Colonial Heights Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterfield, Virginia.
- Location
- 831 Ellerslie Ave, Chesterfield, Virginia 23834
- CMS Provider Number
- 495115
- Inspections on file
- 27
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Colonial Heights Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple active medication orders did not receive five ordered drugs, including an antihypertensive, because they were documented as not available at the time of administration. The MAR showed all five medications coded as not given, and nursing notes stated they were not available, despite the resident having an elevated BP and active physician orders. Staff interviews described a process of checking the Omnicell, contacting pharmacy or the provider, and documenting when medications are unavailable, while policy required searching other areas and contacting pharmacy or using the emergency kit if ordered medications could not be located. Review of the Omnicell list showed only one of the five missed medications was stocked there, and no further information was documented beyond their unavailability.
Facility staff failed to follow their abuse reporting policy for a resident involved in multiple resident-to-resident altercations, including an incident where the resident held a butter knife while yelling at another resident and another incident where the resident was struck from behind and struck back. Documentation review showed that required investigation summaries were not sent to the Ombudsman or APS, despite a written policy directing the Administrator to report all alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to state agencies, APS, the local Ombudsman, and law enforcement within specified time frames.
Facility staff failed to report multiple resident-to-resident abuse incidents to all required agencies and within required timeframes. In one event, a resident was observed yelling at another resident to move from in front of his door while holding a butter knife and refusing to relinquish it; in another, the same resident was struck from behind by another resident and responded by striking back. Documentation review showed no credible evidence that these incidents and related investigation summaries were reported to the state survey agency and Adult Protective Services as required by facility policy, which mandates prompt reporting of alleged abuse and notification of APS, the Ombudsman, and law enforcement.
Staff failed to administer several ordered medications and did not consistently notify the provider when medications were unavailable for a resident. Record review showed missed doses of Hydralazine, diltiazem (Cardizem), and pantoprazole (Protonix) without appropriate documentation or evidence of provider notification, despite active orders. Omnicell records indicated at least one of the medications was available on-site, contradicting a note that it was awaiting pharmacy refill. Interviews with an LPN, the ADON, and others revealed inconsistent practices regarding checking the Omnicell, contacting the pharmacy, and notifying the provider when medications were not available, which did not fully align with the facility’s written medication administration policy.
A resident experienced an unwitnessed fall, was found on the floor with an occipital hematoma and laceration, and complained of head and leg pain. Initial neuro checks were started and documented, but there was a documented gap of several hours during which no neurological assessments were recorded, despite facility policy requiring frequent neuro checks after a head injury. Nursing notes during this period did not include a full neuro assessment, and staff interviews confirmed both the existence of the gap and their understanding that neuro checks should have been completed and documented at specific intervals.
Two residents with cognitive impairments were involved in multiple incidents where one resident repeatedly engaged in sexually inappropriate and aggressive behaviors toward others due to lapses in required 1:1 supervision. Staff confusion and inconsistent implementation of supervision protocols led to repeated failures to protect vulnerable residents from harm.
A resident with moderate cognitive impairment and multiple health conditions alleged that a male CNA forcibly removed a brace, engaged in a verbal altercation, and physically pushed the resident onto the bed, resulting in a fall. Although the resident reported the incident to a nurse, and the nurse informed the Administrator, the facility failed to report the abuse allegation to authorities within the required two-hour timeframe. The delay in reporting and confusion among staff regarding the nature of the allegation led to a deficiency in timely abuse reporting.
A resident with multiple pressure ulcers and total dependence on staff did not consistently receive physician-ordered wound care treatments, as documented by gaps in the Treatment Administration Record and confirmed by staff interviews and resident statements. The resident reported missed dressing changes, use of incorrect wound care materials, and inaccurate documentation of refusals. Despite claims of frequent refusal by the resident, the facility could not provide documentation to support that all missed treatments were due to refusal.
Facility staff failed to consistently check wander guard devices as ordered for two residents at high risk for elopement, resulting in missed checks and multiple incidents of residents exiting the building, including one with injury. Another resident at risk for falls was found in bed without required fall mats, and a resident with hemiplegia did not have a post-fall investigation completed after an unwitnessed fall. Additionally, a dependent resident suffered a fracture during a transfer when staff did not use a gait belt, and the subsequent investigation was incomplete.
The facility did not maintain sufficient nursing staff to meet resident needs, as shown by low staffing levels, frequent call-outs, and staff being assigned more residents than they could manage. Residents experienced delays in incontinence care, slow call bell responses, and missed treatments, with staff reporting they were unable to provide timely care due to inadequate staffing, especially on weekends and nights. Staffing and care improved only after the survey began, according to staff interviews.
Staff failed to keep three dumpsters closed and the surrounding area clean, leaving dumpster lids and side doors open and debris scattered nearby. The food service director confirmed the dumpsters should be kept closed and the area cleaned, in accordance with facility policy, but these practices were not followed.
Facility staff did not ensure call lights were accessible for two residents with cognitive impairment, failed to arrange timely transportation for a resident's follow-up medical appointment, and did not provide prompt assistance to a resident returning from dialysis, resulting in unmet needs and dissatisfaction with care.
Facility staff did not provide required written notification, opportunities to visit new rooms, or introductions to new roommates for several residents who were moved due to census consolidation or medical management. Residents reported being moved with little or no notice, no written communication, and no chance to ask questions or preview their new accommodations, despite facility policy requiring these steps. Staff interviews confirmed that these procedures were not consistently followed or documented.
Facility staff did not notify physicians or responsible parties when several residents missed doses of prescribed medications, did not receive ordered lab tests, or experienced changes in condition such as injuries requiring x-rays. Documentation failed to show required notifications, despite facility policy and staff interviews confirming the need for such communication.
Staff failed to maintain a clean, comfortable, and homelike environment, with persistent odors, visible dirt, debris, pest sightings, and inadequate cleaning practices observed across multiple units. A resident's room was affected by cigarette smoke from a nearby designated smoking area, and several rooms had maintenance issues such as loose molding, stained fixtures, and privacy curtains that did not provide full visual privacy. Residents and staff reported ongoing dissatisfaction with cleanliness and environmental conditions.
Multiple residents were not protected from abuse, including unwanted sexual contact and physical altercations, by another resident with a known history of inappropriate and aggressive behaviors. Staff and documentation revealed repeated incidents, incomplete investigations, and primarily reactive interventions such as separating residents and moving rooms, without comprehensive measures to prevent recurrence or ensure resident safety.
Facility staff did not consistently follow abuse prevention and investigation policies in several cases, including incomplete investigations of resident-to-resident altercations, failure to report and investigate injuries of unknown origin, and inadequate interventions for residents with known behavioral risks. In multiple incidents, residents experienced or were exposed to abuse or inappropriate contact, and required documentation and witness statements were missing from investigations.
Multiple residents did not receive care as outlined in their comprehensive care plans, including late or missed medication administration, infrequent showers, delayed or missed incontinence care, incomplete wound care, and inconsistent safety device checks. Residents dependent on staff for ADLs and pain management experienced lapses in care, with documentation and direct observations confirming missed interventions. Staff interviews acknowledged the purpose of care plans, but implementation and documentation were inconsistent.
Facility staff did not administer medications as ordered for multiple residents, with doses given late or not documented, and failed to notify a physician about a heparin lock for a resident returning from the hospital. Additionally, a nurse did not document a required skin assessment after being called to assess bruising. These actions did not comply with professional standards or facility policy.
Multiple residents did not receive scheduled showers, timely incontinence care, or adequate assistance with feeding and personal hygiene, as required by their care plans and facility policy. Staff failed to document or provide these essential ADL services, with some residents left in soiled linens, others missing regular showers, and some not receiving needed feeding help. Staff interviews confirmed that care was not always provided as scheduled, often due to staffing shortages or workload, resulting in unmet care needs.
Multiple residents did not receive prescribed medications and treatments as ordered, including missed doses of Metoclopramide, antibiotics, and insulin, despite medication availability in the facility. Documentation was often incomplete or missing, and staff interviews revealed confusion about medication access procedures and inconsistent adherence to facility policy regarding unavailable medications.
Staff failed to consistently provide and document physician-ordered wound care and preventive treatments for pressure injuries, including missed wound assessments, incomplete documentation, and lack of regular repositioning for several residents. Multiple instances of incomplete or missing treatment administration records and inadequate wound assessments were observed, despite care plans and facility policies requiring these interventions.
The facility did not ensure that several agency CNAs had documentation of required training in abuse and neglect, dementia, resident rights, infection control, communication, and behavioral health. Administrative and staffing staff confirmed that the necessary records were not available, and the facility assessment had outlined these training requirements for all CNAs.
Facility staff did not obtain multiple physician-ordered laboratory tests for two residents, including CBC, BMP, CRP, CMP, and Vancomycin trough levels, despite documented orders and care plans. Staff interviews and record reviews confirmed that the required labs were not completed or documented as required by facility policy.
Staff failed to ensure food served was palatable on one unit, as a test tray of turkey breast was found to have a gelatinous taste when sampled by two surveyors. The kitchen supervisor declined to taste the turkey due to personal preference. All food items were at safe temperatures, but the palatability issue was confirmed and reported to facility leadership.
Staff failed to store, prepare, and serve food in a sanitary manner, including leaving ham partially uncovered in a refrigerator, storing beverages in a refrigerator at improper temperatures, and a dietary aide handling meal trays without a beard cover, all in violation of facility policy.
Facility staff did not respond to grievances from two residents in a timely manner, failed to provide written responses or copies of grievance forms as required by policy, and did not consistently document or resolve reported concerns, including issues related to care, environment, and missed medical appointments.
Facility staff did not report or investigate an injury of unknown origin after a resident returned from a home visit with family and was observed holding their right wrist and not allowing it to be touched. Although the family reported the issue and staff documented ongoing concerns and interventions, there was no evidence that the required investigation or reporting to authorities was initiated, as outlined in facility policy.
Facility staff did not complete thorough investigations into allegations of abuse and injuries of unknown origin for three residents. In one case, a resident-to-resident altercation was not fully investigated, lacking witness statements from others present. Another case involved a resident with a wrist injury reported by family, but no investigation was documented. A third case involved a resident with a fractured ankle, where the investigation file was missing staff interviews and key documentation. Leadership acknowledged that required investigative steps were not followed in these incidents.
Staff did not change the dressing around a resident's feeding tube insertion site as ordered by the physician, with documentation gaps noted in the TAR and confirmation from a CNA and LPN that daily dressing changes were required but not consistently performed or recorded.
Facility staff did not store a nebulizer mouthpiece in a sanitary manner for a resident who used the device as needed for respiratory symptoms. The mouthpiece was repeatedly observed uncovered on the nightstand or attached to the machine, contrary to facility policy and staff expectations that it be kept in a dated plastic bag when not in use.
A resident with a history of chronic pain conditions was left without prescribed as-needed Hydromorphone for several days due to the facility running out of the medication and delays in obtaining a new prescription and alternative formulation. Documentation showed a lack of timely communication with the pharmacy and provider, and the facility's own policies for medication unavailability and pain management were not followed as required.
Staff failed to provide timely access to prescribed medications for three residents, resulting in missed or delayed doses of pain medications and an antiviral. One resident went five days without as-needed Hydromorphone due to prescription and supply issues, another did not receive Paxlovid until six days after it was ordered, and a third experienced a six-day delay in starting Lyrica. Documentation and communication with pharmacy and providers were incomplete, and facility policy requirements for medication unavailability were not consistently followed.
Staff documented administration of medications and completion of a treatment that did not occur, including recording doses of Paxlovid and Lyrica as given before the medications were delivered, and marking a tube feeding site dressing change as completed when it had not been done. An LPN confirmed that documentation should only reflect actual care provided, and facility leadership was informed of these discrepancies.
Staff failed to ensure a pest-free environment, as evidenced by direct observations of pests such as centipedes and roaches, deteriorating wall and bathroom conditions, and incomplete pest control logs. A resident with moderate cognitive impairment was exposed to these conditions, and another resident reported ongoing pest sightings and unsanitary facilities. Administrative staff witnessed these issues, but not all pest activity was documented or addressed.
The facility staff failed to follow professional standards in medication administration and care for several residents. A resident did not have blood pressures taken before receiving Midodrine, contrary to physician orders. Another resident developed a severe yeast rash due to inadequate incontinence care and monitoring. Additionally, the medication Trulicity was not administered to a resident on three occasions as prescribed. These deficiencies highlight lapses in medication management and resident care.
A resident with multiple health conditions developed a severe yeast rash due to the facility's failure to provide timely incontinence care. The rash was identified by a nurse practitioner, but not documented by nursing staff, indicating a lack of monitoring. Interviews revealed that incontinence care was expected every two hours, but documentation was missing, and the resident was left in waste for extended periods.
The facility staff failed to administer Trulicity as ordered for a resident with diabetes and other conditions. The medication was not given on three Saturdays, despite physician orders for weekly administration. The resident's blood sugar levels varied significantly during this period.
A resident with severe cognitive impairment experienced delays in obtaining and processing urinalysis tests, leading to a late diagnosis of a UTI on the day of discharge. The facility failed to notify the physician of the delays, contrary to their policy, resulting in a deficiency finding during a survey.
A resident with moderate cognitive impairment engaged in sexual activity with another resident on two occasions, but the facility staff failed to notify the physician and the resident's representative. The resident's care plan, which included interventions for behavioral issues, was not updated to reflect these incidents.
The facility failed to implement its abuse policy when two residents with moderate cognitive impairment were involved in a consensual sexual encounter. The responsible party of one resident was not notified, and there was no documentation of family or physician notification, despite the facility's policy requiring such actions.
A resident admitted with urinary retention and other conditions did not have a 48-hour baseline care plan addressing his need for self-catheterization. The resident expressed discomfort due to the lack of necessary catheters, and facility staff were unaware of his needs. An LPN used a Foley catheter to assist, but the care plan still lacked necessary interventions. Facility leadership was informed of these findings.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
Facility staff failed to have five ordered medications available for administration to one resident on 5/4/25. During closed record review, the resident’s MAR for May 2025 showed that on 5/4/25 Fluticasone Propionate nasal spray, Vitron-C, Budesonide-Formoterol inhaler, two doses of Buspirone HCL, and Hydralazine HCL were all coded with “9,” which the MAR legend defined as other/see nurse notes. Nursing progress notes for that date documented that each of these medications was “not available.” Physician orders confirmed that all five medications had active orders on that date. The MAR also documented that the resident’s blood pressure on 5/4/25 was 197/103, and the ordered Hydralazine, used to treat elevated blood pressure, was not administered because it was not available. Interviews with nursing staff and review of facility documentation further described how the deficiency occurred. One LPN stated that when a medication is not available, she checks whether it has been ordered, orders it if needed, checks the Omnicell, and if the medication is not STAT, waits for it to arrive from the pharmacy while documenting in the chart and informing the oncoming nurse and administrator. Another LPN reported that she checks the Omnicell and then calls the provider if the medication is not available, documenting the provider’s intervention. The ADON stated that if a medication is not available, staff notify nursing leadership and the physician, obtain an order to hold the medication until it is received, and call the pharmacy if it is not in the Omnicell. Review of the Omnicell contents list showed that, of the five medications not administered on 5/4/25, only Hydralazine 25 mg was stocked in the Omnicell. The facility’s medication administration policy directed staff to search other areas and contact the pharmacy or use the emergency kit if a medication with a current order could not be located, but the record showed the medications were simply documented as not available and not given.
Failure to Report Resident-to-Resident Abuse Allegations to Ombudsman and APS
Penalty
Summary
Facility staff failed to implement the abuse reporting policy for a resident involved in multiple resident-to-resident altercations. Clinical record review showed a progress note dated 11/2/25 documenting that the resident was witnessed telling another resident to move from in front of his door while holding a butter knife and yelling, "move her from in front of my door." Staff removed the resident and attempted to take the butter knife, but the resident refused to relinquish it. A separate facility investigation summary dated 9/12/25 described an incident in which the same resident was struck from behind by another resident and responded by striking the other resident back. During an interview, the resident was unable to provide details about these incidents and reported that he gets along with everyone. Review of facility documentation on 1/7/26 revealed that the facility failed to send the investigation summary related to these incidents to the Ombudsman and Adult Protective Services as required by its abuse policy. The policy titled "Reporting Requirements/Investigations" required the Administrator to immediately report any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property to the State Agency within specified time frames, and to notify Adult Protective Services, the local Ombudsman, and appropriate law enforcement for any incident of patient abuse, mistreatment, neglect, misappropriation of personal property, or other reasonable suspicion of a crime. Surveyors found no credible evidence that the incidents involving this resident were reported to the Ombudsman in accordance with this policy.
Failure to Report Resident-to-Resident Abuse Incidents to Required Agencies
Penalty
Summary
Facility staff failed to timely report incidents and allegations of abuse involving one resident to all required agencies and within required timeframes. Clinical record review of this resident’s chart showed a progress note dated 11/2/25 documenting that the resident was witnessed telling another resident to move from in front of his door while holding a butter knife, yelling for the other resident to be moved. Staff removed the other resident and attempted to take the butter knife, but the resident refused to give it up. This incident, which constituted an allegation of abuse, was not documented as having been reported to all required external agencies as specified by facility policy. Further review of facility documentation revealed an investigation summary dated 9/12/25 describing an incident in which the same resident was struck from behind by another resident and responded by striking the other resident back. The facility had no credible evidence that this incident was initially reported to the state survey agency or Adult Protective Services when it occurred. Additional review on 1/7/26 showed the facility lacked credible evidence that the investigation summary related to the butter knife incident had been sent to Adult Protective Services. During an interview, the resident was unable to provide details about the incidents and reported getting along with everyone. The facility’s written policy required immediate reporting of alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to the state agency within specified timeframes, and notification of Adult Protective Services, the local Ombudsman, and appropriate law enforcement for any incident of patient abuse, mistreatment, neglect, misappropriation, or reasonable suspicion of a crime, but these requirements were not met for the incidents involving this resident.
Failure to Administer Ordered Medications and Notify Provider of Unavailable Drugs
Penalty
Summary
Facility staff failed to administer medications in accordance with active physician orders and did not consistently notify the provider when medications were not available for a resident in the survey sample. Review of the clinical record and MAR for this resident showed that on one occasion Hydralazine HCL, ordered for blood pressure management, was not administered, with a nursing progress note stating the medication was unavailable and awaiting refill from the pharmacy. However, review of the facility’s Omnicell content listing indicated that this medication should have been available on-site for staff to administer. On another date, the resident did not receive the ordered dose of diltiazem HCl ER beads (Cardizem), used to treat hypertension and other cardiac conditions, and there was no nursing documentation indicating why the dose was missed or that the provider had been notified. Further review of the resident’s June MAR revealed no documentation of administration of pantoprazole sodium (Protonix), a proton pump inhibitor, on a specified date, and there were no progress notes explaining the omission or showing that the physician was informed. Interviews with LPNs and nursing leadership showed variation in how staff responded when medications were not available, including differing practices regarding when to contact the provider and how to document missed doses. The facility’s written policy on medication administration required staff to search for ordered medications in multiple locations and contact the pharmacy or use the emergency kit if the medication could not be located, but the documented omissions and lack of provider notification for this resident demonstrated that these steps were not consistently followed.
Failure to Complete and Document Post-Fall Neuro Checks After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document ongoing post-fall neurological assessments as required by policy for a resident who sustained a head injury. The resident was found on the floor during routine rounds, sitting on the side of the bed with both legs extended, and was noted to have a hematoma with a small laceration to the occipital area, with a small amount of blood on the floor and on the back of the head. The resident verbalized that they felt bad, that their head hurt, and also reported bilateral leg pain. Vital signs were obtained, the resident was assisted back to bed, the head wound was cleansed and gauze applied, and the nurse practitioner (NP) and responsible party were notified. The care plan response documented that neuro checks were initiated and that increased monitoring and safety checks were implemented. Review of the neurological checklist showed that the first neuro check was documented at 4:10 AM with a reported pain score of 8/10, followed by three additional checks at 4:25 AM, 4:40 AM, and 4:55 AM. According to the facility’s neurological assessment policy, neuro checks were to be completed every 15 minutes for the first hour, every 30 minutes for the next two hours, and every hour for the next four hours. However, there was no documentation of any neuro checks or other neurological assessments between 4:55 AM and 7:30 AM, despite the requirement for continued monitoring. A nursing note entered at 7:08 AM stated that the resident was observed sitting upright on the bed, alert and in stable condition, with no acute distress noted and reporting soreness at the back of the head, but this note did not include a documented neurological assessment. Interviews with staff confirmed the gap in monitoring and documentation. The NP stated that when a resident falls and hits or is suspected of hitting their head, neuro checks are ordered to monitor for changes from baseline and should be continued with notification of any changes. The unit manager (an LPN) and another LPN both described the facility’s neuro check protocol, including the required frequency and components such as vital signs, pupil reaction, grip, and range of motion, and acknowledged the importance of these checks. The LPN who assumed care at 7:00 AM reported that she was told to continue neuro checks and did so, but could not account for the lack of checks before her shift. The LPN on duty at the time of the fall confirmed that the resident fell, hit the head, and had bleeding with a bandage applied, and stated she did the neuro checks but suggested she may not have finished entering them into the record. The DON acknowledged there was a gap in evidence of monitoring and assessment from 4:55 AM until 7:30 AM. The facility’s written neurological assessment policy required completion and documentation of the neurological checklist at the specified intervals, which was not met in this case.
Failure to Maintain Adequate Supervision Resulting in Repeated Sexual Inappropriate Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents with cognitive impairments, resulting in multiple incidents of inappropriate sexual behavior by one resident towards others. One resident, with diagnoses including severe dementia and psychotic disorder, exhibited a pattern of sexually inappropriate and aggressive behaviors towards other residents over an extended period. These behaviors included entering other residents' rooms, making unwelcome sexual advances, and physical aggression, as documented in progress notes and staff interviews. Despite being identified as a risk, there were lapses in maintaining the required level of supervision, with confusion among staff regarding whether the resident was on 1:1 supervision or 15-minute checks at various times. On at least two documented occasions, the resident was not under the mandated 1:1 supervision, as evidenced by progress notes indicating only 15-minute checks were being performed. During one such lapse, the resident was found on the floor of his room, and on another occasion, he was discovered in a female resident's room engaging in inappropriate sexual contact. The facility's records and staff interviews revealed ongoing issues with communication and implementation of supervision protocols, contributing to repeated incidents involving the same resident. The second resident involved was cognitively impaired and severely limited in decision-making abilities. This resident was subjected to unwelcome sexual contact while resting in her room, as observed by staff who intervened immediately. The incident was one of several involving the same perpetrator, highlighting the facility's failure to provide adequate supervision and protection for vulnerable residents. Staff interviews confirmed ongoing confusion about supervision requirements and a lack of clear documentation regarding when heightened supervision was in place.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
Facility staff failed to report an allegation of physical abuse involving a resident with moderate cognitive impairment and multiple medical conditions, including idiopathic neuropathy, compression fracture, HIV, opioid use in remission, psychosis, major depressive disorder, and glaucoma. The resident, who required one-person physical assistance and was wheelchair dependent, reported that a male CNA forcibly removed his brace, engaged in a verbal altercation, and physically pushed him onto the bed, causing him to fall. The resident stated he was not injured but felt helpless and subsequently informed a nurse and called the police himself the following day. Despite the resident's disclosure to the dayshift nurse and the nurse's immediate report to the Administrator, there was a delay in reporting the allegation to the appropriate authorities. The Administrator did not initially consider the incident reportable and only notified the State survey agency, adult protective services, and the ombudsman after learning that the resident had contacted the police. Facility documentation and staff interviews confirmed that the required reporting timeframe of not later than two hours after the allegation was not met. Clinical records and interviews further revealed confusion among staff regarding the nature of the allegation, with the CNA involved initially misunderstanding the accusation. The incident was eventually documented as a late entry, and law enforcement was involved after the resident's call. However, the initial failure to report the abuse allegation in a timely manner constituted a deficiency in the facility's compliance with abuse reporting requirements.
Failure to Provide Physician-Ordered Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including paraplegia, neuromuscular dysfunction of the bladder, hydronephrosis, anemia, and malnutrition, did not receive physician-ordered wound care treatments for several pressure ulcers. The resident was totally dependent on staff for bed mobility, transfers, and toileting, and was identified as being at high risk for pressure ulcers, with several Stage 3 and Stage 4 ulcers present upon admission. The care plan included specific interventions for wound care and prevention, but the resident was not consistently care planned to refuse wound care, and there was no documentation of consistent refusal of treatment. Medical record reviews revealed multiple dates on which the resident did not receive the prescribed wound care treatments for various pressure ulcers, including those on the feet, sacrum, buttocks, and heels. The Treatment Administration Record (TAR) showed missed treatments on numerous occasions, and staff interviews did not provide additional documentation or explanation for these missed treatments. The resident reported that staff sometimes argued to avoid changing dressings, failed to use appropriate wound care materials, and documented refusals inaccurately. The resident also described instances where no dressing changes were performed for two consecutive days due to lack of supplies, and incorrect dressings were used, resulting in a skin tear. Progress notes documented worsening wound conditions, including increased purulent drainage, foul odor, and exposed tendon, which led to physician notification and updated wound care orders. Despite the resident's occasional refusal of hospital transfer and some treatments, the medical record and staff interviews did not support that all missed treatments were due to resident refusal. The facility's administration and medical staff attributed the missed care to resident refusal, but could not provide documentation to support this claim for all missed treatments. The surveyor was unable to observe wound care during the survey due to the resident's refusal at that time.
Failure to Prevent Accidents and Incomplete Supervision for At-Risk Residents
Penalty
Summary
Facility staff failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. For one resident with moderate cognitive impairment and a high risk for elopement, staff did not consistently check the placement and function of a wander guard as ordered, with multiple missed checks documented across several months. The facility's policy on elopement/exit-seeking behaviors did not provide guidance on checking the wander guard, and documentation failed to show that required checks were completed. Interviews with staff revealed that checks were supposed to be documented on the electronic treatment administration record (eTAR), but gaps in documentation persisted. Another resident, assessed as severely impaired for decision-making and at risk for falls, was observed in bed without the required fall mats in place, despite care plan interventions specifying bilateral fall mats while in bed. Staff interviews confirmed that fall mats were an intervention for fall prevention and that care plans and Kardexes were accessible to staff, but the required equipment was not in use at the time of observation. The facility's falls management policy referenced a systematic approach and evidence-based interventions but did not prevent this lapse in care plan implementation. Additional deficiencies included failure to complete ordered wander guard checks for another resident with severe cognitive impairment and a history of exit-seeking, resulting in multiple elopement incidents, including one where the resident was found outside with injuries. Documentation showed missed wander guard checks and incidents where the resident exited the building, sometimes following visitors or being unrecognized by staff. For another resident with hemiplegia and moderate cognitive impairment, the facility failed to complete a fall investigation after an unwitnessed fall that resulted in hospital transfer. The nurse's note documented the fall and interventions in place, but no evidence of a post-fall investigation was found. Finally, a resident dependent for transfers suffered a fracture during a transfer when her foot became caught, and staff did not use a gait belt as required by policy. The investigation into the injury was incomplete, lacking staff interviews and supporting documentation.
Failure to Maintain Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to maintain adequate nursing staff to consistently meet the needs of residents across all three units, as evidenced by resident and staff interviews, clinical record reviews, and facility document reviews. The Payroll-Based Journal (PBJ) staffing data for the fourth quarter of 2024 indicated concerns with one-star staffing levels and particularly low staffing on weekends. Resident council minutes and interviews with residents and their representatives revealed ongoing issues such as slow call bell responses, missed snacks, compromised dignity and privacy, infrequent rounding, delayed medication administration, difficulties getting residents out of bed or to activities, long wait times for care, and negative staff attitudes. These concerns were documented over several months, and the minutes showed that while staff education was provided, there was no documented review of staffing levels or patient assignment acuity. Staffing schedules and as-worked records showed frequent call-outs, no call-no shows, staff being moved between units, and staff working double or extended shifts to cover absences. Direct observations and interviews with CNAs and LPNs confirmed that staff were often unable to provide timely incontinence care, with one resident not receiving such care for over five hours, resulting in a strong urine odor and wet bedding. Staff reported being assigned more residents than they could manage, especially on weekends, and having to prioritize care for those at higher risk or with more urgent needs. Treatment nurses were often reassigned to medication carts due to staffing shortages, leading to delays or missed wound care and other treatments. Multiple staff members, including the staffing coordinator and ombudsman, acknowledged ongoing staffing challenges, with reports of units being staffed below budgeted levels, especially at night and on weekends. Staff described significant improvements in staffing and care only after the survey began, with increased numbers of CNAs and nurses allowing for more comprehensive care, timely medication administration, and the ability to perform additional tasks such as vital signs and weights. Prior to these changes, staff consistently reported being overwhelmed, unable to provide all necessary care, and having to delay or skip certain tasks due to insufficient staffing.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
Facility staff failed to maintain three dumpsters in a sanitary manner, as observed during a survey. The tops of the dumpsters were left open to the environment, with the covers of the middle dumpster crushed down inside, and the side sliding doors on all three dumpsters also left open. The area surrounding the dumpsters contained numerous pieces of debris, including plastics and paper products. These observations were made in the back parking area behind the facility. During a follow-up observation with the food service director, it was confirmed that the dumpsters should be kept closed and the area cleaned to prevent attracting rodents. The food service director stated that the kitchen and maintenance departments alternate cleaning the dumpster area every other day. Facility policy requires regular inspection and cleaning of dumpsters and surrounding areas, but these procedures were not followed as evidenced by the observed conditions.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
Facility staff failed to accommodate the needs and preferences of four residents by not ensuring call lights were accessible and by not facilitating a scheduled medical appointment. For one resident with severe cognitive impairment and upper extremity weakness, repeated observations showed the call bell was consistently out of reach while the resident was in a wheelchair, despite care plan interventions requiring reminders to use the call light. Staff interviews confirmed the expectation that call bells should be within reach, but this was not maintained during multiple observations. Another resident, also severely cognitively impaired but without upper extremity limitations, was observed multiple times with the call bell on the floor or clipped out of reach while in bed. The care plan for this resident similarly required reminders to use the call light, but staff did not ensure the device was accessible. Staff interviews again confirmed the standard practice, but observations contradicted this. A third resident, who was cognitively intact and had multiple fractures, missed a scheduled follow-up doctor appointment due to lack of transportation arranged by the facility. Documentation did not reflect the missed appointment or the rescheduling, and staff interviews indicated ongoing issues with transportation reliability. Additionally, a fourth resident, dependent on extensive assistance and receiving regular dialysis, reported waiting up to 45 minutes to an hour for staff assistance after returning from treatment, with the call bell pressed by the transportation driver but not answered promptly. The resident expressed dissatisfaction with the nursing staff and a desire for discharge.
Failure to Provide Required Notification and Choice in Resident Room Changes
Penalty
Summary
Facility staff failed to honor residents' rights regarding room changes for four residents, as evidenced by interviews, clinical record reviews, and facility document reviews. In multiple instances, residents were moved to different rooms without being provided written notification, the opportunity to visit the new room, or meet their new roommate prior to the move. For example, one resident was moved twice within a short period, with little to no notice, and reported not receiving any written communication or opportunity to preview the new room or roommate. Another resident, who was moderately cognitively impaired, stated that staff moved him without explanation or written notice, and documentation did not confirm that the responsible party was properly notified due to disconnected contact information. Staff interviews revealed that the process for room changes was inconsistently followed. The social worker/discharge planner acknowledged that written notifications were not provided to residents or their responsible parties, and that opportunities to visit new rooms or meet new roommates were not routinely offered unless a resident expressed hesitation. Documentation of follow-up with residents after room changes was also lacking, and staff admitted that such follow-ups were not consistently performed or recorded. The facility's own policies required written notification and introductions to new roommates, but these procedures were not implemented as required. Facility records and progress notes sometimes indicated that notifications were made, but interviews with residents contradicted these records, with residents stating they did not receive explanations, written notices, or opportunities to ask questions about the moves. The room changes were primarily initiated due to census consolidation or medical management, but the required resident rights and notification procedures were not followed. Administrative staff were made aware of these findings during the survey, but no additional information was provided prior to the survey exit.
Failure to Notify Physician and Responsible Party of Changes in Condition and Missed Medications/Labs
Penalty
Summary
Facility staff failed to notify physicians and/or responsible parties of significant changes in condition or unavailability of medications and laboratory tests for four residents. For one resident, multiple doses of prescribed medications, including Aricept, Atorvastatin, Memantine, Glucosamine, Namenda, and Sertraline, were not administered on several occasions due to pharmacy changes or family requests, but there was no documented evidence that the physician was notified as required by facility policy. Progress notes indicated communication with the family regarding medication issues, but failed to show physician notification for missed doses. Another resident did not receive ordered laboratory tests (CBC, BMP, CRP, CMP) on multiple dates, and there was no documentation that the physician or responsible party was notified of the missed labs. Additionally, this resident missed several doses of intravenous antibiotics (Piperacillin and Tigecycline) as ordered, with no evidence of physician or responsible party notification. Interviews with LPNs confirmed that the expectation was to notify the physician and responsible party when medications or labs were missed, but this was not documented in the medical record. For two other residents, there were failures to notify the physician and responsible party when medications (Paxlovid and Lyrica) were not available for administration. In one case, there was also a failure to notify the responsible party of an x-ray order and its results following a reported injury. Documentation in the medical record did not reflect required notifications, despite facility policy mandating such communication and documentation when medications or diagnostic tests are unavailable or when there is a change in the resident's condition.
Failure to Maintain Clean, Comfortable, and Homelike Environment
Penalty
Summary
Facility staff failed to ensure a clean, comfortable, and homelike environment on two of three facility units, as evidenced by multiple observations and interviews. On one unit, a persistent musty odor was noted in a hallway across several time points, and the director of environmental services acknowledged ongoing challenges with odor control, particularly in rooms with residents exhibiting certain behaviors. Despite daily cleaning and the use of air fresheners, the odor remained, and staff admitted difficulty in maintaining a homelike atmosphere. Facility policy required the property to resemble a high-quality establishment at all times, but this standard was not met. In another instance, a resident's room located next to the designated smoking area was found to have a pervasive cigarette smoke odor. The resident was cognitively intact and able to make daily decisions. Facility policy specifically prohibited passive smoke from re-circulating into the building, but observations confirmed that smoke odor was present in the resident's room, indicating a failure to maintain a smoke-free environment as required. Additional deficiencies were observed in the cleanliness and maintenance of resident rooms and common areas. Used paper cups and napkins were found under a resident's bed, and no housekeeping staff were observed on the unit for several hours. Multiple rooms across two units exhibited dirty floors, debris, food particles, loose or missing cove base molding, stained sinks, leaking soap dispensers, and privacy curtains that did not provide full visual privacy. Bathrooms shared between rooms were discolored, with dark streaks and stains on walls, floors, and toilets. Residents and staff reported ongoing issues with cleanliness, pest sightings, and inadequate cleaning practices, such as mopping without sweeping. Duct tape was used as a makeshift repair on floor thresholds, and pest control logs did not consistently document sightings. Administrative staff were made aware of these findings, and the facility's capital improvement plan lacked specific details and timelines for addressing the deficiencies.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect multiple residents from resident-to-resident abuse, specifically involving inappropriate sexual contact and physical altercations. In one incident, a cognitively intact resident was subjected to unwanted sexual touching by another resident during an activity, which escalated into a physical altercation resulting in scratches and red marks. The investigation into this incident was incomplete, lacking witness statements, direct statements from the involved residents, and supporting documentation such as skin and pain assessments. Staff interviews revealed that the resident who initiated the inappropriate contact had a documented history of sexually inappropriate and aggressive behaviors toward both staff and other residents, with repeated incidents noted in facility records. Another incident involved a severely cognitively impaired resident who was found in bed with the same resident known for inappropriate sexual behaviors. Staff observed the aggressor with her hand under the covers, rubbing the other resident's private area. This behavior had been previously documented, and staff had attempted to redirect the resident multiple times without success. The facility's records show that the resident with inappropriate behaviors had a pattern of entering other residents' rooms, undressing, and making sexual advances, despite interventions such as redirection and room changes. Staff interviews indicated a lack of consistent knowledge and training on how to manage and prevent such behaviors, with some staff unaware of which residents posed a risk and relying primarily on separating residents after incidents occurred. The facility's care plans and progress notes documented ongoing behavioral issues and repeated incidents involving the same resident as both aggressor and recipient of inappropriate contact. Despite these documented patterns, interventions were largely reactive, consisting of separating residents, moving rooms, and referring to psychiatric services. There was no evidence of comprehensive or proactive measures to prevent recurrence or to ensure the safety of other residents, particularly those with cognitive impairments who could not consent to sexual contact. The facility's own policy emphasized the right of residents to be free from abuse, but the actions taken were insufficient to prevent repeated incidents of abuse and neglect.
Failure to Implement Abuse Prevention and Investigation Policies
Penalty
Summary
Facility staff failed to implement abuse prevention policies and procedures in multiple instances involving resident-to-resident altercations and injuries of unknown origin. In one case, a cognitively intact resident reported being inappropriately touched in the groin area by another resident, leading to a physical altercation. The facility's investigation was incomplete, lacking witness statements, direct statements from both residents, and supporting documentation such as skin and pain assessments. The abuse policy required a thorough investigation, including interviews and evidence collection, which was not fully executed. Another incident involved a resident with a history of sexual and aggressive behaviors who was found in bed with a severely cognitively impaired resident. Staff observed inappropriate sexual contact, and the investigation substantiated abuse. Prior to this, there were multiple documented instances of the same resident engaging in inappropriate behaviors with other residents and staff, but interventions were limited to separating residents, moving rooms, and monitoring, without comprehensive preventive measures or care planning to address ongoing risks. Staff interviews revealed uncertainty about interventions and a lack of consistent communication regarding residents with behavioral risks. Additionally, the facility failed to investigate and report an injury of unknown origin for another resident, despite family concerns and clinical documentation of changes in the resident's condition. The director of nursing acknowledged that an investigation should have been initiated, including assessments and witness statements, but no such investigation was found in the records. Across these cases, the facility did not consistently follow its own abuse policy, which required immediate and thorough internal investigations, reporting to authorities, and protective interventions for residents involved in or at risk of abuse.
Failure to Implement Comprehensive Care Plans and Required Interventions
Penalty
Summary
Facility staff failed to implement comprehensive care plans for multiple residents, resulting in deficiencies in medication administration, activities of daily living (ADL) support, pain management, safety device checks, incontinence care, personal hygiene, and wound care. For one resident with schizophrenia and insomnia, staff did not administer antipsychotic, anticoagulant, and psychoactive medications as ordered, with multiple late or undocumented doses recorded over a month. Another resident requiring substantial assistance with ADLs after spinal surgery reported receiving significantly fewer showers than scheduled, and documentation confirmed missed showers. The same resident experienced a lapse in as-needed pain medication for several days due to a lack of physician authorization and medication availability, despite ongoing pain and documented service concerns. A resident at high risk for elopement due to dementia did not have their wander guard device checked every shift as required by the care plan and physician orders, with several missed checks documented across multiple months. Another resident dependent on staff for toileting and hygiene was observed with strong urine odor and soiled bedding, indicating incontinence care was not provided in a timely manner. The same resident had untrimmed and dirty fingernails over several observations, despite care plan interventions for daily hygiene and grooming. Additionally, this resident's pressure injuries were not consistently treated as ordered, with missed wound care treatments and incomplete wound assessments, including lack of measurements and staging. Further, another resident dependent on staff for showers and incontinence care reported infrequent showers and long waits for incontinence care, corroborated by documentation of missed scheduled showers and direct observation of prolonged periods without care. Staff interviews confirmed that care plans were intended to guide individualized care, but implementation was inconsistent, and documentation often failed to evidence required interventions. These deficiencies were communicated to facility leadership, but no additional information or corrective actions were provided prior to survey exit.
Failure to Administer Medications Timely and Notify Physician of Clinical Changes
Penalty
Summary
Facility staff failed to administer medications in a timely manner for multiple residents, resulting in deviations from physician orders and professional standards of practice. For one resident, several medications, including Depakote, Eliquis, Trazodone, and Seroquel, were administered outside the prescribed time frames, with some doses not documented as given at all. The facility's own policy and nursing standards require medications to be administered within 60 minutes of the scheduled time, and staff interviews confirmed awareness of this requirement. However, audit reports showed repeated late administration and missing documentation, with no evidence that required notifications to the physician or responsible party occurred when medications were late. Another resident did not receive medications such as Renvela and Humalog insulin according to the prescribed schedule, specifically before meals as ordered by the physician. The resident reported that evening medications were often given well after meals, and staff interviews confirmed that medications intended to be administered before meals were sometimes given after, contrary to orders. The medical director and nursing staff acknowledged that the timing of these medications is critical for their effectiveness and that administration outside the prescribed window does not comply with physician orders or best practices. Additionally, the facility failed to notify a physician regarding the presence of a heparin lock for a resident returning from the hospital. The resident's record did not contain any physician orders for the heparin lock, nor was there documentation that the physician had been notified of its presence. Staff interviews confirmed that no orders or notifications were found, and as a result, no IV fluids, flushes, or supplies were provided. In another instance, a nurse failed to document a skin assessment after being called to assess a resident's bruising, with no record of the assessment found in the clinical documentation. These failures demonstrate lapses in following professional standards and facility policies regarding medication administration, physician notification, and documentation.
Failure to Provide Consistent ADL Care, Showers, Incontinence, and Hygiene Assistance
Penalty
Summary
Facility staff failed to provide adequate assistance with activities of daily living (ADLs) for multiple residents, as evidenced by missed or undocumented showers, incontinence care, feeding assistance, and personal hygiene. Several residents who required substantial or maximal assistance with bathing did not receive showers at least twice a week as scheduled or per their preferences. Documentation for scheduled showers was incomplete or missing for multiple dates, and residents reported having to request showers repeatedly or not receiving them at all. In some cases, staff cited short staffing or being too busy as reasons for not providing showers, and showers were sometimes given at inconvenient times for residents with specific needs, such as early morning dialysis appointments. Incontinence care was not provided in a timely manner for several residents who were dependent on staff for toileting and hygiene. Observations revealed residents left in soiled linens with strong urine odors, and staff interviews confirmed that incontinence care should be provided at least every two hours, but this was not consistently done. One resident was found with a urine-soaked towel under them after being left in the same position for several hours, and another reported waiting hours to be changed, resulting in skin soreness. Staff acknowledged the challenges of providing timely care, especially when assigned a high number of residents. Additional deficiencies included failure to maintain personal hygiene, such as oral care and fingernail care. Residents were observed with long, dirty fingernails, and staff interviews indicated that nail care should be performed regularly, particularly on shower days. Feeding assistance was also not consistently documented for a resident requiring substantial help with eating, with several shifts lacking evidence of assistance or meal intake. The facility's own policies and referenced care standards emphasize the importance of regular ADL care, but these were not followed as required, leading to unmet care needs for multiple residents.
Failure to Administer Medications and Treatments per Physician Orders
Penalty
Summary
Facility staff failed to administer medications and treatments according to physician orders for multiple residents. In several cases, medications were not given as prescribed, and documentation was either missing or incomplete regarding the reasons for these omissions. For example, one resident did not receive ordered doses of Metoclopramide despite the medication being available in the facility's in-house supply. Progress notes indicated the medication was 'awaiting arrival,' but inventory records showed it was present in the Omnicell system. Interviews with staff revealed uncertainty about access to the Omnicell, particularly for agency nurses, and a lack of clarity on procedures for obtaining medications when not immediately available on the medication cart. Another resident did not receive several doses of Piperacillin and Tigecycline as ordered for treatment of osteomyelitis and sepsis. The electronic medication administration record (eMAR) showed multiple blanks where administration should have been documented, and nursing progress notes did not provide evidence or explanation for the missed doses. The resident's care plan included instructions to administer medications as ordered, but this was not consistently followed. Additional deficiencies included failure to administer sliding scale insulin before meals as ordered, with insulin often given after meals, and other medications such as Famotidine, Montelukast, Novolin N, and Omeprazole not being administered at scheduled times without documented reasons. Staff interviews confirmed that medications were sometimes not given on time, and that nurses did not always document the reasons for missed doses. Facility policies required that unavailable medications be reported to the provider and documented, but this was not consistently done.
Failure to Provide and Document Pressure Ulcer Care and Prevention
Penalty
Summary
Facility staff failed to provide appropriate care and services to prevent and treat pressure injuries for multiple residents. For one resident, staff did not provide wound treatments to the sacrum and heels as ordered on multiple occasions across several months. The initial documentation of a sacral wound was incomplete, lacking measurements and staging, and the wound was not properly assessed until several weeks later by a wound nurse practitioner, who identified it as a Stage 3 pressure injury. Electronic treatment administration records (eTAR) showed multiple missed or undocumented treatments for wounds on the sacrum and heels, and skin assessments repeatedly failed to include required measurements, descriptions, or staging. Another resident did not receive prescribed treatments to prevent pressure injuries, with several missed or undocumented applications of barrier creams and wound dressings to the sacrum and buttocks. Nurse's notes did not provide explanations for the missed treatments. The care plan for this resident included interventions to administer treatments as ordered, but the documentation did not support that these interventions were consistently carried out. A third resident was observed not being turned or repositioned for several hours, despite care plans and staff interviews confirming the need for repositioning every two hours, especially for residents with pressure injuries. The same resident also had missed or undocumented wound care treatments for a sacral pressure injury, as evidenced by blanks on the treatment administration records. Staff interviews confirmed that treatments should be documented as completed and that it was not appropriate to mark treatments as done if the resident was sleeping. Facility policy required weekly skin assessments and completion of treatments as ordered, but these were not consistently followed for the residents reviewed.
Missing Required Training Documentation for Agency CNAs
Penalty
Summary
Facility staff failed to ensure that four out of ten reviewed certified nursing assistant (CNA) records included documentation of required training in abuse and neglect, dementia, resident rights, infection control, communication, and/or behavioral health. Specifically, several agency CNA files lacked evidence of education in these areas, with one file missing entirely. The review process included examination of both facility and agency CNA records, and interviews with administrative and staffing personnel confirmed that the required documentation was not available. The staffing coordinator stated that agency staff files typically included only licenses, background checks, sworn disclosures, and CPR certifications, and that the facility relied on agencies to provide additional training documentation, which was not always received. The facility assessment, last reviewed prior to the survey, outlined the necessity for staff training in communication, resident rights, abuse and neglect, dementia care, and infection control, as well as the requirement for at least 12 hours of in-service training per year for CNAs. Despite these requirements, the facility was unable to provide evidence that all agency CNAs had completed the mandated training. The staff educator was unavailable during the survey, and administrative staff acknowledged that the files provided were all that were available at the time.
Failure to Obtain Physician-Ordered Laboratory Tests for Two Residents
Penalty
Summary
Facility staff failed to obtain physician-ordered laboratory tests for two residents. For one resident with diagnoses including osteomyelitis and sepsis, staff did not complete multiple ordered lab tests such as CBC, BMP, CRP, and CMP on several specified dates. The resident was cognitively intact and had a care plan indicating the need for labs as ordered due to risks related to cardiac complications, hypotension, anemia, and sepsis. Despite these orders being documented in the physician's order sheets and care plan, the facility was unable to provide evidence that the labs were completed as required. Interviews with staff revealed that the process for obtaining labs involved entering orders into the electronic health record, preparing lab sheets, and placing them in a lab book for the lab technician to review and collect samples. If a lab could not be obtained or was refused, the nurse was to sign the lab sheet. However, the facility's documentation and tracking failed to ensure that the ordered labs were actually performed, as confirmed by the director of nursing who could not locate the required lab results. For another resident, staff did not obtain physician-ordered Vancomycin trough levels on two specified dates, which were required every 72 hours for antibiotic monitoring. The absence of these lab results was confirmed by the regional director of clinical services. Staff interviews indicated that if labs were missed, the process would involve contacting the physician for a STAT order and notifying the lab, but there was no evidence that this occurred for the missed tests. The facility's policy required licensed nurses to monitor, track, and ensure completion of all ordered labs, but this was not followed in these cases.
Unpalatable Food Served to Residents
Penalty
Summary
Facility staff failed to ensure that food served on one of three units was palatable, as required. On 12/18/2024, a test tray containing mixed vegetables, gravy, mashed potatoes, pasta with sauce, and sliced turkey breast was placed in a food cart and sent to the unit. The tray was followed by surveyors and the kitchen supervisor, and after the last lunch tray was served, the test tray was removed and food temperatures were checked, all registering at or above 140°F. The turkey breast was sampled by two surveyors and the kitchen supervisor, though the supervisor declined to taste the turkey, stating a personal dislike. Both surveyors agreed that the turkey breast had a gelatinous taste, indicating it was not palatable. Facility administrative and regional staff were informed of these findings, and no further information was provided prior to exit.
Food Storage and Sanitary Practices Deficiency in Kitchen
Penalty
Summary
Facility staff failed to store, prepare, and serve food in a sanitary manner in the kitchen. Observations included a partially uncovered quarter of a whole ham stored on a refrigerator shelf, containers of juice and iced teas kept in a reach-in refrigerator with internal temperatures recorded at 56 and 51 degrees, and a dietary aide handling resident meal trays without wearing a beard cover. These actions were directly observed during surveyor visits to the kitchen. Interviews with staff confirmed the deficiencies, with the food service director acknowledging that the ham should not have been exposed and that the refrigerator was malfunctioning and subsequently taken out of service. The dietary aide admitted to not wearing a beard guard while handling food, which was against facility policy. Facility policies require food to be stored in covered containers and staff to use appropriate hair restraints to prevent contamination, but these procedures were not followed as observed.
Failure to Timely Address and Document Resident Grievances
Penalty
Summary
Facility staff failed to act upon reported grievances in a timely manner and did not provide written responses or copies of grievance forms to residents, as required by facility policy. For one resident, who was cognitively intact, multiple grievances were filed regarding care, environmental, and food concerns. The resident reported not receiving any follow-up or written documentation, despite repeated requests for copies of grievances and the grievance policy. Facility records did not show documentation of these grievances, and staff interviews confirmed that written responses and copies were not routinely provided to residents. In another case, a resident with multiple fractures and a history of missed medical appointments reported missing a scheduled follow-up due to lack of transportation arranged by the facility. The grievance process for this incident was incomplete, with documentation failing to explain why the appointment was missed and lacking evidence of timely resolution. Staff interviews revealed that grievances were written up and passed to department heads, but there was no consistent follow-up with residents or provision of written summaries or copies of grievances. Facility policy required that grievances be promptly addressed, with written responses provided to residents. However, documentation and staff interviews indicated that these procedures were not consistently followed. Grievances were sometimes misplaced, not logged, or not fully resolved, and residents were not given written responses or copies of their grievances, even when requested.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to report an injury of unknown origin for one resident after the family notified staff that the resident was seen holding their right wrist and not allowing anyone to touch it following a home visit. Despite the family’s report and subsequent documentation of the resident favoring the arm, no signs of pain or discomfort were initially observed by staff, and the nurse practitioner was informed. Over the following days, interventions such as a compression sleeve and discussions about X-rays and an orthopedic consult were documented, but there was no evidence that an investigation into the injury of unknown origin was initiated or reported as required by facility policy. The resident involved was assessed as severely impaired in decision-making and had a documented impairment of one upper extremity. Facility policy required immediate reporting and investigation of injuries of unknown origin, including notification of authorities and collection of witness statements. Interviews with administrative staff confirmed that such incidents should have triggered an investigation and reporting process, but no such actions were documented for this event.
Failure to Fully Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to fully investigate allegations of abuse and injuries of unknown origin for three residents. In the first case, a resident-to-resident altercation occurred during an activity, resulting in one resident sustaining scratches and reporting inappropriate contact by another resident. The investigation folder for this incident contained only a five-day summary and a single witness statement, lacking statements from other residents or staff present during the event. The Director of Nursing acknowledged that the investigation was incomplete and did not meet facility policy requirements for thorough evidence collection and interviews. In the second case, a family member reported that a resident was favoring their right wrist after a home visit, but there was no documented evidence that the facility conducted an investigation into this injury of unknown origin. The Director of Nursing stated that such incidents should prompt an assessment, notification of relevant parties, and a formal investigation, including statements from staff who had contact with the resident. However, no such investigation was found in the facility's records for this incident. The third case involved a resident who sustained a left ankle fracture. The resident reported that the injury may have occurred during a transfer by two CNAs, but could not recall their names. The facility's investigation file contained only a brief synopsis and lacked documentation of staff interviews or further investigative details. The regional vice president of operations confirmed that additional documentation, such as staff interviews and x-ray reports, should have been present but could not be located. Interviews with facility leadership confirmed that the investigation process was not fully followed, and no five-point plan of correction was documented for this incident.
Failure to Change Feeding Tube Dressing per Physician Order
Penalty
Summary
Facility staff failed to provide care and services for a resident with a feeding tube by not changing the dressing around the tube insertion site according to the physician's order. Observation revealed that the dressing was dated two days prior to the survey, and this was confirmed by a CNA. The physician's order required the dressing to be changed every day during shift change, and this order was documented in both the November and December treatment administration records (TAR). Review of the TARs showed multiple instances where the treatment was not documented as completed, with blanks noted on specific dates. On one occasion, a nurse initialed that the treatment was completed, but the observation indicated otherwise. An LPN confirmed that treatments should be documented with initials and date, and that signing off on uncompleted treatments is not permitted. Facility policy also required peristomal site care and dressing changes per provider order. The deficiency was acknowledged by facility administrative and clinical leadership.
Nebulizer Mouthpiece Not Stored Sanitarily
Penalty
Summary
Facility staff failed to store a nebulizer mouthpiece in a sanitary manner for one resident who had a physician's order for Ipratropium-Albuterol via nebulizer as needed for shortness of breath or wheezing. Observations on multiple occasions showed the nebulizer mouthpiece was left uncovered on the resident's nightstand or attached to the machine without any protective covering. The resident confirmed use of the nebulizer when experiencing difficulty breathing. Staff interview revealed that the expected practice was to store the nebulizer mask or mouthpiece in a dated plastic bag when not in use, as outlined in the facility's respiratory care policy. However, this procedure was not followed for the resident in question.
Failure to Provide Timely Pain Medication Due to Medication Unavailability
Penalty
Summary
Facility staff failed to provide a complete pain management program for one resident who required such services. The resident, who was cognitively intact and had a history of spinal surgery, neuropathy, arthritis, and bladder spasms, was prescribed Hydromorphone for pain management. Despite having orders for both scheduled and as-needed pain medications, the resident reported going without the as-needed Hydromorphone for five days over the Christmas period due to the facility running out of the medication. The resident stated that scheduled pain medications were administered but were not effective for her pain, and she was informed that a new prescription could not be obtained promptly because there was no physician available to sign it. Review of facility documentation showed that the pharmacy had Hydromorphone on back order and could only provide the medication in liquid form if a new prescription was obtained. Progress notes indicated that staff did not communicate with the pharmacy about the medication shortage until several days after the resident began going without the as-needed medication. The facility's pain management and medication unavailability policies required timely notification of providers and activation of backup pharmacy procedures, but these steps were not documented as being followed in a timely manner. The in-house inventory did not have the medication available, and the resident's care plan required administration of medications as ordered.
Failure to Ensure Timely Availability and Administration of Prescribed Medications
Penalty
Summary
Facility staff failed to ensure the timely availability and administration of prescribed medications for multiple residents, resulting in missed doses and delays in treatment. For one resident, who was cognitively intact and experiencing frequent pain following spinal surgery, the facility did not provide prescribed as-needed Hydromorphone for five days due to a lack of physician signature for a new prescription and the medication being on backorder. The resident reported ongoing pain and was only able to receive scheduled pain medications, which were not as effective as the as-needed medication. Documentation showed a gap in administration and a lack of communication with the pharmacy prior to the delay, with facility policy requiring provider notification and backup pharmacy procedures that were not evidenced in the records. Another resident did not receive Paxlovid, an antiviral medication, until six days after the physician's order. The medication was not available in the facility, and progress notes indicated the staff were awaiting pharmacy delivery. The facility's process, as described by an LPN, involved checking in-house inventory and backup pharmacy systems, and contacting the physician if the medication was unavailable, but documentation showed delays and incomplete notes regarding these steps. A third resident experienced a six-day delay in starting Lyrica for neuropathic pain after admission. The medication was not available, and progress notes indicated repeated follow-ups with the pharmacy and documentation of the medication being on hold or awaiting delivery. Several scheduled doses were missed, and nurse's notes were inconsistently documented. The facility's policy required provider notification and activation of backup pharmacy processes, but the records did not consistently show these actions were taken.
Inaccurate Documentation of Medication Administration and Treatment Completion
Penalty
Summary
Facility staff failed to maintain accurate clinical records for three residents, as evidenced by documentation of medication administration and treatment completion that did not occur. For one resident, staff documented the administration of Paxlovid on three occasions before the medication was delivered to the facility. Similarly, for another resident, Lyrica was documented as administered on three occasions prior to its delivery from the pharmacy. In both cases, the medication administration record (MAR) reflected doses given when the medications were not available on site. Additionally, a third resident's treatment administration record (TAR) indicated that a tube feeding site dressing change was completed, but observation revealed the dressing had not been changed as required by the physician's order. Interviews with an LPN confirmed that staff are expected to only document treatments and medication administration that have actually been completed, and acknowledged that signing off on uncompleted tasks is not permissible. These findings were communicated to facility administrative and clinical leadership.
Failure to Maintain Pest-Free Environment and Address Environmental Disrepair
Penalty
Summary
Facility staff failed to maintain a pest-free environment, as evidenced by direct observations of pest activity and environmental disrepair. During a lunch meal observation, a resident with moderate cognitive impairment and right-sided weakness was found sitting next to a wall with fallen cove base molding and crumbled sheetrock, where a large, multi-legged brown bug was seen crawling. Another resident in the same unit reported that the wall had been in disrepair for some time and described frequent sightings of centipedes and roaches. This resident also pointed out unsanitary bathroom conditions, a hole in the wall, and a privacy curtain with visible dark stains, as well as a curtain that did not provide adequate privacy. Facility staff, including administrative personnel, were shown these conditions and witnessed the presence of pests, including a centipede, which was killed during the observation. Review of pest control logs and service invoices revealed that while centipede sightings had been documented previously, not all pest sightings observed during the survey were recorded in the logs. The logs did not include the centipede sightings observed by the surveyor or administrative staff during the visit. The pest control process relied on staff to report sightings for targeted treatment, but this process was not consistently followed, resulting in unaddressed pest activity and ongoing environmental issues in resident rooms and bathrooms.
Medication Administration and Care Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice in the administration of medication for several residents. For one resident, the staff did not take blood pressures prior to administering Midodrine, a medication prescribed for hypotension, despite the physician's order to hold the medication if the systolic blood pressure was 120 or greater. The review of the Medication Administration Records for June 2024 showed that blood pressures were not documented before administering the medication, and the systolic blood pressures were 120 or greater 80 out of 90 times during the month. This oversight was acknowledged by the Assistant Director of Nursing, who confirmed that blood pressures should be taken as ordered. Another resident experienced a severe yeast rash on the buttocks and thigh, which was identified by a nurse practitioner. The facility staff failed to assess and monitor the resident's skin condition and did not provide adequate incontinence care. The resident was admitted with bilateral excoriation under her breasts and in the pelvic area, and the nurse practitioner noted the worsening condition due to prolonged exposure to waste. Documentation of incontinence care was missing, and interviews with staff revealed that rounds were made to ensure residents' needs were met, but issues with care provision were not reported. Additionally, the facility staff failed to ensure the availability of the medication Trulicity for another resident, as per physician orders. The medication was not administered on three separate occasions in May 2024, as documented in the Medication Administration Record. This failure to provide the prescribed medication as scheduled indicates a lapse in medication management and adherence to physician orders, contributing to the overall deficiency in care provided by the facility.
Failure to Provide Timely Incontinence Care Leads to Severe Rash
Penalty
Summary
The facility staff failed to provide timely incontinence care for a resident, leading to a severe yeast rash on the buttocks and thighs. The resident, who was admitted with conditions including COPD, diabetes, and VRE of urine, was found to have a significant yeast rash during a visit by a nurse practitioner. The rash was not documented by the nursing staff prior to this observation, indicating a lack of monitoring and reporting of the resident's skin condition. Interviews with Certified Nursing Assistants and Licensed Nurses revealed that incontinence care was expected to be provided at least every two hours, with any changes in skin condition to be reported to the nurses. However, documentation of care was missing, and the resident was left in waste for extended periods, exacerbating the skin condition. The facility's Director of Nursing and other management staff were informed of these findings during the survey, but no further information was provided regarding corrective actions.
Failure to Administer Trulicity as Ordered
Penalty
Summary
The facility staff failed to ensure that three residents were free from significant medication errors. Specifically, for one resident, the staff did not administer the medication Trulicity as ordered by the physician. This resident, who was admitted in 2018 with diagnoses including Diabetes, Cerebral Palsy, Dysphagia, Contracture, and Hypertension, had a BIMS score indicating no cognitive impairment. The physician's order required Trulicity to be administered subcutaneously once a day every Saturday at 9:00 a.m. However, the medication was not administered on three specific Saturdays in May 2024. The resident's blood sugar levels during this period ranged from 120 to 389, as recorded in the clinical records.
Failure to Timely Obtain and Communicate Lab Results
Penalty
Summary
The facility staff failed to obtain laboratory specimens as ordered and did not notify the physician of the delay in obtaining the specimens for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including diabetes and dementia, was admitted to the facility and later discharged home. A urinalysis was ordered on multiple occasions, but there were delays and issues with specimen collection and processing. Specifically, a urinalysis with micro reflex urine culture ordered on May 22 was rejected, and another ordered on May 31 was not collected until June 1. The facility's policy requires that laboratory tests be monitored, tracked, and communicated to the physician in a timely manner. However, the delay in obtaining and processing the urinalysis resulted in a late diagnosis of a urinary tract infection (UTI) on the day of the resident's discharge. The resident was discharged with oral antibiotics for the UTI, and the facility staff did not document the delay or notify the physician as required by their policy. This deficiency was identified during a survey, and the facility's administration was informed of the findings.
Failure to Notify Physician and Representative of Resident's Behavioral Changes
Penalty
Summary
The facility staff failed to notify the physician and the resident representative of a change in the physical, mental, or psychosocial status of a resident, identified as Resident #20, who was found engaging in sexual activity with another resident on two occasions. Despite the resident not being her own responsible party and having a BIMS score indicating moderate cognitive impairment, there was no documentation of family or physician notification. The resident's care plan noted behaviors such as making sexual advances and speaking inappropriately, but it was not updated to reflect these incidents. Resident #20 was admitted with multiple diagnoses, including sequelae of cerebral infarction, bipolar disorder, and generalized anxiety disorder, among others. The facility's Director of Nursing (DON) and Administrator acknowledged that the physician and resident representative should have been informed, as these behaviors could indicate a change in the resident's condition. The care plan interventions included medication administration, education on smoking policy, and behavior redirection, but these were not revised following the incidents.
Failure to Implement Abuse Policy for Residents with Cognitive Impairment
Penalty
Summary
The facility staff failed to implement the abuse policy for a resident who was allegedly having consensual sexual contact with another resident. The staff did not notify the responsible party of the resident, who was not her own responsible party, despite her moderate cognitive impairment as indicated by a BIMS score of 11/15. The resident's care plan noted behaviors such as making sexual advances towards staff and other residents. The facility's documentation did not show any notification to the family or physician regarding the incident. The incident involved another resident who was observed in a compromising situation with the first resident. This resident also had moderate cognitive impairment with a BIMS score of 9-10 and required maximum assistance for all aspects of care. The facility's abuse policy mandates internal investigation and notification of the state survey agency for any suspected or witnessed incidents of abuse, neglect, or exploitation. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and notification regarding the incident involving the two residents.
Failure to Implement 48-Hour Baseline Care Plan for Resident
Penalty
Summary
The facility staff failed to develop and implement a 48-hour baseline care plan for a resident, which is necessary for providing effective person-centered care. This deficiency was identified during a survey where it was observed that the resident, who was admitted with multiple diagnoses including urinary retention and benign prostate hyperplasia, did not have a care plan addressing his need for self-catheterization. The resident was dependent on staff for dressing, toileting, hygiene, and bathing, and was coded as always incontinent of bladder. Despite these needs, the care plan lacked focus, goals, and interventions related to his urinary retention and self-catheterization. During the survey, the resident expressed discomfort due to the lack of necessary catheters for self-catheterization, which he performed three times a day. The facility staff, including an LPN and the Central Supply Coordinator, were unaware of the resident's catheterization needs and the absence of 14 French straight catheters. The LPN eventually used a Foley catheter to assist the resident, but the care plan still did not reflect the resident's needs for catheterization and monitoring of input and output. The facility's administration and nursing leadership were informed of these findings, but no further information was provided before the survey exit.
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Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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