Battlefield Park Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Petersburg, Virginia.
- Location
- 250 Flank Road, Petersburg, Virginia 23805
- CMS Provider Number
- 495252
- Inspections on file
- 16
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Battlefield Park Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and an active elopement care plan, including a wanderguard, was reportedly found outside the building by a visitor, inadequately dressed and visibly cold, while an alarm sounded and no staff were present at the entrance. The visitor stated they could not reach staff by phone, contacted 911, and later informed the DON of the incident. Facility leadership initially denied receiving any report of the event, and the DON later described a prior call with a similar-sounding resident name that they could not match to any resident. Despite a written abuse/neglect policy requiring prompt reporting of all alleged neglect to the administrator and regulatory agencies, the allegation that a resident had been outside unsupervised was not reported as required.
Staff failed to thoroughly investigate an allegation that a cognitively impaired, elopement-risk resident with a wanderguard was found outside the building by a visitor, visibly cold and wearing only a short-sleeved shirt and pants. The visitor reported difficulty reaching staff by phone and stated that a staff member eventually returned the resident inside. Facility leadership initially denied receiving a report, then acknowledged a call but believed the name did not match any resident. Witness statements and a body/skin inspection form were produced with dates that did not align with when staff reported actually giving statements, and some staff denied being asked for statements, resulting in inconsistent and unreliable documentation that did not meet the facility’s own abuse/neglect investigation policy requirements.
Facility staff did not update a care plan to reflect a resident's preference for a plant-based diet, despite being aware of this need. The resident, who was cognitively intact and dependent on staff for self-care, experienced ongoing nausea and vomiting due to not receiving preferred meals. The care plan noted risk for malnutrition but did not specify the plant-based diet, and staff initially enforced policies that prevented the resident from storing preferred foods.
A resident with a contracted hand and multiple medical conditions did not receive necessary assistance with fingernail care, resulting in long, rammed fingernails and discomfort. Staff could not provide documentation of refusals or education regarding fingernail care, leading to a deficiency in maintaining personal hygiene.
A resident with advanced cancer and intact cognition did not receive her preferred plant-based diet as agreed upon, resulting in ongoing nausea and vomiting. The facility failed to update the care plan to reflect her dietary preferences, did not provide requested foods, and restricted her ability to store outside food, leading to unmet nutritional needs.
Staff did not ensure that a resident's clinical record included the most recent hospice plan of care and a description of hospice services, despite the resident being admitted under hospice care with multiple serious diagnoses. The required hospice documentation was missing at the time of review, and the only available hospice plan covered a previous period, not the current one.
A resident with advanced cancer and intact cognition was found with a cup containing two Reglan tablets and one Benadryl left on the over-bed table for several hours. The resident was unaware of the pills and did not take them due to ongoing nausea. Nursing staff confirmed the medications were poured earlier but not administered as ordered, and facility leadership acknowledged that medications should not be left at the bedside.
Several residents in the facility were not provided with adequate personal care, affecting their dignity. A resident with severe cognitive impairment was found with unkempt hair and facial hair, while another was in stained clothing. A third resident had an uncovered foley urine drainage bag, and a fourth was dressed in a hospital gown instead of personal clothing. Staff interviews confirmed these were dignity issues, but no immediate corrective actions were documented.
The facility failed to consistently hold unit council meetings for residents and family representatives due to the absence and resignation of the Activities Director. The Activities Assistant, lacking official training, managed the department alone, resulting in missed meetings. The Executive Director confirmed the inconsistency and provided documentation for some meetings, but not for others, violating the residents' rights policy.
The facility did not ensure residents were aware of their rights to contact the Ombudsman or file complaints with the state agency. During a meeting, none of the residents knew how to contact the Ombudsman or file a complaint. Interviews with staff revealed no practice to inform residents of these rights, despite the facility's policy stating residents have the right to make complaints.
Residents reported that their packages were always opened upon receipt, which they felt was an invasion of privacy. The ED was unaware of this issue, despite the facility's policy stating that residents have the right to receive mail and packages unopened. The issue was discussed with the facility's leadership, but no further information was provided.
The facility failed to ensure a clean and homelike environment, with surveyors observing pests, stains, and cluttered shower rooms lacking clean linens. Pest control recommendations were not followed, contributing to ongoing issues. Staff interviews confirmed the deficiencies, and the Administrator was informed without further action.
The facility failed to complete PASARRs prior to admission for three residents, leading to significant delays in required screenings. One resident with major depressive disorder was observed talking to himself, while another with depression and dementia showed confusion and frailty. A third resident with multiple diagnoses, including epilepsy and depression, had their PASARR completed post-admission. These deficiencies were acknowledged by facility staff during interviews.
Two residents with indwelling catheters experienced deficiencies in care at the facility. One resident's catheter was not properly anchored, risking trauma, while another resident missed multiple urology appointments due to scheduling and transportation issues. These failures indicate lapses in adhering to care plans and ensuring necessary medical follow-ups.
A resident with a history of depression expressed increased depressive symptoms, but the facility failed to coordinate necessary mental health services. Despite being cognitively intact, the resident reported symptoms such as fatigue and loss of interest, and the Preadmission Screening did not capture the depression diagnosis. The care plan included antidepressants, but interventions were limited, and psychiatric recommendations to adjust medication were not followed. The Social Services Director was unaware of the resident's condition, leading to a deficiency in mental health service coordination.
The facility failed to remove expired Covid-19 tests, an expired medication, and expired wound dressings from medication storage rooms. Additionally, medications were found opened and undated on a medication cart, contrary to facility policy. Staff interviews confirmed awareness of these issues.
The facility failed to provide regular bedtime snacks to residents, as observed during a survey. Residents reported that snacks were rarely offered and often consisted of sugary items. The Dietary Manager acknowledged the issue and planned to revamp the snack program. The findings were shared with the facility's leadership, but no additional information was provided.
The facility staff failed to maintain sanitary conditions in the kitchen, with issues such as commingled clean silverware and a sponge with dead insects, sticky and debris-covered carts, unrefrigerated mandarin oranges, and unsanitary condiment bins. Mouse feces and a crusted mouse trap were found under shelving units, and the ice machine's drain pipe was improperly placed, leading to mold-like substance and water damage. The Dining Services Manager admitted to a mouse problem and began cleaning.
The facility failed to maintain an effective pest control program, leading to the presence of pests and rodents. Surveyors observed mouse droppings, flies, and gnats throughout the facility. Despite recommendations from the pest control company to address issues like improperly sealed doors and structural concerns, these actions were not completed. The Maintenance Director was unaware of the necessary repairs, and the Administrator was informed of the concerns without further action.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital discharges. The resident, who was cognitively intact and had multiple medical conditions, was transferred to a hospital on two occasions for seizure activity and infections. Documentation provided by the Social Services Director did not include notifications for these discharges, and the administrative team confirmed the absence of additional records.
A resident with a contracture in the left hand and multiple medical conditions did not have a comprehensive care plan addressing the contracture or measures to prevent its worsening. The resident was observed with long fingernails that could cause a wound, and staff interviews revealed a lack of awareness and action regarding protective devices. The DON acknowledged the risk but no immediate actions were taken.
The facility staff failed to provide adequate assistance with ADLs for three residents, leading to deficiencies in personal hygiene and grooming. A resident with severe cognitive impairment was observed with unkempt hair and facial hair, indicating a lack of assistance with bathing. Another resident, dependent on staff for ADLs, had greasy hair due to infrequent bathing. A third resident was found with long, debris-filled fingernails, showing a lack of routine nail care. These issues were reported to the administrator, but no further information was provided.
A resident with multiple diagnoses, including hemiplegia, was found with a contracture in her left hand and long fingernails that could cause injury. The facility staff failed to implement measures such as splints or palm guards to prevent further contracture, and the PT Director and DON acknowledged the risks but did not take immediate action.
Two residents in a facility experienced deficiencies in enteral feeding management. The staff failed to ensure that syringes used for PEG tube maintenance were clean and changed daily, and tube feeding setups were not correctly labeled and dated. Observations revealed undated and improperly maintained feeding equipment, contrary to facility policy. An LPN confirmed the policy was not followed, and the administrator was informed of the issues.
A resident requiring oxygen therapy did not receive appropriate respiratory care as facility staff failed to date and properly store oxygen tubing, and there was no PRN order for oxygen use. The resident's oxygen tubing was found on the floor, undated, and not in a plastic bag, contrary to facility policy. Additionally, there was no 'Oxygen in Use' sign on the door, and the existing oxygen order was discontinued without a replacement.
A resident was administered duplicate antihistamine therapy with Loratadine and Cetirizine for seasonal allergies, despite both medications having the same mechanism of action. This oversight occurred due to separate orders from the Medical Director and an NP. The resident was also on Gabapentin, which could interact with the antihistamines. The ADON confirmed the error, and the NP discontinued one of the medications.
A resident with multiple health conditions was administered Midodrine for over three months without proper blood pressure monitoring or adherence to a 14-day administration limit. The facility staff failed to check blood pressure as required before administering the medication, and neither the nursing staff nor the pharmacy identified the order's time limit. This oversight was discovered during a survey, revealing significant medication management deficiencies.
Failure to Report Allegation of Neglect After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect related to a cognitively impaired resident who was found outside the building. The resident had vascular dementia, diabetes mellitus, and a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment, but was documented as having clear speech. The resident’s care plan and physician’s orders identified him as an elopement risk and required a wander/elopement alarm (wanderguard) to be in place and checked regularly for placement and function. Treatment administration records showed all required checks as completed. A visitor reported that on an evening visit to return laundry, the front door was locked, no one was at the reception desk, and an alarm was sounding inside. The visitor stated they waited about 10 minutes at the door, then saw a resident come around the side of the building wearing pants and a short-sleeved shirt, without a coat, and appearing visibly cold, with a wanderguard on the right wrist. The visitor asked the resident his name, and he responded with his first name, which matched the resident later identified by the surveyor. The visitor reported calling the facility multiple times with no answer, then calling 911; the 911 operator reportedly called the facility twice before staff answered. A female staff member then came to the door, asked the resident how he got out, and took him back inside toward Unit 1. The visitor stated they called the facility the next day and spoke with the DON to ensure the incident of the resident being outside was reported, and the DON said they would investigate. During the survey, the ED and DON initially stated that no one had called them about the resident being found outside. When informed of the visitor’s account, the DON acknowledged receiving a call on a prior date but said the caller gave a similar-sounding name that did not match any resident, and that an investigation had been done but they could not determine whether any resident had been outside. The facility’s Abuse, Neglect, and Exploitation policy defined neglect to include failure to take precautionary measures to protect resident safety, failure to report observed or suspected abuse or neglect, and failure to adequately supervise a resident known to wander from the facility without staff knowledge, and required reporting all alleged violations of abuse or neglect to the administrator and regulatory bodies within specified time frames. The surveyor concluded the facility failed to report an allegation of neglect involving this resident in accordance with its policy and regulatory requirements.
Failure to Thoroughly Investigate Alleged Elopement and Neglect Incident
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of neglect involving a cognitively impaired resident with vascular dementia and diabetes mellitus who was care planned and ordered for elopement precautions, including a wander/elopement alarm (wanderguard) to the right wrist and routine checks of its placement and function. The resident’s MDS showed severe cognitive impairment but clear speech, and the care plan identified the resident as an elopement risk who wandered aimlessly. Physician orders and the treatment administration record documented that wanderguard placement and function checks were completed as ordered. A visitor reported arriving at the facility in the early evening to return laundry and finding the front door locked with no staff at the reception desk, while hearing an alarm sounding inside. After approximately 10 minutes at the door, the visitor observed a resident walking around the outside of the building from the right side, wearing pants and a short-sleeved shirt without a coat and appearing visibly cold, with a wanderguard on the right wrist. The visitor asked the resident his name, and the resident responded with his first name. The visitor stated they repeatedly called the facility with no answer, then called 911; the 911 operator reportedly called the facility twice before someone answered, after which a female staff member brought the resident back inside toward Unit 1. The visitor later called the DON the next day to ensure the incident was reported, and the DON stated they would investigate. When surveyors interviewed staff, multiple CNAs and an RN stated they did not recall the resident being outside on the reported date. The ED and DON initially stated no one had called them about the resident being outside; the DON later acknowledged receiving a call but believed the name given did not match any resident. The DON provided witness statements and a body/skin inspection form dated around the time of the alleged incident, but the unit manager (LPN) reported obtaining the statements on a later date and instructed staff to date them for the day of the incident, resulting in discrepancies between the actual date statements were taken and the dates written on them. Some staff named on the witness list either denied giving a statement or reported giving one on a different date than documented. These inconsistencies, along with the lack of clear documentation of the alleged elopement and the facility’s own abuse/neglect policy requiring immediate, documented investigation with timely, signed, and dated statements, demonstrated that the facility did not complete a thorough investigation of the neglect allegation.
Failure to Address Resident's Plant-Based Diet Preference in Care Plan
Penalty
Summary
Facility staff failed to develop a care plan that addressed a resident's preference for a plant-based diet, despite being aware of this preference. The resident, who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, morbid obesity, and atrial fibrillation, was cognitively intact and dependent on staff for most self-care activities. The resident reported experiencing frequent nausea and vomiting over several days due to not receiving her preferred plant-based meals, which she stated had been agreed upon with the facility. She attempted to supplement her diet by purchasing bean burritos from a local restaurant, but staff disposed of them due to storage policies, and she was initially told she could not have a personal refrigerator in her room. The resident's nutritional care plan identified her risk for malnutrition and included interventions such as identifying food preferences and offering substitutions, but did not specifically address her plant-based diet preference. Staff interviews confirmed awareness of the resident's dietary preference, but the care plan was not updated to reflect this, and facility policies regarding personal refrigerators were not initially clarified. The deficiency was acknowledged by facility leadership during the survey process.
Failure to Provide Necessary Assistance with Personal Hygiene
Penalty
Summary
Facility staff failed to provide necessary assistance with personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who had a history of stroke, diabetes, hypertension, and a contracted right hand with curled fingers, was assessed as dependent in upper and lower body dressing, footwear, and personal hygiene. During an interview, the resident reported pain in his right hand due to long fingernails and could not recall the last time staff had trimmed them. Observation confirmed the presence of long, rammed fingernails, dry skin, and healed scars on the resident's right hand. The resident also reported removing his splint due to discomfort. Review of the care plan indicated interventions for pain management and contracture care, but there was no documentation of the resident refusing fingernail care or of staff providing education regarding this aspect of hygiene. The Unit Manager acknowledged that the resident was care planned as non-compliant with fingernail care but could not provide evidence of refusals or education attempts. The lack of documentation and failure to maintain the resident's fingernail hygiene led to the deficiency cited by surveyors.
Failure to Honor Resident's Plant-Based Dietary Preferences
Penalty
Summary
Facility staff failed to make reasonable efforts to honor and meet the meal choices and preferences of a resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, use of a nephrostomy tube, and bilateral lymphedema. The resident was cognitively intact and dependent on staff for most self-care activities, requiring setup assistance with eating. Despite a care plan identifying her risk for malnutrition and the need to identify food and beverage preferences, the resident reported ongoing nausea and vomiting over several days due to not receiving her preferred plant-based diet, which consisted mainly of beans, fresh vegetables, and fruit. The facility did not provide these preferred foods as previously agreed upon, and the resident's attempts to supplement her diet with outside food were hindered when staff discarded her purchased bean burritos due to storage policies. Additionally, the resident was informed she could not have a personal refrigerator in her room, further limiting her ability to store preferred foods. Interviews with facility leadership confirmed that the resident's person-centered care plan did not reflect her plant-based food preferences, and the dietary department had not consistently accommodated her nutritional needs as outlined in her care plan. The failure to update and follow the care plan and dietary preferences contributed to the resident's ongoing nutritional issues.
Failure to Maintain Current Hospice Plan of Care in Clinical Record
Penalty
Summary
Facility staff failed to ensure that the written plan of care for a resident included both the most recent hospice plan of care and a description of hospice services, as required. The resident, who was admitted under hospice care from another LTC facility, had diagnoses including malignant ovarian and endometrial cancer, a right nephrostomy tube due to hydronephrosis with ureteral stricture, and bilateral lower extremity lymphedema. The resident was cognitively intact but dependent on staff for most self-care activities. Despite a physician's order to admit the resident to hospice care, the clinical record did not contain the hospice agency's plan of care at the time of review. Staff interviews confirmed that the hospice care plan was not present in the clinical record, and the Assistant Director of Nursing indicated it may not have been uploaded by Medical Records. A hospice document was later added to the record, but it only covered a previous benefit period and did not address the current period. The absence of the current hospice plan of care in the resident's clinical record constituted the deficiency identified by surveyors.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
Facility staff failed to administer medications as ordered for one resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, a right nephrostomy tube, and bilateral lower extremity lymphedema. The resident was cognitively intact but dependent on staff for most self-care activities. On the day of the incident, two white pills and one orange pill were observed in a medication cup on the resident's over-the-bed table at 10:35 AM, and the same pills remained there at 1:50 PM. The resident was unaware of the pills' presence, did not know what they were, and stated she was not going to take them due to ongoing nausea and recent vomiting. A registered nurse confirmed that the pills were two Reglan tablets and one Benadryl, which had been poured at 6:00 AM according to the medication administration record. The nurse stated she had not seen or left the pills at the bedside. The unit manager also stated that medications should not be left at the bedside and should be administered in the presence of a nurse. The facility's leadership team reviewed and acknowledged the findings, confirming that the medications were not administered as ordered and were improperly left at the resident's bedside.
Failure to Maintain Resident Dignity in Personal Care
Penalty
Summary
The facility staff failed to ensure the dignity of several residents by neglecting their personal grooming and clothing needs. Resident #5, who has severe cognitive impairment and multiple health issues, was observed with unkempt hair and long facial hair, indicating a lack of assistance with grooming. Despite being coded as independent in the facility's documentation, interviews with staff revealed that Resident #5 required help with bathing and grooming, which was not being provided. Resident #33, also with severe cognitive impairment, was found wearing stained and dirty clothing, which was not addressed by the staff until it was pointed out by the surveyor. The resident was unable to communicate effectively, and the staff acknowledged the need for changing his clothes and cleaning him up, but this was not done in a timely manner. Additionally, Resident #58 was observed with an uncovered foley urine drainage bag, which should have been covered with a dignity bag according to facility policy. Resident #114 was found wearing a hospital gown instead of personal clothing, with no documentation of refusal to wear personal attire. The facility's staff, including the DON and Administrator, acknowledged these issues as dignity concerns, but no immediate corrective actions were documented.
Inconsistent Unit Council Meetings
Penalty
Summary
The facility failed to consistently arrange regular unit council meetings for residents and/or family representatives, as required by the residents' rights policy. The Activities Assistant (AA) reported that since the Activities Director (AD) went on leave in January and subsequently resigned, she had been managing the department alone without official training to set up these meetings. Although the Executive Director (ED) assisted with the most recent meeting, the AA admitted to missing some months without holding meetings. The ED confirmed the inconsistency in holding these meetings and provided documentation for meetings held in July and September, but none for June and August. The facility's policy on Resident's Rights states that residents have the right to form or participate in a resident group to discuss issues and concerns about the facility's policies and operations. However, the facility failed to uphold this policy consistently, as evidenced by the lack of regular meetings. The ED acknowledged the deficiency and noted that the position of Activities Director is currently posted. Despite being given an opportunity to provide additional information during a meeting with facility leadership, no further information was provided.
Failure to Inform Residents of Ombudsman and Complaint Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights to contact the Ombudsman and file complaints with the state certification agency. During a unit council meeting, none of the six residents present were aware of who the Ombudsman was or how to contact them, nor were they aware of their right to file a complaint with the state agency. This lack of awareness was confirmed through interviews with the facility's Activities Assistant and Admissions Coordinator, who both indicated that there was no established practice to ensure residents were informed of these rights. The facility's policy on Resident's Rights states that residents have the right to make complaints, yet this information was not effectively communicated to the residents. The information regarding how to contact the Ombudsman and the state agency was located in the facility's lobby, but it was not adequately highlighted or communicated to the residents. The deficiency was discussed with the facility's leadership team, but no additional information was provided to counter the findings.
Residents' Packages Opened Upon Receipt
Penalty
Summary
The facility's staff failed to ensure that residents' packages were received unopened, which was identified as a deficiency. During a unit council meeting, three out of six residents expressed their frustration, stating that while their mail was received unopened, their packages were always opened upon receipt. This was perceived as an invasion of their privacy. The Executive Director (ED) of the facility was interviewed and stated that she was unaware of this issue, affirming that residents should receive their mail and packages unopened. The facility's policy on Resident's Rights, which was undated, indicated that residents have the right to privacy in sending and receiving mail. The findings were shared with the facility's leadership team, but no additional information was provided by the staff.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for residents, particularly those on the 100's hall and those receiving food from the kitchen. Over a three-day survey period, surveyors observed flies and gnats in the conference room and dead bugs in light fixtures throughout the building. Stains were noted on the hallway floors near specific rooms, and repairs in one room had not been completed as the area above the bed was spackled but not painted. Additionally, an IV pole and floor in another room had a dried brownish substance, likely tube feeding. The shower room was cluttered with various equipment and dirty linens, and lacked necessary clean linens. A nebulizer machine was found unlabeled and undated in the shower room, and several tiles were missing from the baseboard and floor. The facility's pest control service book revealed that from April to August 2024, the pest control company made monthly recommendations to address pest issues, including cleaning drains, repairing door sweeps and drywall, and sealing entry points for mice. These recommendations were not implemented, contributing to the ongoing pest problem. Interviews with staff, including a CNA and the DON, confirmed the cluttered state of the shower room and the lack of clean linens. The DON was unaware of the missing tiles and acknowledged that the nebulizer should not be left in the shower room. The Administrator was informed of these findings during the end-of-day meeting, but no further information was provided.
Failure to Complete PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for three residents. Resident #92 was admitted with diagnoses including major depressive disorder with psychotic symptoms, anxiety disorder, and avoidant restrictive food intake disorder. The resident was observed to be moving quickly around his room, talking to himself, and not responding to the surveyor. A review of his clinical record revealed that the PASARR was completed eight months after admission, indicating a significant delay in the required screening process. Resident #104 was admitted with diagnoses of depression and dementia with agitation. The resident was observed to be frail, underweight, and confused, with erratic movements and poor skin turgor. The clinical record review showed that the PASARR was completed on the day the survey began, rather than prior to admission, as required. This delay in completing the PASARR was acknowledged by the facility staff during interviews. Resident #84 was admitted with multiple diagnoses, including epilepsy, depression, and aphasia following cerebrovascular disease. The resident's clinical record indicated that a PASARR was not completed prior to admission from the acute care hospital. The PASARR was only completed and uploaded into the clinical record after the surveyor's review. The facility's social worker admitted to completing PASARRs post-admission when they were not done beforehand, highlighting a systemic issue in the facility's admission process.
Deficiencies in Catheter Care and Appointment Management
Penalty
Summary
The facility staff failed to provide appropriate care and services for managing indwelling catheters for two residents. Resident #67, who has quadriplegia and stage 4 pressure ulcers, was observed with an unsecured indwelling catheter, which was not anchored as per the care plan. This oversight was noted during wound care observations, and neither the Assistant Director of Nursing (ADON) nor the Licensed Practical Nurse (LPN) recognized the issue. Resident #67 confirmed that he was unaware of the catheter not being anchored and had not refused the procedure. Resident #81, who also has an indwelling catheter due to obstructive uropathy, experienced issues with attending a follow-up urology appointment. Despite being cognitively intact, Resident #81 reported that due to scheduling and transportation problems, he missed multiple appointments with the urologist. The scheduling coordinator and ADON acknowledged the failure in ensuring the resident's transportation to the appointments, which were crucial for his post-surgical follow-up care. These deficiencies highlight the facility's failure to adhere to care plans and ensure necessary medical follow-ups for residents with indwelling catheters. The lack of proper catheter management and failure to facilitate medical appointments could potentially compromise the residents' health and well-being.
Failure to Coordinate Mental Health Services for Resident with Depression
Penalty
Summary
The facility staff failed to coordinate mental health services for a resident diagnosed with depression, who expressed feelings of increased depression. The resident, who was admitted to the facility in April 2022 and readmitted in November 2023, had a history of depression diagnosed in 2015. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident reported experiencing symptoms of depression, such as feeling tired, having trouble sleeping, and losing interest in activities over a two-week period. The resident also expressed concerns about financial constraints and lack of family support, contributing to his depressive state. Additionally, the resident's Preadmission Screening and Resident Review did not capture the depression diagnosis, and there was a lack of follow-up on psychiatric recommendations to adjust medication. The resident's care plan included the use of antidepressants, with goals to avoid complications from medication side effects. However, the interventions were limited to encouraging the resident to voice feelings and discussing coping skills, without ensuring access to mental health services. The Social Services Director was unaware of the resident's depressive symptoms and had not coordinated mental health services. The resident's chart showed only two psychiatric visits in 2022, with a recommendation to increase medication that was not reflected in the physician's orders. This lack of coordination and follow-up on mental health services contributed to the deficiency identified during the survey.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility staff failed to adhere to proper storage and labeling protocols for drugs and biologicals, as evidenced by the presence of expired Covid-19 tests, an expired medication, and expired wound dressings in two medication storage rooms. Specifically, 11 boxes of BinaxNow Covid-19 tests were found expired, and a multi-dose vial of Insulin Lantus was kept beyond the manufacturer's recommended 28-day usage period after opening. Additionally, 10 Collagen Wound Dressings were stored past their expiration date. Interviews with staff, including a Regional Nursing Consultant and a Registered Nurse, confirmed the awareness of these expired items and the inability to use them. Further deficiencies were observed in the medication administration process, where medications were found opened and undated on a medication administration cart. These included a bottle of 81 mg Aspirin, a bottle of Vitamin D 10 mcg, and a bottle of Osmotic Laxative. An LPN acknowledged that per training and competency requirements, all medications should be dated upon opening. The facility's policy mandates the removal and destruction of expired medications, yet this was not adhered to, as evidenced by the findings during the survey.
Failure to Provide Regular Bedtime Snacks
Penalty
Summary
The facility staff failed to offer and provide snacks at bedtime, as observed during a survey conducted from 9/17/24 to 9/19/24. No observations were made of snacks being offered or provided to residents during this period. During a unit council meeting on 9/18/24, six residents complained about not being offered snacks regularly, stating that it was random and rare to receive snacks at bedtime. They also mentioned that when snacks were provided, they were often sugary items like fig bars and cakes. Additionally, residents reported that dietary staff occasionally brought snacks to the unit, but nursing staff left them at the desk, making them accessible only to residents who could reach the desk. An interview with the Dietary Manager on 9/19/24 revealed awareness of the snack issue and plans to revamp the snack program to include healthier options. The Dietary Manager also mentioned collaborating with nursing leadership to ensure snacks are distributed to all residents as required. The facility provided unit council minutes for meetings held on 7/16/24 and 9/16/24, but there were no meetings in June or August. The findings were shared with the facility's leadership team on 9/19/24, but no additional information was provided by the staff.
Unsanitary Food Preparation and Storage Conditions
Penalty
Summary
The facility staff failed to prepare and serve food in a safe and sanitary manner, as observed during an inspection of the kitchen area. The inspection revealed several unsanitary conditions, including a clean silverware tray commingled with a dish sponge that contained dead insects. Additionally, clean glasses were found on a cart covered in a sticky brown substance, along with bread clips, food crumbs, and other debris. A green cart with a segmented tray was observed to have cloudy liquid and food debris in each segment, despite being reportedly clean. In the dry storage area, trays of mandarin oranges were left unrefrigerated, and a cart with encrusted knives and food debris was found. Condiment bins contained rusted paper clips, crumbs, and spilled condiments, and a Styrofoam box with a dried, half-eaten hamburger was discovered. Further inspection revealed mouse feces and a crusted mouse trap under the shelving units, along with sticky floors and a greasy substance that caused slipping. The ice machine's drain pipe was directly on the floor, surrounded by mildew and a black mold-like substance, with water damage noted on the wall. The Dining Services Manager acknowledged the issues, admitting to a mouse problem and stating that cleaning would begin immediately. The Regional Director later confirmed that a deep cleaning had started, and the Dining Services Manager had resigned.
Pest Control Deficiency Due to Inaction on Recommendations
Penalty
Summary
The facility staff failed to maintain an effective pest control program, resulting in the presence of pests and rodents throughout the facility. During a survey conducted from September 17 to September 19, 2024, surveyors observed mouse droppings in the kitchen's dry storage area, small flies in a dishwashing sponge, and flies and gnats in various resident rooms and the conference room. Dead bugs were also found in light fixtures throughout the building. The pest control book revealed multiple service receipts indicating ongoing issues, such as improperly sealed exit doors, rusted fire doors, and the presence of mice in the kitchen. Despite recommendations from the pest control company to install or replace door sweeps and address structural concerns, these actions were not completed. The Maintenance Director admitted to fixing the doors but noted that wheelchairs frequently knocked off the door sweeps. He was unaware of other necessary repairs and recommendations from the pest control company. Observations on September 19, 2024, confirmed that the drywall over the kitchen baseboards had not been repaired, exit doors still had gaps, and floor drains required cleaning. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided.
Failure to Notify Ombudsman of Resident's Hospital Discharges
Penalty
Summary
The facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for a resident, identified as Resident #67, during a survey. Resident #67 was originally admitted to the facility in early 2022 and had been readmitted after an acute care hospital stay. The resident's medical conditions included quadriplegia, stage 4 pressure ulcers, and obstructive uropathy. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) during a quarterly assessment. The deficiency was identified when the Social Services Director (SSD) provided documentation that only included notification of a discharge on a later date, but not for the hospital discharges on two earlier occasions. The resident had been transferred to a hospital due to seizure activity and sepsis on one occasion, and for a urinary tract infection and seizure activity on another. During interviews, the administrative team, including the Regional President of Operations, confirmed that no additional documentation was available to show that the Ombudsman had been notified of these earlier discharges.
Failure to Address Contracture in Nonverbal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with multiple medical conditions, including a contracture in the left hand. The resident, who is nonverbal and unable to express discomfort, was observed with a closed left hand and long fingernails that could potentially cause a wound. The care plan did not address the existing contracture or measures to prevent its worsening. Interviews with facility staff revealed a lack of awareness and action regarding the resident's condition. A CNA was unaware of any protective devices for the resident's hand, and the PT Director mentioned that a splint or palm guard was not used due to the resident's inability to express discomfort. The DON acknowledged the risk posed by the resident's long fingernails and the need for intervention to prevent further contracture. However, no immediate actions were taken to address these issues, and the care plan remained incomplete.
Deficiencies in Personal Hygiene and Grooming for Residents
Penalty
Summary
The facility staff failed to provide adequate assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #5, who has severe cognitive impairment and multiple health conditions, was observed with unkempt hair and facial hair, indicating a lack of assistance with bathing and grooming. Despite being coded as requiring assistance, the facility's documentation inaccurately recorded her as independent, and staff interviews confirmed that she needed help with bathing and grooming. Resident #38, who is dependent on staff for all ADLs except eating, was observed with greasy and unkempt hair. The facility's records showed infrequent bathing, and the care plan did not address any refusal of showers. The facility's policy requires hair to be shampooed at least weekly, but this was not adhered to, as confirmed by staff interviews. Resident #60, with moderate cognitive impairment and multiple health issues, was found with long, debris-filled fingernails, indicating a lack of routine nail care. The facility's policy mandates nail hygiene as part of bathing, but records showed inconsistent bathing schedules, and staff interviews confirmed that nail care was not routinely performed. These deficiencies were brought to the attention of the facility's administrator, but no further information was provided.
Failure to Address Contracture and Nail Care in Nonverbal Resident
Penalty
Summary
The facility staff failed to provide appropriate care for a resident to maintain or improve mobility, specifically regarding the contracture of the resident's left hand. The resident, who was admitted with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with her left hand closed and fingertips pressing into the palm. The CNA noted that the resident's fingernails were too long and could potentially cause a wound by digging into the palm. Despite this, the CNA was unaware of any devices such as splints or palm guards being used to protect the resident's hand. The PT Director confirmed that the resident had been assessed on admission, but due to her nonverbal status, it was decided not to use a splint or palm guard. The PT Director also indicated that using a rolled washcloth as a preventive measure was a nursing responsibility. The DON acknowledged that the resident's nails were too long and posed a risk of creating a pressure wound, and agreed that there should be some intervention to prevent further contracture. However, no immediate actions were taken to address these concerns, and the administrator was informed of the issues without further information being provided.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility staff failed to provide appropriate treatment and services for residents with enteral feeding, leading to deficiencies in care for two residents. For one resident, the staff did not ensure that the 60 ml syringe used for PEG tube maintenance was clean and changed daily. Additionally, the tube feeding was not correctly labeled and dated. An observation revealed an empty, undated bottle of tube feeding hanging, an undated used syringe with curdled feeding, and a water flush bag that was half empty and undated. The clinical record indicated specific orders for enteral feeding, but these were not followed as per facility policy, which requires daily changes and proper labeling of the feeding setup. For another resident, similar deficiencies were observed. The syringe used for PEG tube maintenance was not clean and had dried tube feeding in it, and the tube feeding bottle was incorrectly dated. The tubing for the feeding had no date or time, and the water flush bag was empty and undated. The clinical record showed specific orders for enteral feeding, but the facility staff did not adhere to the policy of changing and labeling the feeding setup daily. Interviews with an LPN confirmed that the facility policy was not followed, and the administrator was informed of these concerns during an end-of-day meeting.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for a resident who required oxygen therapy. The deficiency was identified when the resident was observed with an oxygen concentrator by her bedside, but the oxygen tubing was found on the floor, undated, and not stored in a plastic bag as per facility policy. The resident reported using oxygen only when experiencing shortness of breath or at night, but there was no PRN order for oxygen use documented in her clinical record. The existing order was for oxygen at 2L/min via nasal cannula for chest pain, which was discontinued the following day. Further investigation revealed that the facility's policy required oxygen tubing to be dated when opened and stored properly when not in use. The LPN interviewed confirmed that the tubing should be dated and acknowledged the absence of a PRN order for the resident's oxygen use. Additionally, there was no 'Oxygen in Use' sign on the resident's door, which is part of the facility's procedure for oxygen administration. These oversights indicate a failure to adhere to professional standards of practice for respiratory care.
Duplicate Antihistamine Therapy Administered to Resident
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medications, specifically duplicate drug therapy involving two second-generation antihistamines, Loratadine (Claritin) and Cetirizine (Zyrtec). Both medications were prescribed to the resident for seasonal allergies and were administered simultaneously during the 9:00 a.m. medication pass. The orders for these medications were entered by different healthcare providers, the Medical Director and a Nurse Practitioner, leading to the oversight. These medications have the same mechanism of action and are not typically prescribed together, as doing so constitutes duplicate drug therapy. Additionally, the resident was also on Gabapentin, which has the potential to interact with both antihistamines, increasing the risk of excessive drowsiness and other side effects. The Assistant Director of Nursing (ADON) confirmed that it is not common practice to administer both antihistamines simultaneously, acknowledging the error. The issue was identified during a clinical record review and was later communicated to the Nurse Practitioner, who discontinued the Claritin prescription. The facility's Administrator was informed of the findings during an end-of-day meeting.
Failure to Monitor Blood Pressure Before Administering Midodrine
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Midodrine, a vasopressor medication. The resident, who is nonverbal and has a BIMS score of 99, was diagnosed with multiple conditions including intracranial injury, intraparenchymal hemorrhage, seizures, right hemiplegia, DVT/pulmonary embolism, dysphagia, and is under hospice care. The clinical record indicated an order for Midodrine to be administered via PEG-Tube every 8 hours as needed for hypotension, with specific parameters to hold the medication if the systolic blood pressure (SBP) was above 115. However, the medication was administered for over three months without adhering to the 14-day limit specified in the order, and blood pressure was only checked three times during this period. Interviews with facility staff revealed a lack of awareness and adherence to the order's requirements. An LPN stated there was no order for blood pressures to be taken prior to administering the medication, while the ADON acknowledged the importance of checking blood pressure due to the parameters for holding the medication. The ADON admitted that neither the nursing staff nor the pharmacy identified the 14-day limit on the order, leading to the continued administration of Midodrine without proper monitoring. The deficiency was brought to the attention of the facility's administration during the survey, highlighting a significant oversight in medication management and monitoring protocols.
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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