Failure to Schedule and Document Physician-Ordered Swallow Studies and Consults
Summary
The deficiency involves the facility’s failure to provide medically related social services by not ensuring that physician-ordered consultations and diagnostic tests were scheduled and properly documented for three residents. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing notes documented that the physician made rounds, examined the resident, and issued the MBS order, and that Social Services was notified. The assigned LVN stated that the Social Services Director (SSD) was responsible for scheduling the MBS after receiving the order and that nursing did not typically follow up once the order was handed off. However, there was no documentation in the electronic medical record (EMR) that the MBS was scheduled, completed, refused, or that any follow-up attempts or contacts with the resident or responsible party occurred. Another resident with seizures, dystonia, a history of traumatic brain injury, and a gastrostomy tube had a physician’s order dated 7/22/25 for a Barium Swallow consult. Nursing notes indicated that the physician examined the resident and issued a new order for the Barium Swallow consult and that the Social Services Assistant was notified. The LVN stated that the resident had swallowing issues and received nutrition and medications via G-tube because he was not safe to eat or drink by mouth, and that Social Services should have scheduled the appointment and documented follow-up in the EMR. The Speech Therapist (ST) confirmed that this resident had an MBS ordered to assess whether he could tolerate an oral diet and reported that she followed up with the SSD months later and was told the SSD was still working on scheduling the test. The SSD later stated she had contacted the resident’s sister because the hospital required the responsible party to attend the appointment, and that she called the sister several times but did not document any of these attempts or contacts in the EMR. A third resident with hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, and a G-tube had physician’s orders dated 12/10/25 for an ENT consult to assist with vocal cord mobility and for an MBS to rule out silent aspiration and determine if a by-mouth diet was possible. The LVN stated this resident had been dependent on G-tube feeding on admission and had progressed to an oral diet while in the facility, and that the MBS was ordered to ensure he could safely tolerate oral intake. The ST stated she was treating this resident and that he needed an MBS to confirm he could tolerate an oral diet without aspirating and also needed an ENT consultation to help with communication. The SSD stated the resident had been scheduled for an in-house ENT consultation but discharged before the appointment, and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD acknowledged she did not document the appointment, her attempts to obtain authorization, or any notifications to the ST or primary physician in the EMR. Across these three residents, the SSD described a process in which physician orders were delivered to her, sometimes placed under her office door, and she would then begin scheduling. She admitted she did not document attempts to schedule appointments or follow-up notes in the EMR, instead keeping papers with orders and handwritten notes in a folder in her office, and that when she did enter information into the EMR it was in a communication section that was automatically cleared and not part of the permanent medical record. The SSD stated that if something was not documented, it was considered not done, and acknowledged she should have documented her efforts in the EMR. The facility’s policy and procedure for Social Services referrals required Social Services to collaborate with nursing and other disciplines to arrange physician-ordered services and to document the referral in the resident’s medical record. The DON and Administrator both stated that the SSD was responsible for scheduling such appointments and that appointment scheduling and follow-up notes needed to be part of the resident’s medical record, but they were unaware that the SSD had not scheduled the ordered tests and consultations or documented her actions in the EMR. The surveyors concluded that these failures caused a delay in care and had the potential for the residents’ needs to go unmet.
Penalty
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A resident with Alzheimer’s disease, major depression, and a BIMS score of zero had no healthcare POA or guardian, while the listed financial POA declined involvement in healthcare decisions. The care plan identified impaired cognition and behaviors but did not address the resident’s capacity to consent to sexual activity, despite two separate incidents in which the resident was found partially or fully undressed in bed with male residents and engaged in sexual contact. Staff and leadership acknowledged relying solely on BIMS scores to judge consent capacity, did not complete formal assessments of sexual consent capacity, and did not document any attempts to obtain guardianship, while the Social Service Designee and PCP both stated the resident could not make her own decisions or give informed consent.
The facility failed to coordinate and provide timely audiology and related social services for two residents with hearing needs. One resident, with multiple complex medical conditions, had a physician order for audiology evaluation and ear flushing, but was never seen by the facility audiologist over several months, and ordered ear drops were reportedly not administered, leading the family to arrange outside audiology care. Another resident with diabetes, hypertension, depression, anxiety, and a documented hearing deficit had bilateral hearing aids that were lost, replaced, then reported as needing repair and later broken, yet was not scheduled with the audiologist during a recent visit and reported that staff did not insert her hearing aids daily as ordered. The Administrator acknowledged that after the social worker left, no one was covering audiology or other ancillary services, despite a policy stating the facility would assist residents in obtaining routine audiology services.
The facility failed to ensure timely follow-up on a guardianship process for a cognitively impaired resident with multiple chronic conditions, despite an expert evaluation recommending guardianship and prior agreement to initiate it. The social worker submitted a referral to the county probate investigator and later sent correspondence to inquire about services, but no further documentation of progress or outcome was recorded for many months. The Director of Social Services reported believing the process was delayed due to the resident owning a house and acknowledged she had not followed up after her last note, while the Regional Business Office Manager was unaware of any housing barrier and had asked the social worker to follow up. This inaction did not align with the Social Service Director’s job description, which required coordinating services and performing resident advocacy, including applications for supplementary services.
A resident with severe cognitive impairment, depression, dementia, and multiple medical conditions alleged sexual abuse by a CNA and exhibited upset and guarded behavior when questioned about the incident. Although a social worker designee and another staff member interviewed the resident and the social worker designee reported multiple follow-up contacts to assess emotional and cognitive status, there was no documentation of the allegation, the psychosocial change, or any social services assessments or notes in the medical record for the period following the event. This failure to document conflicted with the social worker designee’s job responsibilities to accurately record psychosocial needs, interactions, and follow-up actions.
A resident with cognitive deficits and a history of combative behavior was not provided with adequate podiatry care due to repeated refusals, lack of family notification, and insufficient documentation by untrained social services staff. The staff member responsible had not received formal training or a job description, resulting in prolonged neglect of the resident's toenail care.
A resident with a history of depression, anxiety, and alcohol dependence was unable to attend AA meetings due to a broken facility van, and no alternative support or social services were provided during this period. The resident, who relied on AA for social interaction and emotional support, did not receive follow-up or in-house interventions from the social worker or other staff, despite clear care plan directives and facility policy requirements.
Failure to Obtain Guardianship and Assess Consent Capacity for Severely Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to ensure a resident with severe cognitive impairment had appropriate decision-making support, including guardianship, to attain the highest practicable well-being. The resident was admitted with diagnoses of Alzheimer’s disease, hypertension, and major depression, and had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. Her care plan identified impaired cognition and thought processes related to Alzheimer’s disease, with interventions such as yes/no questioning, reorientation, supervision, and consistent routines. She had a friend listed as POA for finances who, according to the facility, did not want involvement in healthcare decisions, and there was no POA for healthcare or guardian documented. The record shows that the resident was involved in two separate incidents of sexual activity with male residents. In the first incident, staff found her in another resident’s bed with both residents’ pants down, and they were separated. In the second incident, staff found her naked in another resident’s bed with a male resident, who had his fingers in her vaginal area while she lay with her legs open allowing access; both residents were again separated and placed on 15‑minute checks. The facility’s care plan for the resident included interventions for tearful episodes and crying out, and later added frequent observation and 15‑minute checks, but there was no care plan documentation addressing her capacity to consent to sexual activity. The Kardex listed behavior interventions such as distraction from wandering and behavior monitoring, but did not include the 15‑minute checks or any information about sexually inappropriate behaviors. Interviews with facility leadership and staff confirmed that there was no assessment or evaluation of the resident’s capacity to consent to sexual activity either before or after the incidents, and that the facility relied solely on BIMS scores to determine consent capacity. The DON and RN staff stated they believed both involved residents could not consent based on their BIMS scores, yet no formal consent-capacity assessment was documented. The Social Service Designee stated the resident could not make her own decisions, that the financial POA refused involvement in healthcare decisions, and that the resident needed a guardian, but there was no documentation of any attempts to obtain guardianship. She further stated that, in practice, the facility made the resident’s healthcare decisions because there was no one else to do so. The PCP reported that the resident could not give informed consent, describing a blank stare and lack of communication when questioned, and stated that the resident almost required one‑on‑one supervision due to constant ambulation, but this information had not been communicated to facility leadership. Overall, the facility failed to initiate or document efforts to secure a guardian or other appropriate decision-maker for a resident known to be unable to make informed decisions.
Failure to Coordinate Audiology and Hearing Aid Services for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medically related social services and coordination of ancillary audiology services for two residents. One resident was admitted with multiple medical conditions, including COPD, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, and a history of malignant tumors with a urostomy. A physician order dated 02/13/26 directed that this resident be evaluated and treated by audiology after returning from an outside physician appointment, where the physician also discontinued two medications. Despite this order and the facility’s policy stating it would assist residents in obtaining routine audiology care, review of audiology visit records from 09/11/24 through the most recent visit on 04/01/26 showed that the resident was never examined by the facility audiologist. The resident’s sister reported that the resident was supposed to see the facility audiologist in January 2026 and again on 02/11/26, but the resident was not examined on either occasion. The facility reportedly told the sister that the audiologist had gone to the resident’s former facility and later stated they would arrange an emergency audiology appointment, which had still not been scheduled three weeks later. The sister stated that on 02/13/26 she brought the resident back from a physician appointment with an order for audiology to see the resident for ear flushing due to hearing difficulty, and that Debrox ear drops were said to have been ordered weekly but were never administered. She further stated she had repeatedly met with the Administrator, ADON, and Ombudsman without changes, and ultimately arranged an outside audiology appointment herself so the resident could have her ears flushed. The second resident had diabetes, hypertension, depression, anxiety, and a documented communication problem related to a mild hearing deficit, with a care plan indicating bilateral hearing aids and staff assistance with insertion, removal, and audiology consultation as indicated. Physician orders directed staff to insert the hearing aids each morning and remove them at night, with storage in the medication cart. Nursing notes documented that the resident’s hearing aids were lost and later replaced, and that by late February and early March 2026 the hearing aids needed repair, were not working properly, and were broken, with the NP and social worker notified. At a care plan meeting, the resident’s representative asked about the hearing aids, and the note indicated follow-up with nursing staff. The resident’s MDS showed adequate hearing with hearing aids, but the audiology visit list for 04/01/26 showed the resident was not seen by the audiologist. During observation and interview, the resident reported not having seen the audiologist in a long time, wanting to see him on his last visit, concern about excessive ear wax, and that nursing staff did not place her hearing aids daily as ordered. The Administrator confirmed that the former social worker, who had made audiology appointments, left on 03/16/26 and that no one was covering audiology or other ancillary services until a new social worker started, despite an undated facility policy stating it would assist residents in obtaining routine audiology services.
Failure to Follow Up on Guardianship Process for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services by not timely arranging and following up on guardianship for Resident #78 as recommended by an expert evaluation. Resident #78 was admitted on 03/22/23 with multiple diagnoses including chronic myeloid leukemia, COPD, chronic heart failure, aphasia, dementia, epilepsy, spondylosis, gout, and depression, and had moderately impaired cognition per the comprehensive MDS 3.0 assessment. A hospital social work discharge summary documented that the hospital social worker had spoken with the facility about starting guardianship and the facility agreed. An expert evaluation completed on 03/05/25 concluded that guardianship should be established or continued for this resident. Progress notes showed that on 04/24/25 the facility social worker submitted a referral to the county probate investigator following the expert evaluation, and on 07/08/25 the social worker sent correspondence to the county probate office to inquire about services and the prior referral, noting she was waiting on a response and would update the facility team and discuss next steps. However, from 07/09/25 to 03/23/26 there was no additional documentation in the medical record regarding the resident obtaining a guardian. In interviews, the Director of Social Services stated she believed the guardianship process had been delayed due to the resident having a house that had not been previously known, acknowledged she did not know if this had been followed up since her 07/08/25 note, and later confirmed she had no further information and had not followed up after submitting information for guardianship. The Regional Business Office Manager reported being unaware of any housing situation that would prevent guardianship and stated she had asked the social worker to follow up. The facility’s Social Service Director job description required planning, assessing, coordinating, and implementing services to enhance residents’ social and psychosocial well-being and performing all duties involved in resident advocacy and applications for supplementary services, which was not met in this case.
Failure to Provide and Document Medically Related Social Services After Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide and document medically related social services for a resident who experienced a significant psychosocial event related to an allegation of staff-to-resident sexual abuse. The resident, admitted with multiple diagnoses including stroke, depression, dementia, and severe cognitive impairment, required extensive assistance with mobility and had a care plan for mood and behavioral alterations, including delusional thinking and yelling out. Despite this, there was no documentation in the medical record of the alleged sexual abuse incident, no social services notes, and no psychosocial assessments entered between 03/10/26 and 03/19/26. The quarterly MDS showed severe depression with no documented change since the prior assessment, and the behavior and mood assessments reflected no behaviors since the prior annual assessment, despite the reported allegation. During an interview, the resident became guarded and defensive when asked about the alleged abuse, reported being told by the Administrator and police officers that she was safe and that the male staff member would no longer care for her, and refused to elaborate further. The social worker designee reported being informed of the allegation by an LPN, interviewing the resident when she was upset and yelling about a man trying to put his “thing” in her mouth, and confirming the description of the alleged perpetrator matched a CNA on duty. The social worker designee stated she met with the resident several times after the alleged incident to follow up on her emotional and cognitive status and to check in with her, but acknowledged she did not document the resident’s behaviors or allegations on the date of the incident, nor any follow-up visits or updated psychosocial assessments. This lack of documentation and failure to accurately record psychosocial needs and interactions conflicted with the written job responsibilities for the social worker designee.
Plan Of Correction
The facility will continue to provide SS support and document in medical record accordingly to ensure emotion needs and support of their residents. Resident #171 continue to reside at the facility. SSD followed up with resident #171 on 3/18/26 and documented in the medical record. Psych nurse practitioner assessed residents #171 on 3/19/26 with no changes noted to psychosocial wellbeing. Resident #171 denied any complaints and appeared calm and relaxed stating to the NP that she feels safe. Further SSD follow up was conducted on 3/27/26 with resident #171, no negative findings noted. On 4/6/26, the SSD conducted a psychosocial assessment on resident. On 4/8/26, Resident #171 care plan was reviewed by the IDT team. An initial audit was conducted of all current facility residents, by the Regional LISW-S, of the last 30 days ensuring SSD has proper follow up and documentation in medical record for changes in condition related to mood and behavior. Initial audit was completed on 4/6/26. The DON reviewed the facilities change in condition policy with SSD on 3/27/26. The Regional LISW-S, reviewed facility expectations for support of a resident with a change in condition and documentation requirements to ensure the psychosocial well-being of residents. Reeducation for facility SSD was completed on 3/31/26. A QA committee meeting was held on 4/8/26 reviewing survey results and findings, investigation and medical record documentation requirements, policy and procedures for abuse prevention and reporting abuse, SS policy and procedure, and facilities change in condition policy and procedure. Weekly for 2 weeks, or as directed by the QA committee, audits will be conducted by the Regional LISW-S all aspects of the resident's medical record including but not limited to: clinical and social service documentation, behavioral alerts and Point Click Care dashboard ensuring changes in condition are addressed by the SSD and documented accordingly. Negative findings will be corrected by reeducation and providing immediate support to residents. Negative findings will be reported to the QA committee for review. The Regional Administrator will ensure the weekly audits are completed. The Administrator is responsible for the ongoing compliance.
Failure to Provide Adequate Social Services and Podiatry Care Due to Untrained Staff
Penalty
Summary
The facility failed to ensure that social services staff were adequately trained and performed their duties as required, specifically affecting one resident with a history of traumatic brain injury, aphasia, and cognitive deficits. This resident was rarely understood, had self-care deficits, and exhibited combative behaviors during personal care, including resistance to nail care by both staff and an outside podiatrist. Despite repeated refusals of podiatry care and ongoing issues with extremely long, thick, and curled toenails, there was no documentation that the resident's family was notified of these refusals, nor was there evidence that these issues were discussed during care conferences. Observations confirmed the resident's toenails had been neglected for an extended period, and the podiatrist noted the condition may have persisted for years. Further review revealed that the staff member responsible for social services, who also served as the Activities Director, had not received official training for the social services role, had not been provided with a job description, and was unaware of all required duties. The personnel file lacked a signed job description, and the staff member admitted to learning the role informally and not documenting care refusals or family notifications as required. Facility policy required proper treatment and care to maintain foot health, but this was not followed in the resident's case.
Failure to Provide Medically-Related Social Services for Psychosocial Well-Being
Penalty
Summary
The facility failed to provide medically-related social services to support a resident's psychosocial well-being, specifically for a resident with a history of major depression, anxiety disorder, and alcohol dependence in remission. The resident was identified as being at risk for psychosocial issues due to social isolation, depression, and physical limitations, and his care plan included interventions such as access to psychiatric services and opportunities for social engagement. Despite these identified needs, the resident was unable to attend Alcoholics Anonymous (AA) meetings, which he considered his primary source of social interaction and support, after the facility's transportation van broke down. Interviews revealed that the resident missed multiple AA meetings due to the lack of transportation, and no alternative arrangements were made to support his psychosocial needs during this period. The resident reported not being aware of the facility's social worker and stated that no one had offered him additional support while he was unable to attend AA. The social worker acknowledged not following up with the resident or providing in-house services to address his needs during the transportation disruption. Other staff members confirmed the importance of AA meetings to the resident's well-being and noted a decline in his mood when he was unable to attend. The facility's social services job description outlined responsibilities for addressing residents' emotional adjustment and ensuring appropriate psychosocial interventions, but these were not fulfilled in this case. The lack of timely and appropriate social services intervention resulted in the resident not receiving the support necessary to maintain his highest possible quality of life, as required by facility policy and regulatory standards.
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