Autumn Care Of Mechanicsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Mechanicsville, Virginia.
- Location
- 7600 Autumn Parkway, Mechanicsville, Virginia 23116
- CMS Provider Number
- 495413
- Inspections on file
- 17
- Latest survey
- February 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumn Care Of Mechanicsville during CMS and state inspections, most recent first.
Staff failed to keep a dumpster lid closed, leaving trash bags exposed. The responsibility for maintaining the dumpsters was shared between dietary and maintenance departments, but the trash was not pushed down to allow the lid to close. Facility leadership was informed of the issue.
A resident with CHF and severe cognitive impairment did not have daily weights documented as ordered by the physician. Multiple dates showed missing weight entries in the eMAR and EHR, with no explanation provided by staff for the omissions, despite the importance of daily weights for CHF management.
A resident who experienced significant weight loss was not monitored according to physician orders, as daily weights were missed on multiple occasions. The resident, who was on a pureed diet and tube feeding, had a notable decrease in weight, and the RD had requested close monitoring. Staff cited time management and equipment uncertainty as reasons for not obtaining the required daily weights, despite facility policy and medical orders.
Staff failed to store opened food items in a sanitary manner by not sealing or dating them, and did not maintain required hot holding temperatures for several food items during meal service. Despite policy requiring food to be reheated if below 135°F, food was served at lower temperatures and not returned to the kitchen for reheating.
Facility staff did not complete or document required bed and bed rail safety inspections for four residents who used bed rails or positioning bars. Despite care plans indicating the need for these devices due to severe cognitive and physical impairments, inspection records were incomplete and staff acknowledged that the inspection process was not finished at the time of the survey.
A CNA was observed standing over a resident while feeding them, rather than sitting as required for a dignified experience. Staff interviews confirmed that sitting is the expected practice to ensure resident comfort and dignity, in line with facility policy.
Facility staff did not provide written notice to a resident before two room changes, despite facility policy requiring such notification. The resident expressed dissatisfaction with the new room, and staff interviews confirmed that written notice was not part of the current process. Review of records showed no documentation of written notification prior to the moves.
Facility staff did not inform a resident of the reason for a room transfer or document the notification, despite facility policy requiring both. The resident expressed dissatisfaction with the new room and was unaware of the reason for the move, which staff later attributed to a roommate conflict but failed to record.
Facility staff did not notify the physician when a resident with severe cognitive impairment refused ordered lab tests on two occasions. Although the refusal was recorded on lab logs, there was no documentation in the progress notes or evidence that the physician was informed, contrary to facility protocol.
A resident's quarterly MDS assessment was inaccurately coded to reflect the use of a restraint, specifically a chair that prevents rising, despite no documentation or observation supporting its use. The error was identified as a data entry mistake by the MDS coordinator.
Staff did not follow care plans for three residents, resulting in missed daily weights for a resident on enteral feeding and improper oxygen administration for two residents with respiratory conditions. One resident's weights were not obtained on several days due to time management and equipment confusion, while two others received oxygen at lower rates than ordered, despite clear care plan and physician instructions. Nursing staff acknowledged these discrepancies during interviews.
Staff did not update care plans for two residents to include physician-ordered adaptive eating equipment, orthotic devices, and interventions for significant weight loss. One resident was not provided with required adaptive utensils or a special cup despite documented needs and orders, and another was not offered a prescribed orthosis or adaptive utensils for a hand contracture. Care plans were not revised to reflect these needs, resulting in staff being unaware and the equipment not being used.
Facility staff did not clarify a physician order for a tracheostomy tube change for a resident who performed their own tracheostomy care. Although the order required a tube change every two months, documentation was lacking regarding who performed the procedure, and the LPN who signed off was unsure about the specifics. The facility's policy did not provide guidance on clarifying physician orders, and there was no evidence the order was clarified or the procedure documented.
A resident with diabetes, severe cognitive impairment, and multiple health conditions was observed with thick, overgrown toenails, and there was no evidence of recent foot care or podiatry visits. The resident stated that toenail care was not provided in the facility, and staff confirmed that residents with diabetes or thick nails are not given toenail care by nurses but should be referred to a podiatrist, with no documentation showing this was done.
A resident with a right-hand contracture was not consistently provided with a prescribed carrot orthotic device, despite an active order and occupational therapy recommendation for its daily use to prevent further contracture and skin breakdown. The device was present in the resident's room but not regularly offered, and the care plan lacked documentation of the need for the orthosis, indicating a failure to implement necessary interventions for range of motion and contracture management.
Staff failed to administer oxygen at the physician-prescribed rates for two residents requiring continuous oxygen therapy. In both cases, the oxygen concentrators were set below the ordered 4 liters per minute, contrary to facility policy and physician orders, as confirmed by staff interviews and direct observation.
Two residents with physician orders and therapy recommendations for adaptive eating equipment did not receive the prescribed devices during meals. One resident with hand tremors and ulnar drift was observed without a two-handled cup or foam utensil handles, while another resident with similar needs was left to use regular utensils and resorted to finger feeding. Staff were unaware of the residents' requirements, and care plans lacked necessary documentation, resulting in noncompliance with facility policy.
Dumpster Lid Left Open, Exposing Trash
Penalty
Summary
Facility staff failed to maintain one of two dumpsters in a sanitary manner by not ensuring that the lid was closed. During an observation, it was noted that the left lid of the right-side dumpster was left open, resting on a bag of trash, which resulted in the trash bags being exposed. Staff interviews confirmed that the responsibility for maintaining the dumpsters was shared between the dietary and maintenance departments, alternating monthly. The assistant dietary manager acknowledged that the trash should have been pushed down to allow the lid to close and that the lid should have been closed to prevent pest access. Further interviews with the director of environmental services confirmed the shared responsibility for dumpster maintenance and the frequency of trash removal. The director also agreed that the trash should have been managed to allow the lid to close. The deficiency was brought to the attention of facility leadership, including the administrator, director of nursing, and regional vice president of operations. No additional information was provided prior to the survey exit.
Failure to Follow Physician's Order for Daily Weight Monitoring in CHF Resident
Penalty
Summary
Facility staff failed to follow a physician's order for daily weight monitoring for one resident diagnosed with congestive heart failure (CHF). The order specified that the resident's weight should be obtained once daily, with instructions to notify the physician or nurse practitioner if the resident gained more than 2.5 pounds in three days or more than 5 pounds in a week. Review of the electronic medication administration record (eMAR) and electronic health record (EHR) revealed missing documentation of the resident's weights on several specified dates. The eMAR indicated 'Other' for these dates, but no explanation was provided in the records or nursing notes. The resident in question was admitted with CHF and was severely cognitively impaired, as indicated by a score of 0 on the Brief Interview for Mental Status (BIMS). Staff interviews confirmed that daily weights were required for CHF monitoring to detect fluid retention, which could impact the resident's heart function. However, the facility was unable to provide evidence that weights were obtained or documented on the specified dates, and staff could not explain the omissions when questioned.
Failure to Obtain Physician-Ordered Daily Weights After Significant Weight Loss
Penalty
Summary
Facility staff failed to monitor a significant weight loss for one resident by not obtaining physician-ordered daily weights after the resident experienced a notable decrease in body weight. The resident's weight dropped from 159 lbs. to 142 lbs. within a month, representing a 10.69% loss. The registered dietician documented concern over a 14% loss in less than a month and requested a reweigh for accuracy, noting the resident was on a regular, pureed diet and receiving tube feeding, which was increased in frequency due to poor oral intake. Despite a physician's order to obtain daily weights, the clinical record showed that weights were not recorded on several specified dates. Staff interviews revealed that daily weights were not obtained due to time management issues among CNAs and uncertainty about the appropriate equipment to use for weighing the resident. The registered dietician emphasized the importance of daily weights for accurate monitoring of the resident's nutritional status. Facility policy required weights to be obtained more frequently if risk was identified or as ordered, but this was not followed in the resident's case.
Deficient Food Storage and Holding Temperatures in Kitchen and Dining Areas
Penalty
Summary
Facility staff failed to store food in a sanitary manner and did not maintain required holding temperatures for food served to residents. During an observation of the kitchen's walk-in refrigerator, an open package of sliced ham and an open bag of shredded cheddar cheese were found without open dates. In the walk-in freezer, two bags of frozen breaded shrimp were found, one of which was open to the environment and the other resealed but not dated. The facility's policy requires all refrigerated and frozen foods to be appropriately dated to ensure proper rotation and to prevent contamination, but this was not followed. Additionally, during lunch service, holding temperatures of several food items on the steam table were recorded below the required minimum of 135°F. Items such as BBQ pork, pureed BBQ pork, pureed vegetables, mixed vegetables, and hamburger were all measured at 100°F to 120°F. Despite this, the food was not returned to the kitchen for reheating as required by facility policy. Staff interviews confirmed a lack of adherence to proper temperature protocols and food storage procedures.
Failure to Complete and Document Bed and Bed Rail Safety Inspections
Penalty
Summary
Facility staff failed to conduct and document required bed and bed rail safety inspections for four residents who utilized bed rails or positioning/assist bars. The facility's policy required annual inspections and additional checks when bed or mattress configurations changed, with documentation maintained by environmental services or maintenance. However, review of inspection records since the last survey showed that inspections were only completed in January 2023 and February 2024, and not all residents with bed rails had evidence of current inspections. For the four residents involved, observations confirmed the use of bed rails or positioning bars, and interviews with staff revealed that the inspection process was incomplete at the time of the survey. Maintenance staff indicated that inspections were performed annually, but also stated that the 2025 inspections were still in progress and not finished. Review of inspection documentation failed to show completed inspections for the affected residents during the relevant period. The residents affected had significant medical conditions and functional impairments, including severe cognitive impairment, congestive heart failure, diabetes mellitus, cerebrovascular accident with hemiplegia, cellulitis, and muscle weakness. Care plans for these residents included the use of bed rails or positioning bars for assistance with turning, repositioning, and mobility. Despite these needs, the facility did not provide evidence that the required safety inspections for beds and bed rails had been completed and documented for these individuals.
Failure to Provide Dignified Dining Experience
Penalty
Summary
Facility staff failed to provide a dignified dining experience for one resident. During observation, a CNA was seen standing over the resident while feeding them as the resident sat up in bed. In a subsequent interview, another CNA confirmed that staff are expected to sit in a chair when feeding residents, as standing does not provide a dignified experience and residents are more comfortable when staff are seated. The facility's own inservice documentation on resident rights emphasizes the right to be treated with dignity. No additional information was provided prior to the survey exit.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
Facility staff failed to provide written notice to a resident prior to two separate room changes, as required by facility policy. The resident reported having recently moved rooms and expressed dissatisfaction with the new room. Review of the clinical record confirmed that the resident was transferred to different rooms on two occasions, but there was no evidence of written notification being provided before either move. Interviews with staff revealed that the social services assistant was responsible for notifying residents of room changes, but acknowledged that the facility's policy did not require written notice. The facility's own policy stated that residents or their representatives should be notified prior to a room or roommate change, with documentation of the notification and the reason for the change. No documentation of written notice was found in the resident's record.
Failure to Notify and Document Reason for Resident Room Change
Penalty
Summary
Facility staff failed to provide a resident with the reason for a room change and did not document the notification or rationale for the transfer. The resident, who had recently been moved to a new room, reported dissatisfaction with her current room and was unaware of the reason for the move. Review of the clinical record confirmed the room transfer but showed no evidence that the resident was informed of the reason. Staff interviews revealed that the move was due to a conflict with a roommate, but this was not documented in the resident's record. Facility policy requires that residents be notified of room or roommate changes, including the reason, and that this notification be documented, but this was not followed in this instance.
Failure to Notify Physician of Resident's Refusal of Lab Testing
Penalty
Summary
Facility staff failed to notify the physician when a resident, who was severely cognitively impaired according to a BIMS score of three, refused ordered laboratory testing on two consecutive days. Physician orders were in place for a basic metabolic profile (BMP) and complete blood count (CBC) to be performed overnight on both dates, and the responsible party had been made aware of the new orders. However, there was no documentation in the resident's progress notes indicating that the labs were obtained, that the resident refused the labs, or that the physician was notified of the refusal. Laboratory patient log sheets confirmed that the resident refused the lab testing on both occasions, but these logs did not show any evidence that the physician was informed of the refusals. Staff interviews revealed that the expected protocol was for the nurse to notify the physician and responsible party and document the refusal in the progress notes when a resident declined lab work. Despite this, there was no documentation to support that these notifications occurred for the resident in question.
Inaccurate MDS Assessment Coding for Restraint Use
Penalty
Summary
Facility staff failed to maintain an accurate Minimum Data Set (MDS) assessment for one resident. The quarterly MDS assessment for this resident was incorrectly coded to indicate the use of a chair that prevents rising, which is considered a restraint, during the 7-day look-back period. However, a review of the resident's clinical record did not show any documentation supporting the use of such a restraint, and direct observation of the resident during the survey also did not reveal the use of a restraint or chair that prevents rising. The MDS coordinator acknowledged that the coding was a data entry error.
Failure to Implement Comprehensive Care Plans for Weight Monitoring and Oxygen Administration
Penalty
Summary
Facility staff failed to implement comprehensive care plans for three residents, resulting in deficiencies related to weight monitoring and oxygen administration. For one resident requiring enteral tube feeding and at risk for dehydration and aspiration, the care plan and physician's order required daily weight monitoring. However, clinical records showed that weights were not obtained on multiple specified dates. Staff interviews revealed that daily weights were missed due to time management issues and uncertainty about the appropriate equipment to use for weighing the resident. Another resident with a physician's order for continuous oxygen at four liters per minute for respiratory failure was observed receiving oxygen at a lower rate, between two and a half and three liters per minute, on two separate occasions. The care plan specified oxygen and nebulizer treatments as ordered, but staff did not administer oxygen at the prescribed rate. Nursing staff confirmed that oxygen should be administered per the physician's order and acknowledged the discrepancy in the observed flow rate. A third resident, who was cognitively intact and required continuous oxygen therapy for COPD and respiratory failure, was observed with their oxygen concentrator set at 3.5 liters per minute instead of the ordered four liters per minute. The care plan directed staff to administer oxygen as ordered, and physician instructions included checking the concentrator and oxygen saturation every shift. Staff interviews confirmed the oxygen was not set at the prescribed rate, and the resident was unaware of the correct flow rate. In all cases, the facility's policy required direct care staff to know and follow each resident's care plan, but this was not consistently done.
Failure to Update Care Plans for Adaptive Equipment and Weight Loss
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents, resulting in deficiencies related to adaptive eating equipment, orthotic devices, and significant weight loss. For one resident, the care plan did not include physician-ordered adaptive eating equipment such as a two-handled cup with a lid and straw, or red foam handles for utensils, despite clinical documentation and staff interviews confirming the resident's need due to hand tremors and ulnar drift. Observations showed the resident was not provided with the required adaptive equipment during meals, and staff were unaware of these needs. Additionally, the care plan did not address a significant, undesired weight loss, even though the dietician had documented the issue and recommended close monitoring and adaptive equipment to assist with eating. Another resident with a visible right-hand contracture was observed feeding herself with her fingers and without adaptive eating equipment, despite occupational therapy recommendations and physician orders for a right-hand carrot orthosis and lightweight utensils. The care plan for this resident did not include these devices, and the resident reported not being offered the orthosis or adaptive utensils, having lost them and not using them regularly. Staff interviews confirmed the recommendations and orders for these devices, but the care plan had not been updated to reflect these needs. Facility policy requires that comprehensive care plans be reviewed and updated at least every 90 days by the interdisciplinary team. However, in both cases, the care plans were not revised to include essential adaptive equipment and interventions as ordered by physicians and recommended by therapy staff, leading to a lack of implementation and awareness among direct care staff.
Failure to Clarify Physician Order for Tracheostomy Tube Change
Penalty
Summary
Facility staff failed to clarify a physician order regarding the scheduled change of a tracheostomy tube for one resident. The resident, who was cognitively intact and had a long-standing tracheostomy, reported performing their own tracheostomy care, with staff providing necessary supplies. Nursing staff offered to assist, but the resident preferred self-care. The physician order specified that the tracheostomy tube should be changed every two months and as needed, with documentation in the electronic medication administration record indicating a tube change was performed. However, there was no documentation in the progress notes regarding the actual procedure. During interviews, the LPN who signed off on the tube change was unsure who performed the change and believed it might have been done by an RN. The LPN admitted to not having changed the tube herself and expressed uncertainty about the specifics of the order, indicating a need to clarify with the nurse practitioner. The facility's policy on physician/provider orders did not provide guidance on clarifying such orders, and there was no evidence that the order had been clarified or that the procedure was properly documented.
Failure to Provide Foot Care for Resident with Diabetes and Impaired Mobility
Penalty
Summary
Facility staff failed to provide appropriate foot care for one resident, as evidenced by observations of the resident in bed with thick toenails on both large toes and toenails approximately one-half inch in length. The resident, who was admitted with diagnoses including congestive heart failure, diabetes mellitus, and osteoarthritis, was assessed as severely cognitively impaired and required maximum assistance with activities of daily living. The care plan indicated a need for assistance with ADLs due to multiple health conditions, and a physician's order was in place for a podiatry consult as needed. Despite these documented needs, there was no evidence that foot care had been provided. The resident reported that toenail care was not performed at the facility and that their son had to take them out for nail trimming. The only podiatry visit note available was from over a year prior, and there was no documentation of recent podiatry appointments or nail care in the resident's records. Staff interviews confirmed that nurses do not trim toenails for residents with diabetes or thick nails and that such residents are supposed to be placed on a podiatry list, but there was no documentation that this had occurred for the resident in question.
Failure to Provide Prescribed Orthotic Device for Contracture Management
Penalty
Summary
Facility staff failed to implement necessary interventions to prevent the worsening of a right-hand contracture for a resident with limited range of motion. The resident was observed multiple times with a visible contracture of the right hand, and although a carrot orthotic device was prescribed and present in the resident's room, it was not consistently provided to the resident. The resident reported that staff did not usually offer the orthotic device, despite being willing to use it to help with her contracture and skin integrity. Clinical records confirmed an active order for daily use of the right-hand carrot orthosis, as tolerated, to prevent skin breakdown and further contractures. Further review revealed that the resident's comprehensive care plan did not include information regarding the need for the right-hand orthotic device, despite occupational therapy's recommendation and discharge summary specifying its use. Interviews with staff indicated awareness of the device and its intended purpose, but observations and resident statements demonstrated a lack of consistent implementation. Facility policy required dissemination of adaptive equipment instructions and coordination among care team members, but this was not reflected in the resident's care plan or daily care practices.
Failure to Administer Oxygen at Prescribed Rates for Two Residents
Penalty
Summary
Facility staff failed to provide respiratory care and services consistent with professional standards of practice for two residents who required continuous oxygen therapy. For one resident with chronic obstructive pulmonary disease and a physician's order for continuous oxygen at 4 liters per minute (lpm), observations revealed the oxygen concentrator was set at 3.5 lpm instead of the prescribed rate. The resident reported using 3 lpm, and the LPN confirmed the concentrator was not set to the ordered rate. The care plan and facility policy both required adherence to the prescribed oxygen flow rate, and the manufacturer's manual specified proper adjustment of the flowmeter. For another resident with a physician's order for continuous oxygen at 4 lpm due to respiratory failure, observations on two occasions showed the oxygen concentrator was set between 2.5 and 3 lpm. The RN interviewed confirmed that oxygen should be administered at the rate specified in the physician's order, with the flowmeter ball aligned with the 4-liter line. These findings indicate that staff did not administer oxygen at the prescribed rates for both residents, as required by physician orders and facility policy.
Failure to Provide Prescribed Adaptive Eating Equipment and Utensils
Penalty
Summary
Facility staff failed to provide physician-prescribed adaptive eating equipment and utensils to two residents with documented needs for such devices. One resident, who was cognitively intact but had a physician's order for a two-handled cup with lid and straw, as well as red foam handles for utensils due to hand tremors and ulnar drift, was observed without the required adaptive equipment during multiple meals. The resident reported that her special cup and foam handles had gone missing, and staff interviews revealed a lack of awareness regarding the resident's need for adaptive equipment, despite clear documentation in the clinical record and meal tray tickets. Another resident, who had occupational therapy recommendations and physician orders for lightweight and built-up utensils to assist with self-feeding, was repeatedly observed attempting to use regular utensils and ultimately resorting to finger feeding. The resident acknowledged losing the adaptive utensils and stated that staff had not provided replacements. Staff interviews indicated a lack of knowledge about the resident's need for specialized eating equipment, and the resident's care plan did not include information about adaptive devices, despite therapy recommendations and orders. Facility policy required provision of adaptive devices per order, but this was not followed.
Latest citations in Virginia
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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