties in scheduling a surgical consult for a resident with a rectal prolapse. The resident, who had diagnoses including rectal prolapse, Barrett's Esophagus, GERD, and dementia, was assessed as having intact or borderline cognition. After a physician assistant identified a rectal prolapse and attempted but was unable to reduce it, a referral to colorectal surgery was ordered. Despite the referral being sent and multiple documented follow-up attempts by the facility scheduler over several months, no appointment was secured for the resident. Throughout this period, staff continued to document the resident's condition and made repeated calls to the surgical clinic, but were consistently informed that no appointment had been scheduled. The scheduler also attempted to contact another clinic, which did not perform the required surgery. At no point during these delays did staff seek the Medical Director's assistance, and the Medical Director later confirmed he had not been contacted regarding the issue. The deficiency centers on the staff's failure to utilize the Medical Director's role in coordinating medical care when standard processes were unsuccessful.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to follow established infection control guidelines for a resident with spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia, who was dependent for toileting hygiene and always incontinent of bowel and bladder. The resident was on enhanced barrier precautions due to a PEG tube, as indicated in the care plan and by a sign on the resident's door. During incontinence care, two CNAs did not wear proper PPE, specifically gowns, and placed soiled incontinence briefs and wet shorts on the floor beside the resident's bed. One CNA later confirmed only wearing gloves and was unaware that a gown was required, despite the presence of a sign indicating enhanced barrier precautions. The DON acknowledged that staff should have worn proper PPE and not placed soiled items on the floor. The facility's enhanced barrier precautions signage clearly outlined the requirement for gloves and gowns during high-contact care activities, including changing briefs and providing hygiene for residents with devices such as feeding tubes.
Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
Facility staff failed to offer pneumococcal conjugate vaccines (PCV20 or PCV21) to two residents following their admission, despite both having previously received PCV13 and being assessed as not up to date with pneumococcal vaccination. For both residents, clinical records and the Minimum Data Set (MDS) indicated moderate cognitive impairment and documented that the pneumococcal vaccine was not up to date, with the stated reason being that it was not offered. Both residents had significant medical histories, including Alzheimer's disease and other chronic conditions. The facility's policy required assessment and offering of pneumococcal immunization upon admission in accordance with CDC guidelines, with documentation of efforts to obtain immunization history. However, staff interviews and record reviews revealed that these steps were not completed for the two residents in question. The assistant director of nursing, who also served as the infection preventionist, was unable to provide documentation that the vaccine had been offered or administered, and no further information was provided prior to the survey exit.
Failure to Permit Resident to Remain and Inadequate Discharge Documentation
Penalty
Summary
Facility staff failed to permit a resident with multiple complex diagnoses, including seizures, COPD, hypertension, anxiety, heart failure, a history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance, to remain in the facility. The resident had moderate cognitive impairment and required maximum assistance for most activities of daily living. Despite the resident's preferences for certain activities and his non-ambulatory status, the facility initiated a transfer to the emergency room following an incident where the resident reportedly exhibited behavioral issues, including hitting staff and making threats. However, documentation from hospice and EMTs indicated that the resident was calm and non-combative during their assessments, and the resident expressed a desire not to be transferred to the hospital. The facility administrator cited a policy requiring ER evaluation for aggressive behaviors, but the current administrator later clarified that this was not a formal policy but rather a section in the admission agreement. The facility issued a 30-day discharge notice after learning more about the resident's psychiatric history, despite a care plan being developed in collaboration with hospice to address his needs. Interviews with hospice staff revealed that the facility did not attempt to implement the agreed-upon interventions before issuing the discharge notice. The discharge notice cited the facility's inability to meet the resident's needs and concerns for the health, safety, and well-being of others, but there was no documentation of specific needs that could not be met or of attempts to address those needs as required by facility policy. Medication management for the resident was also inconsistent, with delays in starting prescribed medications and some orders not being administered as intended. Staff interviews indicated that while the resident had some behavioral incidents, there was no evidence that he attempted to harm other residents. The facility's own assessment stated that it could care for residents with psychiatric and behavioral needs, yet the documentation and actions taken did not reflect adequate attempts to meet this resident's needs prior to discharge. The required documentation supporting the discharge, including specific unmet needs and efforts to address them, was not found in the medical record.
Latest citations in Virginia
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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